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What is the role of a physiatrist?
- MD specializes in physical medicine and rehab
- initiates rehab program and coordinates the work of health care team
- orders meds, braces, wheelchairs
what is the role of the PT?
- teaching patients to be independent as possible
- evals, treatments
- bed mobility, transfers, operating ADs
- may teach patients to walk again
what is the role of the OT?
- reach max level of physical and psychosocial function to live independently
- teach ADLs
- improve strength in UE
what is the role of the SLP?
- evals for communication problems
- work to improve communication skills
what is the role of the psychologist?
- evaluates intellect, personality
- evaluates cognition-thinking, perception, memory, emotions
what is the role of the recreational therapist?
- initiates involvement and participation in therapeutic recreational programs
- patient becomes more socially involved
what is the role of the respiratory therapist?
assess breathing status
what is the role of the social worker?
- patient and family advocate
- provides educational material concerning discharging
- assistance in financials
what is the role of the rehab nurse?
- provides 24 hour care
- keeps physicians informed of patients status
- works on self-care, bowels, healthy skin
what is the role of the dietitian?
- determines each patients unique needs
- monitors nutritional status
- teaches healthy eating behaviors for later
what is the role of the case manager?
- provides clinical coordination for all services provided to patient
- acts as liason between patient and family, insurance company and professional team
what does level 7 on FIM mean?
- complete independence
- performed safely
what does level 6 mean on FIM?
- modified independence
- requires more than 1 of these: AD, more time, or safety issues
what does level 5 mean on FIM?
- supervision or setup
- no more help than standby cuing or coaxing
- needs help with supplies-braces, orthotics etc
what does level 4 mean on FIM?
- minimal contact assistance
- patient does 75% of work
what does level 3 mean on FIM?
- moderate assistance
- patient is able to do 50% -75% of work
what does level 2 mean on FIM?
- maximal assistance
- patient does less than 50% of work
what does level 1 mean on FIM?
- total assistance
- patient does less than 25% of work
when you have a right sided brain injury what are common symptoms you see?
- left side paralysis
- spatial-perceptual deficits
- quick impulsive behavior
- memory deficit
when you have a left sided brain injury what are common symptoms you see?
- right side paralysis
- speech language deficits
- slow cautious behavior
- memory deficits
definition of stroke (CVA)
disruption of blood supply to an area of the brain resulting in neurologic impairment
risk factors for stroke
- males more susceptible
- heart disease
warning signs for a stroke
- onset of weakness or numbness in face, arm, leg or side of body
- loss of vision
- loss of speech
- severe headaches
- unexplained dizziness, unsteadiness, or falls
types of strokes: occlusive
results from thrombosis and emboli formation in cerebral vessels
most common form
- onset is gradual-periods of improvement
- occurs in vessels already narrowed
- sudden onsent-no warning
- main source is heart
- 80% lodge in middle cerebral a.
- 11% lodge in posterior cerebral artery
- infarcts in deep regions of brain
- pure motor-contralateral internal capsule
- pure sensory-contralateral thalamus
- ataxic hemiparesis-contralateral internal capsule or basis pontis
- dysarthria and clumsy hand with hemiataxia (contralateral internal capsule or basis pontis)
intracerebral bleeds which occur abruptly with few or no symptoms
- penetrating artery from MCA
- displaces and compresses surrounding brain tissue
- edema formation from compressed tissue
- once bleeding stops normally doesnt rebleed
lobar intercerebral hemorrhage
- circular clots in subcortical white matter
- causes: AVM, hemorrhage into tumor, aneurysm of circle of willis
ruptured saccular aneurysm
most common cause of subarachnoid hemorrhage
ruptured arterio-venous malformation
- 2nd most common cause of subarachnoid hemorrhage
- occurs more in males
- developmental defect causing weakness in tunica media
- atherosclerotic hypertensive changes causing weakness of the tunica media
- occurs mostly in vessels of circle of willis
- developmental defects of cerebral veins and capillaries
- abnormal vessels become engorged and their thin walls are vulnerable to rupture
- bleeding occurs in subarachnoids space
- increased ICP and meningeal irritation
true or false: site and size of lesion is more critical to production of deficits/clinicals signs than is type of CVA
increased ICP and cerebral edema
deficits minimal or temporary
if not permanent damage may occur
where do most lesions affecting speech occur?
why does shouting work in speech disorder patients?
shouting= shorter more concise sentences =easier to understand
what is aphasia?
- communication disorder caused by brain damage
- impaired language comprehension, formulation and use
- does include writing
what is fluent aphasia?
impaired comprehension, naming, reading, writing
what is nonfluent aphasia?
speech is slow, poorly articulated, hesitant with limited vocab
good comprehension, reading
what is global aphasia?
- all aspects of language affected
- unable to speak, comprehend, write, read
what is dysarthria?
- impaired speech due to damange to PNS or CNS
- causes weakness, paralysis, or incoordination of motor-speech system
what is dysphagia?
- swallowing dysfunction
- imparied oral muscle activity
behavior associated with L CVA
negative, anxious, hesitant, and depressed, cautious, insecure, uncertain
behavior associated with R CVA
impulsive, poor awareness of deficits, poor judgement of own abilities, uncooperative, unmotivated, overly dependent, confused
spatial-perceptual tasks: NON PT related
- judge distances, size, shapes
- common in R CVA
- examples: hitting walls in w/c
- confusing inside/outside of clothes
- shave part of face
- treatment: OT/speech, psychology referral
- cues for safety
what is emotional lability?
- lose emotional control
- laughing to crying for no reason
treatment: redirect or distract
what is sensory deprivation?
- emotional responses following decreased sensory input
- visual impairments
- worse at night (sundowning)
treatment: balance between increased sensory stim and not enough
what is dementia?
faulty judgements, poor memory, mood alterations
what is social judgement (quality control)
- change in personality or social behavior
- example: say wrong thing at wrong time
- spend impulsively
treatment: provide more cues, feedback and information
what is memory?
- perception stored at earlier time that can be brought forward
- due to language (L CVA)
- due to spatial-perceptual probs (R CVA)
treatment: consistent routine and environment
what are some internal memory aids to help with memory?
- elaborating-pt works on details and relate to what they already know
- visual imagery
- self-reference-how info relates to them
what are some external memory aids to help with memory?
- cues: be specific
- memory notebook
- labels: color coding
generalization-once skill remembered practice in multiple settings
retention span-how many pieces of info remembered
what is attention?
active process that determines which sensations and experiences are relevant to the individual
what is sustained attention?
maintain attention to taks
what is selective attention?
screen and process relevant info while screening out irrelevant info
what is divided attention?
perform two tasks at same time
example walking and talking
what is alternating attention?
go back and forth between two different tasks
treatments for attention issues
- nondistracting environment
- structured environment
- keep it simple
how do planning and organization fit into CVAs?
determine what may need or want and how to achieve may lackk foresight and attention to achieve after a CVA
treatment: control amount of feedback and structure
how do mental flexibility and abstracting fit into CVA?
- experiences and behavior is interpreted by pt at most obvious value
- linked with memory problems
what is confabulation?
- stories or words that are used to fill in gaps in memory
- patient believes they are true
how does depression tie into CVA?
- due to psychological reaction to loss
- occurs in 1/3 of all cases
how does body scheme tie into CVA?
normally R side
postural model of body including relationship of parts to each other and relationship of body to environment
how does body image tie into CVA?
- mental image of one's body: includes feelings about one's body
- -also may result in person having lack of awareness of one side of body despite intact sensation
what is agnosia?
inability to recognize sensory stimuli
what is visual agnosia?
inability to recognize objects when seen but can recognize when touched
what is tactile agnosia?
- parietal lobe
- inability to recognize objects by touch , but can recognize visually
what is auditory agnosia?
inability to recognize sounds
what is figure-ground discrimination?
when asked to lock right brake on w/c patient cannot find it despite repeated attempts and looking general area
what is visuo-spatial neglect?
when asked to lock left brake on w/c patient initially makes no attempt
when asked to use right hand does not reach midline and does not look left without visual and tactile cues
what is ipsilateral pushing? (pusher syndrome)
- strong lean toward hemi side
- high fall risk
- resist midline
- more common with R CVA
- poor/absent tactile and kinesthetic sense
what is unilateral neglect?
- cannot perceive one side of body
- usually in R CVA
- may be independent of visual deficits
- diminshed sensation of side
- parietal lobe lesion on nondominant side
what are some treatments to unilateral neglect?
- activities to stimulate affected side
- rubs or ranges affected side
- do activities that force patient to look at that side
- bilateral activities
what are superficial sensations?
- light touch
what are deep sensations?
- movement sense
- position sense
what is visual neglect?
inattention to visual stimuli on involved side
what is hyperasthesia?
increased sensitivity to sensation
what is hypesthesia?
decreased sensitivity to sensation
what is anesthesia?
loss of feeling or sensation
what is dyesthesia?
unpleasant or abnormal sesnation produced by normal stimuli
what is paresthesia?
abnormal sensation: burning, prickling, formication
what is hyperalgesia?
excessive sensitivity to pain
what is hypalgesia?
decreased sensitivity to pain
what is analgesia?
absence of sense of pain and noxious stim
how is paresis involved in CVA?
- UE usually more affected than LE
- distal more than proximal
- changes in motor unit
- changes in muscle
how is ROM impacted in CVA?
- decreased AROM due to decreased strength
- decreased ROM due to contractures, increased muscle tone
what is hypotonia/flaccidity?
- lack of resistance to movement
- present immediately after stroke
what is hypertonia?
- increased above normal resting levels
- ROM limited
- mmt requires effort
- deformities results
what is dystonia?
- disordered tone
- repetitive involuntary movements
- basal ganglia lesions
what is spasticity?
- increased resistance to passive stretch
- in anti-gravity muscles
- leads to contractures
where is spasticity likely to occur in UE?
- scapular retractors
- shoulder adductors
- internal rotators
- elbow flexors
- forearm pronators
- wrist and finger flexors
where is spasticity likely to occur in LE?
- pelvic retractors
- hip adductors
- internal rotators
- hip and knee extensors
- ankle PF
- ankle supinators
- toe flexors
what is abnormal synergy?
- limited group of muscles that
- 1. act as unit
- 2.may be activated reflexively or voluntarily
- 3. individual or isolated joint movements are possible
what is flexion synergy of UE?
- retraction/elevation of shoulder
- Abduction of shoulder to 90d
- ER of shoulder
- flexion of elbow to 90d
- full supination of forearm
- wrist/finger flex
- dominant synergy in UE
- elbow flexion strongest component 1st to return
- abd/ER weakest components last to return
what is extension synergy of UE
- protraction and/or depression of shoulder girdle
- adduction of UE in front of body
- IR of shoulder
- full extension of elbow
- full pronation of forearm
- extended wrist with flexed fingers
- weaker UE synergy
- adduction/IR strongest components
typical UE posture
- usually combo of 2 synergies
- strongest components of each appear:
- elbow flexion
- add/IR of shoulder
- pronation of forearm
- may see wrist ext
- usually see wrist flex
flexion synergy of LE
- abd/ER of hip
- flexion of hip
- flexion of knee to 90d
- DF and inversion of ankle
- DF(ext) of toes
- weakest synergy of LE
- hip flexion strongest component
- DF strong but only activated with hip flex
- abd/ER are weak
- knee flex weakest
extension synergy of LE
- add/IR of hip
- ext of hip
- ext of knees
- PF and inversion of ankle
- PF of toes. sometimes ext of great toe
- dominates in LE
- knee ext strongest
- hip add strong
- hip ext weakest
- knee ext brings ankle pf/inversion
what is grade 0 on modified ashworth scale
no increase in muscle tone
what is grade 1 on modified ashworth scale
slight increase in muscle tone manifested by catch and release or by minimal resistance at the end of the ROM when the affected part is moved in flexion or extension
what is grade 1+ on modified ashworth scale?
slight increase in muscle tone, manifested by catch followed by minimal resistance throughout the remainder of the ROM
what is grade 2 on modified ashworth scale
more marked increase in muscle tone throught most of the ROM but affected parts easily moved
what is grade 3 on modified ashworth scale?
considerable increase in muscle tone; passive movement difficult
what is grade 4 on modified ashworth scale?
affected part rigid in flexion or extension
what are the causes of associated reactions?
- reflex stim due to yawn, cough, sneeze, stretch
- involuntary limb mmt to due to voluntary mmt of another extremity
what are the associated reactions of the UE?
Flexion of UNINVOLVED UE evokes flexion of INVOLVED UE
extension of UNINVOLVED Ue evokes extension of INVOLVED UE
what are the associated reactions of the LE?
flexion of UNINVOLVED side evokes EXTENSION of INVOLVED side
extension of UNINVOLVED side evokes FLEXION of INVOLVED side
what is Raimiste's Phenomena?
resistance to ABDUCTION in UNINVOLVED sides elicits ABDUCTION of INVOLVED side
resistance to ADDUCTION in UNINVOLVED side elicits ADDUCTION in INVOLVED side
what is homolateral limb synkinesis?
flexion of hemiplegic UE elicits flexion of hemiplegic LE
what is apraxia?
inability to carry out purposeful movements despite lack of motor, sensory, cognitive or behavioral deficits
treatment for apraxia?
- provide proprioceptive feedback and tactile input
- brief verbal commands
- perform activities in as nearly normal an environment as possible
- have pt visualize task
- provide support
what is reactive postural control?
reacting to destabilizing external force
what is anticipatory postural control?
- unable to:
- maintain sitting
- maintain standing
- move in WB posture
what is asymmetrical posture?
most of weight in sitting or standing shifted to nonparetic side
what are postural synergies disorganized?
proximal muscles activated in advance of distal or proximal muscles to be activated late
- compensate with excessive hip and knee mmts
- usually fall in direction of weakness
urinary incontinence is due to?
- bladder hyperreflexia or hyporeflexia
- sensory loss
- loss of sphincter control
bowel function impairments because?
DVTs and CVA
- increase risk esp in acute stage
- venous stasis from bed rest, paralysis and decreased activity
signs: rapid leg swelling, tight feeling in calf, pain with passive DF
contractures and CVA
flexibility of CT is lost
UE: limitations in shoulder motion, elbow flexors, wrist and finger flexors, pronators
LE:plantarflexors and hamstrings
shoulder subluxationa and CVA in flaccid stage
- proprioceptive impairment
- decreased muscle tone
- muscle paralysis decrease support and action of rotator cuff muscles
- ligaments and capsule become sole support for shoulder
- humerus subluxes
shoulder subluxation and CVA spastic stage
- abnormal tone leads to poor scapular position which leads to subluxation and restricted movement
- poor positioning contributes
- PROM may traumatize the shoulder
- also injured by pulling on arm during transfer
respiratory impairment and CVA
- paralysis of one side of thorax= decreased lung capacity
- clients with hemiplegia use 50% more O2 walking slowly than by subjects without hemiplegia
- increased O2 demand due to atypical mmt patterns
what are the functional limitations associated with CVA
- bed mobility
- ADLs and functional tasks
- w/c mobility and management
- stair ambulation
- sit to stand
what is ataxia?
- loss of muscular coordination
- associated with cerebellar stroke
what does ataxic gait look like?
- uneven step length
- irregular step width
- even more tremoring with increased effort
treatment for ataxia
- postural stability
- slow weight shifts
what is a cerebral aneurysm?
- weak point in blood vessel in brain
- artery bulges outward and fills with blood
cause of cerebral aneurysm?
- hardening of arteries
- congenital (most common)
symptoms of cerebral aneurysm
- enlarged pupil
- drooping eyelid
- pain behind 1 eye
- localized headache (worst of my life)
- gait problems
- visual disturbances
- numbness to face
treatment of cerebral aneurysm
- prior to rupture :
- may do nothing depending on location and surgical risks
- may clip it or remove it
what is an ateriovenous malformation? AVM
- abnormal collection of blood vessels
- lack the tiny capillaries
- blood does not go to tissues but is pumped thru the shunt and back to heart without ever giving nutrients to tissues
what is the risk of AVM?
what are symptoms of AVM?
headache, seizures, dizziness, neuro symptoms
prior to rupture:worst headache ever
what is embolization?
- plugging the blood vessels of AVM
- catheter is guided from femoral artery in the leg up into the area to be treated
what is the most defining characteristic of a pusher?
they push toward their hemi side
what is thalamic antasia?
- -Unable to sit up/ fall to hemiplegic side
- –Fail to use axial or trunk muscles
- –do not resist correction
what is lateropulsion?
tendency to fall sideways
–Cerebellar and Brain Stem lesions: (Wallenberg’s Syndrome)
–Tilt of visual vertical = vision aligns improperly with environment
–Deviate ipsilaterally = toward brain lesion
–do not resist correction or push with nonparetic side
what is listing phenomenon?
–Lose balance due to hemiparesis and fall to hemi side but:
- loss of balance
- onto something with non-paretic hand to prevent fall
what are vestibular cortex lesions?
tilt of visual vertical without pushing behavior
what is the cause of pushing?
- neglect: R sided problem
- 40-50% of all pushers are L CVA
left or right lesions are to the posterior........?
less frequently affected are .......?
insula and post central gyrus
what do thalamus, insula and post central gyrus do?
- process the afferent sensory signals that mediate graviceptive information about upright body
- orientation in humans
besides the visuo-vestibular system what else is a graviceptive system?
sensory from skin and tendons
what are Truncal graviceptors in humans?
•Afferents from kidneys via renal nerve
- •Posterior Thalamus, Insula, and postcentral gyrus may represent structures which
- provide afferent info from truncal sensors
Stim Vagus nerve = activates these structures
what causes pushing? vestibulo-visual system
lesions of vestibular cortex DO NOT cause contraversive pushing
what are associated postural changes in pushers?
Head rotated and laterally flexed to right
-Left shoulder, thorax and pelvis retracted
-Left lower extremity laterally rotated
-Abduct and extend limbs on non-paretic side when at rest or when changing positions
-Can visually identify objects that are vertically aligned
what is the prognosis for pushers?
- there are treatment techniques
- when it subsides in 1 side it doesnt mean it starts on other side
treating a "pushy" patient
- visual input that corresponds to
- Midline orientation/ weight shift =
- learn movements needed to reach midline
- –Bed Mobility
- -weight shift activities
first step in pusher treatment
- draw patients attention to problems
- -use vision
- -vestibular system-allow them to safely lose balance
second step in pusher treatment
- encourage them to use correct posture
- shifting weight
- use vision to align up
- reaching to nonparetic side
third step in treatment of pusher
- internalize newly learned compensation
- perform other tasks while maintaining posture