Day 3 - Spasticity & Neuro Rehab Flashcards
(35 cards)
Treatment of Central Pain Post Stroke 🔑
First Line
- Amitriptyline (75mg/d)
- Gabapentin (Neurontin) 900mg/d
Others
- Pregabalin (Lyrica) 150mg/d
- Naloxone (8mg)
- I.V. Lidocaine → short-term (45 min) pain relief only
- Morphine infusion (9-30mg)
Pathophysiology of Thalamic/Central Pain States Post Stroke (CPSP)
Damage to spino-thalamic pathway → impaired temperature (hot, cold) and pain (pinprick)
→ hyperalgesia +/or allodynia
Risk factors for Post-Stroke Fatigue (PSF)
- Depression
- Chronic pain
- Sleep disorders
Treatment of Post-Stroke Fatigue (PSF)
- Modafinil 200mg/d
- Cognitive Therapy/Graded Activity Training
List 2 screening tools for depression 🔑
- Patient Health Questionnaire (PHQ)-9
- Hospital Anxiety and Depression Scale (HADS)
List 4 Risk Factors for Depression post stroke
- Female sex (especially those with severe depression)
- Previous history of depression
- Stroke severity, functional limitations or need for assistance with activities of daily living
- Cognitive impairment
- Social factors (living alone, divorced or living in a nursing home)
List 2 Pharmacological & 2 Non-Pharmacological Management for Depression Post-Stroke
Non-Pharmacological Management
- Exercise
- Cognitive-Behavioural Therapy (CBT)
Pharmacological
- TCA → Amitriptyline 10-25mg
- SSRI → Escitalopram (Cipralex) 5mg Fluoxetine (Prozac) 10mg
- CNS Stiumlant → Methylphenidate (Ritalin) 5mg
Explain brain lobes and their clinical relation.
Frontal lobe
- Laterally separated from the temporal lobes by the Sylvian fissure.
- Primary motor cortex → voluntary movement → Weakness
- Problem solving, thinking and planning → Apraxia
- Behavior & personality
Parietal lobe
- Primary somatosensory cortex → Perception → Neglect
Temporal
- Primary auditory cortex → Language → Aphasia
- Memory, Object and face recognition
Occipital
- Primary visual cortex → Vision and orientation
List 5 descending tracts.
- Corticospinal
- Vestibulospinal
- Rubrospial
- Olivospinal
- Reticulospinal
Mini-Mental State Examination (MMSE) ORAL.C.
Orientation
- D/M/Y, Season and Time
- Location From country to Ward
Registration
- 3 Objects
Attentions
- 100 minus 7 five times
Language
- Name 2 object
- Give 3 order command
- Read command
- Write sentence
Copy
- Pentagon
Main challenges in bladder for stroke patient.
- Incontinence → areflexia
- Aphasia → communication
- Impaired mobility → WC
- Neurogenic Bladder → neurodynamic study
- Repeated UTI
Cuccurollo
How do you manage bladder dysfunction in stroke patient?
Failure to store
Antimuscarinic agents
- MOA: Prevent acetylcholine release from parasympathetic nerves by binding to receptors on the detrusor muscle, thus assisting in bladder storage.
- Drugs: Solifenacin (Vesicare) or Oxybutynin (Ditropan)
- Side effects: dry mouth, blurry vision, and constipation
Failure to pass
Adrenergic antagonists
MOA: Inhibit smooth muscle activity in the prostate and at the bladder neck
Side effects: Postural hypotension, abnormal ejaculation, and nasal congestion
Spastic Bladder (Hyperactive)
Baclofen, tizanidine, diazepam, and dantrolene sodium
Botulinum toxin type A
Underactive Bladder
Intermittent catheterization (IC)
List 2 investigation you would like to do before treating bladder dysfunction?
- Urodynamics evaluation
- Post void residuals (PVRs)
List 2 pharmacological and 2 nonpharmacological treatments for stress incontinence.
Pharmacological
- Adrenergic agonists
- Oxybutynin (Ditropan)
NonPharmacological
- Take fiber to avoid constipation
- Avoid jumping or running
- Pelvic floor muscle exercises
Stroke patient with diarrhea, how do you manage?
- Treat underlying causes (e.g., bowel infection, diarrhea)
- Timed toileting schedule
- Training in toilet transfer
- Communication skills
Stroke patient with constipation, how do you manage?
- Adequate fluid intake/hydration
- Diet modification (e.g., increase dietary fiber),
- Bowel management (stool softeners, stool stimulants, suppositories 3-2-1 program)
Decreased sexual activity post-stroke attributed to:
- Inability to discuss sexuality with spouse
- Unwillingness to participate in sexual activity
- Reduced body image and self-esteem
- Positioning problems due to disability and spasticity or muscle weakness
Treatment of sexual dysfunction post-stroke
- Emotional support
- Psychotherapy
- Medical consultation (urology)
- PDE5 inhibitor
- Treat underlying spasticity/weakness/contracture
Define Spasticity & Modified Ashworth Scale
A motor disorder characterized by an abnormal, velocity-dependent increase in the tonic stretch reflexes (muscle tone) with exaggerated phasic stretch reflexes (tendon jerks, clonus) resulting from hyperexcitability of the stretch reflex. It is a component of the UMNS.
Modified Ashworth Scale:
0 No increase in tone
1 Slight increase in muscle tone, manifested by a catch and release or minimal resistance at the end of the ROM when the affected part(s) is moved in flexion and extension
1+ Slight increase in muscle tone, manifested by a catch, followed by minimal resistance throughout the remainder (less than half) of the ROM
2 More marked increase in muscle tone through most of the ROM, but affected part(s) easily moved
3 Considerable increase in muscle tone, passive movement difficult
4 Affected part(s) rigid in flexion or extension
List 5 management options for spasticity.
Prevention first (non-pharmacological)
- Remove factors or noxious stimuli that may increase spasticity (UTI, etc).
- Exercises: positioning, stretching/ROM.
- Bracing: splinting (static vs dynamic), Serial casting.
- Modalities: cold, electrical stim, FES
Treating second (pharmacological)
- oral medications → Baclofen
- focal treatments → BotoX
- intrathecal baclofen.
- surgical options (selective dorsal rhizotomy)..
Ref: http://www.abiebr.com/set/case-study-2/27-spasticity-post-abi
What is the mechanism of botulinum toxin? 1 Mark
Inhibition of acetylcholine release at the neuromuscular junction
What is the mechanism of botulinum toxin? 1 Mark
Inhibition of acetylcholine release at the neuromuscular junction
Postural abnormalities in upper limb and where to inject.
Postural abnormalities in wrist and where to inject.
