PTA Neuro - CVA and TBI Flashcards
(77 cards)
1
Q
What is CVA?
A
Cerebrovascular Accident
The sudden onset of neurological signs and symptoms resulting from a disturbance of blood supply to the brain that persists longer than 24 hours.
2
Q
Name two causes of CVA
A
Ischemic - lack of blood flow
Hermorrhagic - abnormal bleeding due to blood vessel rupture or trauma
3
Q
Name two types of Ischemic CVA
A
Cerebral Thrombosis
Cerebral Embolus
4
Q
Explain cerebral thrombosis
A
Formation of thrombus (clot) within the cerebral, carotid, or vertebral arteries leads to infarction/tissue death.
Atherosclerosis is the cause (process of plaque buildup in an artery)
5
Q
Explain cerebral embolus
A
A detached clot causes occlusion of cerebral arteries
Associated w cardiovascular disease (A-fib, valvular, MI)
6
Q
Name three causes of hemorrhagic CVA
A
hyptertension
aneurysm
ateriovenous malformation
7
Q
What is TIA?
A
Transient Ischemic Attack
temporary interruption of blood supply to the brain
8
Q
How long does a TIA last?
A
Symptoms last from a few minutes to several hours, but < 24 hours
9
Q
What causes a TIA?
A
May be due to embolus, arrhythmias, hypotension, cerebrovascular spasm
10
Q
What damage is done during a TIA?
A
No evidence of residual brain damage or permanent neurological dysfunction afterwards
11
Q
What is the risk of CVA after TIA?
A
33% of patients who have 1 or more TIAs will go on to have a CVA within 1 year
12
Q
List risk factors for CVA
A
Hypertension Smoking Hypercholesterolemia Age (Risk doubles with each decade over the age of 55.) Heart disease Arrhythmias Diabetes Hyperlipidemia Physical inactivity Hx of CVA or TIA Male gender up to 80 yo Race – African American Family Hx ↑ alcohol consumption Drug abuse Hormonal treatment Abdominal obesity
13
Q
What are the motor signs and symptoms of CVA?
A
- Flaccidity →hypertonicity—due to abnormal processing of afferent input after reaches spinal cord; decreased inhibition from higher cortical centers and spinal interneuron pathways
- Paralysis, paresis
- Posturing/moving in synergistic patterns
- Reflex changes – clonus, Babinski sign
- Associated reactions
- Incoordination secondary to cerebellar lesion, decreased proprioception, or motor weakness
14
Q
What are the sensory signs and symptoms of CVA?
A
- Sensation often impaired on hemiplegic side but rarely totally absent
- Loss of superficial touch, pain, and temperature sensation are common
- Loss of proprioception may be a major problem and is common
15
Q
What are language signs and symptoms of CVA?
A
Aphasia
- impaired language comprehension, oral express or formulation and use of symbols to communicate ideas
- usually from L CVA (R hemiplegia)
- three kinds
16
Q
What are the three types of aphasia?
A
Expressive (Broca’s)
Receptive (Wernicke’s)
Global
17
Q
What are the speech/language/swallowing signs and symptoms of CVA?
A
Agraphia Alexia Anomia Aphasia (three kinds) Apraxia Dysarthria Dysphagia Perseveration
18
Q
What is the visual sign/symptom of CVA?
A
Homonymous Hemianopsia
- blindness of the nasal half of one and the temporal half of the other eye
- visual field deficit on the hemiplegic side
19
Q
What are Cognitive-Perceptual deficits you would see in CVA?
A
Agnosia Anosognosia Apraxia Body Image Distortion Body Scheme Distortion Figure-Ground Discrimination Deficit Position in Space Deficit Problem Perceiving Verticality Topographical Disorientation Unilateral Neglect
20
Q
Define two types of Apraxia
A
- Ideational Apraxia - inability to do purposeful movements on command or automatically
- Ideomotor Apraxia - inability to do purposeful movements on other’s command, but can do automatically
21
Q
Cognitive Perceptual Deficits are more common in left or right CVA?
A
Right CVA (left hemiplegia)
22
Q
List changes in mental function and behavior associated with Right Hemiplegia
A
Slow Cautious Uncertain Insecure Negative Anxious Depressed Problems w/processing information in sequential/linear fashion
23
Q
List changes in mental function and behavior associated with Left Hemiplegia
A
Quick Impulsive Overestimates abilities Denial of diabilitiy Poor judgement (safety) Difficulty grasping a whole idea or overall organization of an activity Pusher syndrome
24
Q
List changes in mental function and behavior associated with either side hemiplegia
A
memory probems emotional lability (pseudobulbar affect) confusion, irritability dementia (due to multiple infarcts) seizure (in small % of cases)
25
List Secondary Complications to CVA
- Contractures & deformities
- Deep vein thrombosis or pulmonary emboli
- Urinary incontinence; bowel impactions or incontinence
- Hemiplegic shoulder pain or subluxation
- - Shoulder-hand syndrome = Complex regional pain syndrome = Reflex sympathetic dystrophy
- --- Hand edema & shoulder pain → wrist & hand pain → ↓ed shoulder ROM, vasomotor changes, hypersensitivity
26
Distribution and Deficits of Anterior Cerebral Artery
- Supplies the medial aspect & superior border of the frontal and parietal lobes
- Contralateral weakness and sensory loss primarily in the lower extremity, incontinence, aphasia, memory and behavioral deficits
27
distribution and deficits of Middle Cerebral Artery
- Supplies the surface of the cerebral hemispheres and the deep frontal and parietal lobes
- Contralateral sensory loss and weakness in the face and upper extremity, less involvement in the LE, homonymous hemianopsia
28
distribution and deficits of Verterbrobasilar Artery
- Supplies the brain stem and the cerebellum
- Cranial nerve involvement, ataxia, vertigo, headaches, dizziness, diplopia, dysphagia, dysarthria
- Locked-in syndrome – basilar artery thrombosis
29
distribution and deficits of Posterior Cerebral Artery
- Supplies the occipital and temporal lobes, thalamus and upper brain stem
- Contralateral sensory loss, thalamic pain syndrome, homonymous hemianopsia, visual agnosia and cortical blindness
30
What is Lacunar Infarct?
- Small vessel arteriolar disease
- Associated with diabetes & HTN
- Affect deep brain structures, ie. internal capsule, thalamus, basal ganglia, pons
- Impairments:
- - Contralateral weakness & sensory loss
- - Ataxia – uncoordinated movement
- - Dysarthria
- - Pusher syndrome (R thalamic damage)
31
What are early warning signs of CVA?
- sudden numbness or weakness of the face, arm, leg; especially on one side of the body
- sudden confusion, trouble speaking or understanding
- sudden trouble seeing on or both eyes
- sudden trouble walking, dizziness, loss of balance or coordination
- sudden, severe headaches with no known cause
32
What are the Brunnstrom Stages of Recovery?
```
I. Flaccidity
II. Spasticity begins to develop
III. Spasticity Increases and reaches its peak
IV. Spasticity begins to decrease
V. Spasticity continues to decrease
VI. Spasticity is essentially absent
VII. Return to normal function
```
33
Which muscles tend to develop spasticity in the Neck & Trunk?
lateral flex on hemiplegic side
34
Which muscles tend to develop spasticity in the Upper Extremity?
- scapular retractors and downward rotators
- shoulder adductors and IRs
- elbow flexors
- forearm pronators
- wrist flexors
- finger flexors
35
Which muscles tend to develop spasticity in the Lower Extremtiy?
- pelvic retractors
- hip extensors, adductors and IRs
- knee extensors
- ankle/foot PFs and inverters
- toe flexors
36
What are Bobath's 3 main recovery stages?
1. initial flaccid
2. stage of spasticity
3. relative recovery stage
37
Recovery and Prognosis
- Recovery generally fastest in first weeks after onset w/ the most recovery occurring in first 3 months, slower in next 3 months
- May continue functional gains at a reduced rate for months or years after insult
- Late recovery of function has been demonstrated for patients w/ chronic stroke (>1 year) who undergo extensive functional training (“Function-induced plasticity”)
- Initial extent of paresis is an important predictor of motor recovery
38
What are two kinds of Recovery?
Spontaneous
| Function-Induced
39
What is Spontaneous Recovery?
- occurs (within 3-4 wks)
- repair processes occurring immediately after insult
- influenced by return to function of undamaged parts of the brain with resolution of temporary blocking factors (shock, edema, decreased blood flow, decreased glucose utilization)
40
What is Function-Induced Recovery?
neural reorganization that occurs as a result of increased use of involved body segments in behaviorally relevant tasks (This is where we come in.)
41
What is Neuroplasticity?
ability of brain to change and repair itself
42
What are two kinds of Neuroplasticity?
Regenerative
| Reactive
43
What is Regenerative Synaptogenesis?
sprouting of injured axons to innervate previously innervated synapses
44
What is Reactive Synaptogenesis?
sprouts from neigboring axons synapse with sites of the injured axon.
- also called collateral sprouting
45
What is the incidence of TBI?
1.7 million/yr in USA
2:1 males:females
Age Ranges- 0-4, 15–19, & > 64
46
What are causes of TBI?
```
#1 Falls
#2 MVA
#3 Assaults and Violence
#4 Sports and Recreation
```
47
What are outcomes of TBI in US?
52,000 DEATHS/YR
LEADING CAUSE DEATH & DISABILITY IN CHILDREN AND ADULTS AGES 1-44
NO CURE!
MUST PREVENT!!
48
What are TBI classifications?
Open Head Jury
- local (focal) lesion
Closed Head Injury
- diffuse axonal injury
49
describe Local Lesion brain injury
- Predictable neuro signs
| - Due to gunshot or stabbing
50
describe Diffuse Axonal Injury
- Scattered shearing of subcortical axons within myelin sheaths
- Comatose, abnormal posturing, autonomic dysfunction
51
Name some Closed Brain Injuries
```
concussion
cerebral contusion
epidural hematoma
subdural hematoma
brain laceration
```
52
What is Concussion?
- Temporary loss of consciousness and reflexes.
- Synapses disrupted; No structural damage
- Amnesia may occur
53
What is Cerebral Contusion?
- Hemorrhage from small blood vessels.
- Bruising on brain surface during impact.
- COUP/CONTRECOUP LESIONS
54
What is Epidural Hematoma?
- Between skull and dura mater
- Due to blow to head or MVA
- Unconscious, then alert, then rapidly deteriorates if hematoma enlarges
- If hematoma enlarges, need immediate craniotomy
55
What is Subdural Hematoma?
- Between dura & arachnoid mater
- Venous hemorrhage
- Occurs more slowly (hrs – a week)
- Often seen in elderly from falls
- Symptoms often resemble CVA
- Larger ones need surgical removal
56
What is Brain Laceration?
wound or tear of brain tissue
57
Describe some Secondary Problems to TBI
INCREASED ICP
Signs & Symptoms - Decreased responsiveness &/or consciousness
Due to edema &/or blood compressing brain tissue; possible herniation
- Severe headache
- Vomiting
- Change in VS -BP up, HR down
- Irritability
- Papilledema (edema/inflammation of optic nerve)
Contraindication - trendelenburg
ANOXIA DUE TO CARDIAC ARREST
HETEROTOPIC OSSIFICATION
58
What is the purpose of the Glascow Coma Scale?
* to Assess level of consciousness at acute stage
- evaluates: eye opening, motor response, verbal abilities
* score range is 3 - 15
- 3 to 4: often die
- 8 or less: coma, severe injury
- 9 to 12: mod TBI
- 13 or higher: mild TBI
* BEST PREDICTOR OF OUTCOME
- Depth & Duration of unconsciousness per GCS with CAT scan results
59
Levels of Cognition
| Ranchos Los Amigos Scale
```
LEVEL I – NO RESPONSE; TOTAL
ASSIST
LEVEL II – GENERALIZED RESPONSE;
TOTAL ASSIST
LEVEL III –LOCALIZED RESPONSE;
TOTAL ASSIST
LEVEL IV - CONFUSED/AGITATED;
MAX ASSIST
LEVEL V – CONFUSED/INAPPROPRIATE;
MAX ASSIST
LEVEL VI – CONFUSED, APPROPRIATE;
MOD ASSIST
LEVEL VII – AUTOMATIC, APPROPRIATE;
MIN ASSIST
LEVEL VIII – PURPOSEFUL, APPROPRIATE;
STANDBY ASSIST
LEVEL IX – PURPOSEFUL, APPROPRIATE;
SBA ON REQUEST
LEVEL X – PURPOSEFUL, APPROPRIATE;
MODIFIED INDEPENDENT
```
60
Describe Low Level on Ranchos Los Amigos scale
LEVELS I, II, & III (LOW LEVEL)
- Needs highly structured, stable closed environment
- Consistency in schedule, Tx length, location, & PT personnel
61
Describe Mid Level on Ranchos Los Amigos scale
LEVELS IV – VI (MID LEVEL)
- Needs very structured, controlled environment, quiet area; consistency.
- PTA/PT offer calming attitude
62
Describe High Level on Ranchos Los Amigos scale
LEVELS VII AND VIII (HIGH LEVEL)
- Wean from highly structured, controlled environment.
- Prep for reintegration into community
63
Per the Ranchos scale, what are the learning possibilities?
- No carryover of new information through level V.
- Can relearn prior skills at level V.
- Can learn and carry over new info at level VI.
64
What is the scope of deficits for TBI?
- MOTOR DEFICITS
- PERCEPTUAL
- PROPRIOCEPTIVE/KINESTHETIC
- COGNITIVE
- BEHAVIORAL & SOCIAL
65
What will be Physical Therapy management for TBI?
- LEVEL OF COGNITIVE FUNCTIONING (LOCF) DETERMINES ABILITY
- POSITIONING – PREFERRED POS.?
- ORIENTATION
- SENSORY STIMULATION TO ASSESS LEVEL OF AROUSAL
- PATIENT/FAMILY EDUCATION
66
What therapy will happen in In-Patient Rehab?
- WHEELCHAIR POSITIONING
- WHEELCHAIR PROPULSION
- ROM EXERCISES
* SERIAL CASTING OR SPLINTING
- INCREASE AWARENESS OF SELF & ENVIRONMENT
- FUNCTIONAL MOBILITY TRAINING
* INHIBIT ABNORMAL TONE/POSTURES
* TRANSFERS
* GAIT TRAINING
- BALANCE ACTIVITIES
- COORDINATION ACTIVITIES
- STRENGTH & ENDURANCE ACTIVS.
- NORMAL MOTOR SKILLS DEVEL. & DEVELOPMENTAL SEQUENCING
- EQUIPMENT; ASSISTIVE DEVICES
- DISCHARGE PLANNING
67
Things to consider with TBI
- METHODS TO INHIBIT ABNORMAL TONE & POSTURES
- DEVELOPING POSTURAL CONTROL
- SITTING ACTIVITIES
- STANDING ACTIVITIES
- COGNITIVE & BEHAVIORAL CONSIDERATIONS
68
Margaret Rood's 4 Basic Principles
- Sensory input is required for normalization of tone and evocation of desired muscular responses.
- Sensory motor control is developmentally based.
- Movement is purposeful; engagement in activities is required to produce a normal response.
- Repetition of movement is necessary for learning.
69
8 developmental motor patterns
1. Supine withdrawal
2. Segmental rolling
3. Pivot prone (prone extension)
4. Neck co-contraction
5. Supporting self on elbows
6. All fours movement patterns
7. Standing
8. Walking
70
MCA stroke
middle cerebral artery
71
What is the purpose of the Glascow Coma Scale?
to assess a patient's level of arousal and function of the cerebral cortex
72
What does the Glascow Coma Scale evaluate?
- pupillary response
- motor activity
- ability to verbalize
73
On the GCS, what is the pupillary reponse scale?
4 - spontaneous
3 - to speech
2 - to pain
1 - no response
74
On the GCS, what is the motor activity scale?
```
6 - obeys verbal command
5 - localized
4 - withdraws to pain
3 - decorticate posturing
2 - decerebrate posturing
1 - no response
```
75
On the GCS, what is the verbal response scale?
```
5 - oriented
4 - conversation confused
3 - use of inappropriate words
2 - incomprehensible sounds
1 - no response
```
76
How is TBI classified?
Mild
- GCS >= 13, loss of consciousness < 2- minutes, normal CT scan
Moderate
- awake on arrival, dazed confused, complaining of headache and fatigue, GCS 9-12, maybe have permanent physical, cognitive, behavioral deficites
Severe
- GCS 3-8, coma, usually permanent functional and cognitive impairments
77
Demonstrate entry-level competence in the implementation of PNF
extremity patterns and a sampling of other PNF techniques; identify
specific components of PNF extremity diagonals.
PNF
