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1

The dutch guideline stroke uses three conceptual frameworks in clinical reasoning with a stroke patient.
Name those three and explain why they are important

First the ICF: The physical therapy process aims to optimize the patient’s condition in terms of impairments of body functions, limitations of activities, and restrictions of participation, while also addressing the context of the patient’s health problem. the ICF can help physical therapists in structuring and
presenting the stroke patient’s functional performance from a wider perspective.
Second time course: Recovery after a stroke is not linear, but follows a curve, with most of the recovery taking place during the first days to months. This line can help you to estimate if the patient is on track or deviating from this line of time and then you can ask why.
Physical therapeutical process: The methodical approach to physical therapy consists of eight
steps which can give you guidance in your performance.

2

What are the main important facts in the definition of stroke by the WHO.

rapidly developing signs (FAST), Focal disturbance in the brain, more than 24 houres

3

Describe the 4 characters of the acronym FAST. Elaborate on the reason why knowing this in the general population is important.

FAST is an acronym used as a mnemonic to help detect and enhance responsiveness to the needs of a person having a stroke. The acronym stands for Facial drooping, Arm weakness, Speech difficulties and Time to call emergency services.

4

Describe the natural course of a stroke in 4 phases.

Hyperacute phase 24 houres, early rehabilitation phase 3 months, late rehabilitation phase 6 months and the chronic phase after 6 months.

5

Name the eight steps of the physical therapeutic process with a stroke patient. Explain also why this is important to know.

Diagnostic process: 1 Presentation, defining the patients problem, screening and informing the patient. 2 History taking 3 Physical therapy examination 4 establishing a physiotherapy diagnosis and indication.
Therapeutic process: 5 Treatment plan 6 implementation of the treatment plan.
Evaluation and monitoring: 7 Evaluation 8 Conclusion
Knowing this process is important for your performance. By taking these steps you are working in a methodical way and by knowing what is in it it can help you to formulate criteria for the process. For example after the diagnostic process I am able to define the patients main problem (THE WHAT)

6

Describe the domains of functional disorders and explain why they are important.

There are three domains of functional disorders. Somatosensoric, Neuropsylogical (cognitive) and psychological (socio emotional). With those domains you are dividing the functions in domains and that gives a structure. But it is also important to decide which professionals are needed to treat this patient.

7

Explain the old and new paradigm in treating patients with a stroke.

In the past, a static central nervous system was assumed. Now one starts from a plastic central nervous system. The nervous system adapts by learning, by motor learning. Principles such as symmetry and tone normalization (principles from NDT) have therefore been abandoned and functional training that has task specificity has been replaced. The intensity of training is also important and variation in training is also important to allow the plastic brain to adapt, to learn.

8

Name the advantage of a stroke unit in a hospital. Ex.plain what the reason could be of these advantages

Systematic literature reviews have shown that patients benefit from very rapid admission to a hospital stroke unit, which specializes in the treatment of patients with a stroke. Treatment at a hospital stroke unit considerably reduces the risk of death and of ADLdependence compared to treatment at non-specialized treatment
centers.
There are indications that it is the combination of the quality of coordinated interdisciplinary collaboration (also known as multidisciplinary collaboration) and the practice of establishing shared functional goals for treatment (goal setting) which determines
the outcome in terms of ADL-independence and the mortality risk among patients admitted to a stroke unit. they are following.

9

What is the legal status of this an other guideline.

It is the best evidence for this moment and is the consensus of the physiotherapist. You can deviate from the guideline because the guideline is about an average patient. But you are obliged to do this with sound arguments and you have to explain this in your patientjournal.

10

Explain why thinking in fundamental movement skills is to restricted in (stroke) patients.

The problem in a stroke patient is caused by brain damage. The impairment is in the brains and not directly in the leg or arm (this can develop but is not the main cause) So in are therapy we have to influence the brain. The brain is the main focus of our therapy. Think about motor learning and the motor learning principles.

11

50% of the patients will be discharged from the hospital to the home. What are important treatment goals for those patients.

The patient can do his personal care.
The patient can do as much as possible of his ADL as formulated in the helpquestion (or helpquestion of the partner f. ex) related to his prognosis.
The patient is involved in a movement program to prevent a second CVA
The patients general health is monitored by the pt to inform the gp
The progress of the patient is monitored by measurement instruments.

12

What is transdisciplinairy care. What is the advantage of it and what is the disadvantage.

It is care in which the borders between professions are vanishing so every professional can do a part of the job of an other. Advantage every professional takes in account the whole health situation of the patient and not only his or hers part. Disadvantage is the danger that professionals are passing their knowledge border.

13

Intensity of training is a parameter. What is an important characteristic of the training of a stroke patient and what is the effect of it.

Intensity has to be high. High intensity training is related to more rapid recovery of selective movements, comfortable walking speed, walking distance and so on.

14

Explain the concept of training specificity of a CVA pt.

It is important to train ADL task in a specific manner in the context that resembles the situation in which the task has to be performed.

15

"Lost brain tissue won't come back." Why is this statement true or not true?

Comment: neurogenic neuron formation (neurogenesis) has recently been demonstrated. The statement is not particularly positive; even if the lesion persists, the brain has other strategies to cope with the effects of a local lesion: to some extent, lost brain tissue does not have to come back to achieve functional recovery.

16

Statement: "No further recovery is to be expected after six months." Is this right or wrong and why?

Numerous examples show the opposite. Research with forced use shows that the mobility and muscle strength of a paralyzed arm can also increase considerably years after the stroke.
There are aphasia patients who start talking again after two years, there are patients with outbursts of anger that they get under control in the long run.

17

Statement: "Rehabilitation in a stroke patient can be seen as a learning process with the sensormotory circle as the basis for learning an action/acitivity"
Explain why this statement is important to remember for the treatment of a stroke patient.

A CVA can cause failure of a brain area, activities in the extremities can become limited. The cause of this limitation lies mainly in the brain. The brain has a plasticity whereby either brain cells around the leasie take over the function or other areas in the brain take over the function and this is done by (senso) motor learning. By offering learning stimuli (performing the activity may be with some help or facilitation), the patient simulates learning not only by making the movement but also by the reafference that the movement causes.

18

Describe why torso muscles are affected less than muscles distal to the extremities.

In most stroke patients there is no significant failure of the trunk muscles. This is because these fundamental muscle groups are bilaterally innervated. This is essential, given that these muscle groups main function is as a good 'suspension system' for the organs and also have a supporting function for breathing.

19

There are different domains in the deficits in functions with a stroke patient. Explain why one is called the somatosensory domain and explain why it is so important for the therapy in stroke patients.

The term 'sensor-motor' is a combination of sensory and motor. Sensory motor disorders lead to reduced motor functioning. And visa versa. "One thing is clear: plastic changes occur when information flows through the nervous system: there are stimuli and there is action ." Van Cranenburgh, 2019, §.3.1)

20

Explain what spasticity is.

Spasticity
Central tone disregulation (CTD) is characteristic of a Stroke. Spasticity is an expression of tonus disregulation that we often see as a result of a stroke. Spasticity occurs when an increased resistance is felt with passive movement in combination with an increased myotatic reflex activity (Lance 1980).
Spasticity is negatively influenced by fatigue, pain, speed and stress. Under the influence of these stressors, spasticity will be more prominent and will adversely affect functioning.

21

Describe the Ashworth scale for spasticity. he Ashworth scale is a test in which the tone is manually examined passively

The test uses a 5-point scale:
1.
not increased tone;

2.
slightly raised tone: a catch followed by minimal resistance for the rest of the range of motion (ROM);

3.
moderately increased tone: a clear resistance during the ROM;

4.
sharp increase in tone: strong resistance and passive movement are difficult;

5.
rigidity: passive redress is virtually impossible

22

Describe the test of Tardieu for spasticity.

The Tardieu measures the stretch speed in relation to the muscular response (also called catch). This determines the dynamic component of the muscle length. R1 is the catch that is felt when moving fast and R2 is the catch that is felt when moving slowly. This clinimetric finding is clinically relevant because the speed-dependent effect is included in the test. Spasticity is known to have a negative influence on the degree of spasticity.

23

Name the spastic pattern in the shoulder, elbow, wrist and hand (so the whole upper extremity)

upper extremity:
1.
shoulder: retraction, endorotation and depression;

2.
elbow: flexion and pronation;

3.
wrist: palm flexion and ulnar deviation;

4.
fingers: flexion;

5.
thumb: adduction and flexion

24

Name the spastic pattern of the lower extremity

Lower extremity:
1.
hip: retraction, endorotation and elevation;

2.
knee: extension and endorotation;

3.
single: plantar flexion and inversion;

4.
toes: claws or flexion

25

Sometimes term like spasticity and hypertonia are used as synomyms. Basicly that is wrong. So explain the difference between hyperonia and spasticity.

Hypertonia is an increased basic tension in some or the total musculature, without there being an increased resistance with passive movement (think about the spasticy test Ashworth and Tardieu) and an increased myotatic reflex activity (for example an increase in the tone in the trapezius descendens in the case of work stress). In practice, hypertonia and spasticity are sometimes considered synonymous, but this is not correct.

26

Describe what rigidity is (Seen a lot with Parkinsons disease)

Rigidity is a form of central tone dysregulation that manifests itself through an increased tone in both the agonist and the antagonist. This expression of tone disregulation is often the case with subcortical lesions. The basic nuclei also lie in the subcortical structures. That is why the Parkinson's patient speaks of rigidity.

27

Research often uses the dependent and the independent variable. Explain the difference

In research, people often have a hypothesis that they want to confirm. For example, therapy A has a certain effect on the outcome. For example, strength training with a certain dosage has an effect on strength. In this case, one wants to demonstrate a causal effect between strength training and the degree of strength. The degree of strength here depends on the strength training that has been determined in advance. In short, the strength training is the independent variable and the strength as an outcome is the dependent variable.

28

Jane has to write a case report about a patient. Her PIO question is: what is the effect of exercise therapy in the form of stability training on the stability of the knee measured with the Y balance test in a patient with patellafemoral pain complaints. Explain what the dependent and what the independent variable is.

Exercise therapy in the form of stability training is the independent variable because this training has an effect on the dependent variable namely the knee stability measured with the Y balance test. In short, the result on the Y balance test depends on this training. (if the underlying theory is correct that this exercise therapy influences stability (because that is Jane's hypothesis))

29

Jane is doing another research. Jane compares the Bobath method and the eclectic method in the treatment of stroke on the degree of ADL independence measured with the Barthel index. Her PICO question is. What is the effect of exercise therapy according to the Bobath method compared to the eclectic exercise therapy method in stroke patients with left hemiplegia on ADL activity after 6 months measured with the Barthel index.
Explain what the independent and what the dependent variables are.

In this case Jane looks at the effect of the Bobath method on ADL activity (measured with the Barhel index) so the Bobath method has an effect on the outcome ADL. This makes the Bobath method the independent variable and the outcome depends on this method, so is the dependent variable.
This also applies to the eclectic method, so it must have a causal effect on ADL. The eclectic method is the independent variable with an effect on the dependent variable the ADL activity measured with the Barthel index.

30

In the case report, Jane measures the stability with the Y balance test and that is in centimeters. Explain what level of the dependent variable is expressed (nominal, ordinal etc)

This is a ratio scale, because the interval 1 and 2 cm is equal to the difference between 21 and 22 cm and 2 is exactly twice as much as 1, which means that 0 is also 0. (at temperature you can't say that 40 degrees is twice as hot as 20 degrees)