Lecture 6: Stroke management 2025 Flashcards
(118 cards)
1
Q
NOTE:
Home health = does not set multiple disciplines
Inpatient = multiple disciplines
* PT, OT, Speech
A
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Q
Stroke Time frames
Acute - Recovery (medical), early mobilization, prevent learned nonuse, education
* however, dont want to do too much too soon - brain needs time, can make things worse
Subacute - rehab setting?
Chronic - typically more than 6 months post stroke, varies, 3-6 months
* this is a hard pt because if deficits are already ingrained they’re harder to turn around
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3
Q
w/ stroke you can have so many deficits
pseudobulbar effect = when they laugh/cry inappropraitely
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4
Q
Brunstrom stages are for what?
A
motor recovery following stroke
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Q
Stage 1 brunstrom
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Extremeitites flaccid. Typically occurs immediately following lesion, and typically persists hours to days
* would not do modified ashworth here
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Q
Stage 2 brustrom
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Minimal volitional motions are possible and associated reactions are seen in synergistic patterns. Spasticity begins to develop
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Q
Stage 3 brunstrom
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Voluntary control of the synergies is possible through partial range. spasticity will peak at this stage
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Q
Stage 4 brunstrome
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Limited motions combining the synergistic movements are possible. Spasticity begins to decline
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Q
Stage 5 brunstrome
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More advanced movement combinations are possible as spasticity continues to diminish
* so start getting better movement
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Q
Stage 6 brunstrome
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Isolated movements are possible with near normal coordination. Spasticity has declined and amy only be evident w/ increased speed of movement
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Q
synergy patterns
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12
Q
pt has lesion to R hemisphere
* what is is hemiplegia/paresis?
* What side is sensory loss?
A
L sided hemiplegia/paresis
L sided sensory Loss
13
Q
What side of the brain does the lesion have to be in for the pt to be quick and impulsive
A
R brain lesion = quick and impulsive
* poor judgement / unrealistic
* unable to self correct w/ cueing
14
Q
What side is the lesion on if the pt has poor insight, awareness of impairments, denial of disability (increased safety risk)
A
Right
15
Q
What side is the lesion on if the pt has neglect?
A
most likely R sided lesion (left side unilatearl neglect) - ignoring that side
16
Q
Lesion on what side of the brain leads to issues with perception/knowing where they are at
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R side
17
Q
What side is the brain lesion on if the pt has difficulty w/ abstract reasoning / problem solving?
A
R
18
Q
What side is the lesion on if the pt has a difficult time grasping the whole idea
A
R
19
Q
What side of the brain is the lesion likely on if they have memory problems?
A
R
20
Q
What side of the brain is the lesion on if the pt has difficulty w/ the ability to percieve emotions
A
R
21
Q
What side of the brain is the lesion on if the pt has difficulty w/ expression of negative emotions?
A
R
22
Q
KNOW: w/ R sided brain lesion they’ll have fluctuations in task performance
A
23
Q
Know w/ Left sided lesion
* Right side hemiplegia/paresis
* Right side sensory loss
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24
Q
w/ right sided lesions we see more visual-perceptual impairments, while w/ L sided we see more speech and language impairments
A
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What 3 kinds of aphasia do we see w/ left sided lesions?
Nonfluent (broca's) aphasia
Fluent (Wernicke's) aphasia
Global - both
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aphasia defintion
a language disorder that affects a person's ability to communicate effectively
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A lesion on what side of the brain would lead to the pt having difficulty processing verbal cues / verbal commands?
Left
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A lesion on what side of the brain leads to the pt having slow, cautious behavior style?
L (exact opposite of the impulsivity w/ R lesion)
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A lesion to what side of the brain leads to the pt being disorganized?
L
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A lesion to what side of the brain leads to the pt being very awayre of impairments and the extent of disability?
L (exact opposite of right)
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Which side of the brain is the lesion in if the pt is having memory impaorments associated w/ language?
L (makes sense, this is the side w/ all the aphasias)
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A lesion to what side of the brain leads to perseveration?
L
NOTE: will also have
* Disorganized problem solving
* Difficulty initaiting tasks, processing delays highly distractible
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Which side of the brain is the lesion in the the pt has difficulty w/ expression of positive emotions?
L
* opposite of R
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Apraxia defintion
a neurological disorder that affects the ability to plan and execute purposeful movements
* difficulty planning and sequencing movements
motor planning is impacted
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A lesion to what side of the brain leaads to apraxia?
L
* ideational
* Ideomotor
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deficits common w/ L and R brain lesions (can be either)
* Visual field defects: homonymous hemianopsia
* Emotional abnoramlities: Labilty, apthy, irritability, low frustration levels, anxiety, depression
* Cognitive deficits: confusion, short attention spasn, loss of memory, executive functions
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A pt has a lesion on what side of the brain if they are impulsive, have poor judgement, and this leads to an increased safety risk
R
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PASS = can use in any of the 3 settings, but best for acute/in patient
Functional reach test = any of the 3 settings
the below shows what settings you can use different tests
NOTE: not just talking about stroke w/ this table
DGI = okay for out pt
ashworth any setting but don't do w/o tone or super rigid and know that already
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PT interventions: - stroke - remember to check vital signs because may have had a hypertensive issue leading to this
Restorative
* think restoring function of arm post stroke
Preventative
* ROM = to prevent contratcutes w/ stroke
Compensatory
* compensating for something thats actually lost
* Think a wheel chair for leg loss
* think more assistive devices / things changing mobility
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because strokes can present so differently
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Rehab bridges the gap between maladaptive behavior and independent function
* we stop maldaptive behavior
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Explain a remedial apprach (stroke intervention)
Bottom up appraoch
Focused on the pts deficits and retraining behaviors
Recovery of underlying skills (bottom) to generalize these skills to function
So start w/ the most basic things and build to a goal essentialy
* more focused on impairments
* think getting back strength / Rom focused at gaining ambulation
48
Explain the adaptive/compensatory stroke intervention approaches
Top down apprach
Direct training in the functional deficit
not targeting directly the impairments - basically ignoring the imapirments focusing on function
* neuro is more fucntion focused - so i guess you would use this one more - no right or wrong answer here
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Which appraoch focuses more on deficits the remedial or adaptive approach?
Remedial
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DGI and Pass fall where on ICF table?
Activity
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The perception, attention, thinking, and memory
* act of knowing
Cognition
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Integration of sensory impressions into psychologically meaningful information
* Cognition and visual subsets
Perception
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look under cognition and see what deficits they could potentailly have if cognitiion is impacted
* same thing w/ perception
perception deficits = agnosias = not perceving body as they did before
* spastial realtions = discrimitive tasks - think losing depth perception
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types of attention fall under cognition (the act of knowing) what kind of attention is this: easily distracted by any activity in the environment: responds to background noise: difficulty attending to therapists directions while in a croweded therapy clinic
Selective
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types of attention fall under cognition (the act of knowing) what kind of attention is this: Difficulty with details; stops a task midway; stops doing exercises after six reps when asked to do 15
Sustained
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types of attention fall under cognition (the act of knowing) what kind of attention is this: unable to do two things at one time: complete dressing and answer questions about weekend plans
Divided
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types of attention fall under cognition (the act of knowing) what kind of attention is this: unable to return to original task if interrupted: during cooking activity, therapist stops patient to correct use of mobility device; patient requires cue to resume cooking task
alternating
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Which theoretical treatment appraoch to cognitive and perceptual dysfunction is this: Skills learned for one task can generalize to others
Retraining
so maybe breaking a task down and working on a walking peice and then we want to generalize it to longer distance walking. Breaking something down.
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Which theoretical treatment appraoch to cognitive and perceptual dysfunction is this: Promote normal CNS processing of sensory information to elicit specific desired motor responses
Sensory integrative
do more sensory retraining (she doesnt do sessions like this)
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Which theoretical treatment appraoch to cognitive and perceptual dysfunction is this: Practice every activity in its true context in order to recover function
Neurofunctional
Not always easy to do depending on ur pts level of assist. more working functional i guess
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Which theoretical treatment appraoch to cognitive and perceptual dysfunction is this: direct repetitive practice of specific functional skills that are impaired
Rehabilitative/compesatory (functonal)
more functional - kind of like blocked practice - keep doing sit to stands etc...
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Which theoretical treatment appraoch to cognitive and perceptual dysfunction is this: training individuals with brain injury to structure and organize information
Cognitive rehab/quadraphonic
more cognitive practice
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What are our 4 kinds of attention deficits?
* damage to these 4 areas in the brain can lead to deficits w/ these?
Types
1) sustained
2) Focused/selective
3) Alternating
4) Divided
Lesion area
* Reticular formation
* Sensory systems
* Limbic system
* Frontal lobe
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Memory impairments can be immediate recall, short-term memory, or long term memory
* what 5 areas can the lesion be in to have memory problems?
Lesion area:
* Frontal
* Parietal
* Temporal
* Occipital
* limbic
so like everything lmfao
some thigns that could help pts w/ memory impairments
* getting info in smaller chunks (not overhwleming them w/ too mcuh verbage)
* routine
* real life activities to understand a concept (so releate it to them)
* store items into the same lcoation
* go back over stuff you went over in session
* Whole list on next slide
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Executive function impairments
Volition, planning, purposive action, effective performance
Lesion area =
lesion = frontal and prefrontal cortex, subcortical structires
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vision test if they can't register one side of body = do visual field tests
* note not somethign wrong w/ eyes but sensory perception
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The inability to recognize or make sense of information **despite intact sensory capabilities**
Agnosia
* visual
* aduitory
* Tactile/asterognosis
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What is a visual agnosia?
Difficulty recognizing an object (even though they can see it fine, they just can't recognize it)
* think seeing someones face but not being able to recognize what it is
* the perception is damaged, not the sensory
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Explain auditory agnosia
Can hear it (have sensory) but not understand
* so they cant make meaning out of sensory environment - sensory is intact
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Explain tactile/astereognsis agnosia
Can feel something but don't know what it is
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Inability to perform purposeful movement despite intact abilities
Apraxia
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What is ideomotor apraxia?
Unable to perform on command, but can at other times
* so sometimes they can do the motor, just not when you need them to
* "ask them to stand up" and they can't do it. But other times they will be able to stand
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What is ideational apraxia?
Does not understand the concept (ex - brushing teeth)
* they might put the toothbrush in hair
* doesnt understand the concept of the motor movement
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The inability to register and integrate stimuli and perceptions from one side of the body or environment, awareness impaired
Neglect
they are very teachable - can teach them to constantly look at that side
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Complete lack of awanress, or denial, of a paretic extremity as belonging to the person, or a lack of insight concerning, or denial of, paralysis and disability
Anosognosia
so i guess worse than neglect - they dont even register it / deny whats going on
* difference is that they're denying that that side is even involved
Since they are denying that its even going on these pts are very unteachable - these pts are harder to rehab
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where is the lesion for apraxia?
Frontal and parietal lobe
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What are our 3 kinds of aphasia?
1) Brocas/non fluent/expressive - meaning speech is choppy - maybe one word - not speaking normally - expressive ebcause they're having a hard time talking and physically expressing themselves
2) Wernikckes/fluent/receptive - talking a ton. (fluent) but doesnt make any sense
3) global - mix of both
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What is dysarthria?
Difficulty speaking
* think dys articulatiuon
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What is dysphagia?
Difficult swalling
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Type of aphasia that is fluent / receptive
Wernickes
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Type of aphasia that is non-fluent/expressive
Brocas
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type of aphasia that is both receptive and expressive
Aphasia
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which kind of aphasia has **loss of auditory comprehension** with fluent speech and word substiutions; where reading and writing are impaired
Wernicke
* know: this is lesions in posterior portion of temporal gyrus
* considerd fluent
**so not going to give this pt something to read - going to have to give them a gesture.**
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Which kind of aphasia has intact comprehension of oral and written language with difficulty producing speech, articulating, naming, and writing; limited vocab.
Broca aphasia
* considered non fluent
* Lesions are anterior lesions, third frontal convolution (left hemisphere)
so you can write things to these pts if wanted
* want it to be a Y/N answer because they'll have a hard time responding
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Which kind of aphasia describes a severe aphasia that involves loss of production and comprehesnion of language including writing; usually results from a large MCA infarct
Globa aphasia
* considered non fluent
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Which kind of aphasia has fluent speech with difficulty naming, repeating words while retaining written and oral comprehension
Conduction Aphasia
can be fluent or non fluent
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This is for dysarthria (different than aphasia)
* difficulty physically speaking
* Adequate lighting, take advatngae of visual cues - you want to be able to hear the pt
* dont want to communicate for 30 minutes straight w/ them - would be too taxing on them
* maybe communicate w/ other methods like writing
* encourage pt to take their time when they're talking
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Knowledge check: Type of aphasia w/ fluent speech but not inteligable
* Wernicikes, receptive (need to know the receptive part)
* so know both names because she tested here on it
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NOTE: That visual aphasia is not a visual field cut, its a perception issue
however, you can teach both to do visual scanning etc... just need to learn that they arent aware of one side of their body
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parietal lobe?
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Spatial relations disorder = where person recieves their body in space
* people often have a hard time recignizing they have a problem when they have perceptual deficits like this
Figure-ground discrimination, form discrimination, spatial relations, position in space, topographical disorientation, depth and distance perception, vertical disorientattion
Lesion area: Parietal, occipital, temporal
man putting on shirt below
* all those areas in the brain have to be active to put the shirt on
* which i guess is kind of a spatial relations thing
deficit in sensory processing = simple tasks become hard
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Depth perception: ability to judge the distance between objects or between objects and self
Figure ground: distinguishing objects in the foreground from pattern in the background
* think finding an object thats in a junk drawer / purse
Spatial relations: Ability to interpret where objects are in space and how they releate to self and to other objects
* where objects are in space and how they relate to self/other objects
* "Where am I in relation to walker"
Right/L discrimination: Ability to understand and apply concepts of right and left personal: left and right as they releate to own body parts extrapersonal: how left and right are interpreted in the environment
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She emailed us a different verson of this slide
**named for vision field thats lost**
* If I have left hemonimouys hemiansopsia I cannot see the left visual field
different than neglect because they litteraly dont even sense it
visual scanning
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neglect = awareness issue
* dont know they have it a lot of the time
**Visual field loss = processing issue**
* easier to treat - use scanning in direction of loss
* are aware they have this
Can help w/ visual scanning by:
* Visual search board
* Visual scan on wall/door
* Technology
* Scavenger hunt- grocery store, cabinets
* Card games, word search
* walking
can also do oculomotor exercises
Field expanders/prisms - equipment that helps shift images from the cut field
Prism glasses (for tx of diplopia)
* Refract light and focus it on the same place in both the retinas
* Helps the brain to produce a single image leading to clearer vision
* Changes the way light enters the eye and brain, therefore affecting the NS
* Can start w/ tape on glasses before getting prism glasses
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Is neglect an awareness of perception problem?
* Tx?
Awareness - the sensory is intact, the just don't know what they're seeing (which is why its an awarness problem)
Treatment: Scanning to increase attention
* 1) - present all information on involved side
* 2) Present all information on involved or neglected side
* When to use each appraoch? - if it just happened use option 1 to make them functional. Eventually want to challenging them and teach them to scan to be more attentitve
Moving involved side arm/leg within neglected environment
Image: left neglect, right
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Is this right or left neglect?
* meaning which side of the brain is impacted
Left neglect, right brain damage
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differeniate neglect from visual field cut questions
Both will look like they're having visual field loss because they're unaware of that side
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neglect = tyicallu L side because its on the R side of brain
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Strategies to maximize interactions when treating pt w/ unilateral neglect (left sided)
* Improve comprehension of information by having the pt read along using his/her infex finger a guide
* During transfers and mobility, cue the pt to locate and safely position the left limb before movement
* Anchor the left side of the pts environment by placement of a brightly colored item or border. Ask the pt to look to the left until the border is seen
* Utilize functional, meaningful activities when addressing issues of neglect. This assists in generalization of skills
* Conduct therapeutic activities in natural settings
* Improve the pts awareness of deficits by providing direct feedback during activities
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**Visual field cut** is a problem w/ awareness or information processing?
Visual field processing
* don't have the sensory at all
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**Neglect is a problem w/ awareness or information processing?**
Awareness
* they're processing the sensory and just not doing anything w/ it
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tx for visual field cut and neglect = scanning (compensatory tx)
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Strategies to structure clinical communication interactions
Altering the presentation of information for pts w/ attention deficits
* Establish and maintain eye contact w/ your pt before presenting directions
* Offer instructions in small chunks
* Slow the rate of presentation by asking the pt to repeat (in their own words) or demonstrate understanding of instructions before providing additional information
* When family is present or when you are participating in a cotreatment, avoid interruptions and designate one person to dl all the instructing
* Incorporate short breaks into tx that involve a high level of attention in order to manage fatigue
* Avoid interrupting the pt in the middle of a task. Limit unncessary converstations
* Stop the pt to provide additional information during natural breaks between steps
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knowledge check: in which deficit does the pt experience denial of the deficits
Agnosagnosia
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Locked in syndrome:
* acute hemiparesis rapidly progressing to tetraplegia and lower bulbar paralysis - the pt cannot move or speak but remains alert and oriented
* what imaired horizontal or vertical eye movements
* occulsion of what system causes this
* does this pt have the potential to recover
horizontal eye movements are impaired but vertical eye movements and blinking remain intact
Occlusion of the vertebrobasilar system - so vertebrobaslar stroke
Patient can demonstrate some improvements over time
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w/ Pusher syndrome
* know: its a behavior phenomenon
* **leaning and active pushing toward the hemiplegic side or nonhemiplegic side?**
* do they have resistance to any attempot at possive correction of posture towards midline or across the body toward the nonaffected side
Typically R or L brain?
* is recovery process fast or slow?
Leaning and active pushing toward the hemiplegic side in all positions using the nonparetic arm and leg
* they are pushing toward the hemiplegic (impacted) side - so toward more involved side / weaker side
Resistance to any attempt at passive correction of posture towards midline or across the body toward the nonaffected side
* so you can't just push them back to center
Also called ipsilatearl pushing, contraversive pushing, pusher behavior
Research:
* 80% R brain lesions
* "Graviceptive" neglect - she didnt know why this word was used
* Involvement of thalamus? - they arent sure so dont memorize
* recovery process is low
think of it like not having any muscles on the weak side so the ones that are actually firing drag us over there
| note: they are pushing w/ their stronger side toward weaker side (falls)
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Pusher syndrome patient observation
* **sits or stands asymmetrically**
* Most of the weight shited toward the weaker side
* Uses the stronger UE or LE to push over to the weaker side leads to instability and falls
Considerations **EXAM**
* **pt will push more forcefully if therapist tries to passively correct posture** - she said this is on exam
* training needs to emphasize upright with **active** movement shifts toward stronger side (opposite way they're shifted)
* environmental prompts
* Use visual cues and cognitive strategies
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Considerations - Tx
**EXAM**
Typical stroke
* **Treat from hemi side** - so target weaker side w/ tx
* Stabilize hemi leg
* Tone management and wt bearing
* Forced use
Hemineglect
* **treat from front and progress to hemi side** - because they litteraly cant see if you if you're on the impacred side - teach them to be aware of that side
* **Use of mirrors to engage hemi side**
* Stabilize hemi leg
* Tone management and wt bearing
* Forced use
Pusher syndrome
* **Treat from front** - cant pick a side, thats a safety concern - **EXAM**
* Stabilizing force from front, back, or circumferentially - **NOT ON THE SIDE!!!!!**
* Use of vertical cue (wall, door frame)
* Use of physical cue (wall, person)
* remove pushing ability or use it to your advantage (self tone management) - if they're pushing to weaker side you can work on joint approximation by utilizing this already done movement
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Cerebellar damage = ipsilateral
Cerebellar damage
* can come from a cerebellar stroke, spinocerebellar ataxia, lesions, infectious disease complications
* Dizziness/vertigo, nausea.vomiting, ipsilateral ataxia and hypotonia, nystagmus, impaired balance, incoordinated gait and speech
* Symptoms are ipsilateral (same side as damage)
* Strength is not normally the issue, its movement coordination
Remember theres speech deficits w/ this as well **dysarthria**
NOTE: these pts are very high fall risks
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for post stroke
CIMT = constraint induced movement therapy
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not going to post specific questions on gait
* must knwo normal gait to recignize abnormal gait
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estem for fibular/personeal nerve?
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outcomes less sucessful for pts w/
* advanced age
* Severe motor impairments
* Persistent medical problems
* Impaired cognitive function
* Severe langauge disturbances
* Severe visospatal neglect
* lower SES
**Depression: Single major risk factor for mobility decline**
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knowledge check: hemineglect (neglect to one side) should be treated from which side initally?
Treat from the front
