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  1. 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
  2. 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
  3. what is the role of the OT?
    • reach max level of physical and psychosocial function to live independently
    • teach ADLs
    • improve strength in UE
  4. what is the role of the SLP?
    • evals for communication problems
    • work to improve communication skills
  5. what is the role of the psychologist?
    • evaluates intellect, personality
    • evaluates cognition-thinking, perception, memory, emotions
  6. what is the role of the recreational therapist?
    • initiates involvement and participation in therapeutic recreational programs
    • patient becomes more socially involved
  7. what is the role of the respiratory therapist?
    assess breathing status
  8. what is the role of the social worker?
    • patient and family advocate
    • provides educational material concerning discharging
    • assistance in financials
  9. 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
  10. what is the role of the dietitian?
    • determines each patients unique needs
    • monitors nutritional status
    • teaches healthy eating behaviors for later
  11. 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
  12. what does level 7 on FIM mean?
    • complete independence
    • performed safely
  13. what does level 6 mean on FIM?
    • modified independence
    • requires more than 1 of these: AD, more time, or safety issues
  14. 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
  15. what does level 4 mean on FIM?
    • minimal contact assistance
    • patient does 75% of work
  16. what does level 3 mean on FIM?
    • moderate assistance
    • patient is able to do 50% -75% of work
  17. what does level 2 mean on FIM?
    • maximal assistance
    • patient does less than 50% of work
  18. what does level 1 mean on FIM?
    • total assistance
    • patient does less than 25% of work
  19. 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
  20. 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
  21. definition of stroke (CVA)
    disruption of blood supply to an area of the brain resulting in neurologic impairment
  22. risk factors for stroke
    • HTN
    • diabetes
    • hereditary
    • males more susceptible
    • obesity
    • heart disease
    • age
  23. 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
  24. types of strokes: occlusive
    results from thrombosis and emboli formation in cerebral vessels

    most common form
  25. thrombosis (clotting)
    • onset is gradual-periods of improvement
    • occurs in vessels already narrowed
  26. embolism
    • sudden onsent-no warning
    • main source is heart
    • 80% lodge in middle cerebral a.
    • 11% lodge in posterior cerebral artery

    80% recur
  27. lacunar
    • 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)

    cause:uncontrolled HTN
  28. hemorrhagic strokes
    intracerebral bleeds which occur abruptly with few or no symptoms
  29. hypertensive hemorrhage
    • penetrating artery from MCA
    • displaces and compresses surrounding brain tissue
    • edema formation from compressed tissue
    • once bleeding stops normally doesnt rebleed
  30. lobar intercerebral hemorrhage
    • circular clots in subcortical white matter
    • causes: AVM, hemorrhage into tumor, aneurysm of circle of willis
  31. ruptured saccular aneurysm
    most common cause of subarachnoid hemorrhage
  32. ruptured arterio-venous malformation
    • 2nd most common cause of subarachnoid hemorrhage
    • occurs more in males
  33. berry aneurysm
    • developmental defect causing weakness in tunica media
    • outpouching
  34. fusiform aneurysm
    • atherosclerotic hypertensive changes causing weakness of the tunica media
    • occurs mostly in vessels of circle of willis
  35. arterio-venous malformation
    • 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
  36. true or false: site and size of lesion is more critical to production of deficits/clinicals signs than is type of CVA
  37. acute CVA
    increased ICP and cerebral edema
  38. later CVA
    deficits minimal or temporary

    if not permanent damage may occur
  39. where do most lesions affecting speech occur?
    parietooccipital cortex

    left hemisphere
  40. why does shouting work in speech disorder patients?
    shouting= shorter more concise sentences =easier to understand
  41. what is aphasia?
    • communication disorder caused by brain damage
    • impaired language comprehension, formulation and use
    • does include writing
  42. what is fluent aphasia?
    aka Warnicke's/receptive/sensory

    impaired comprehension, naming, reading, writing
  43. what is nonfluent aphasia?
    aka Broca's/expressive/motor

    speech is slow, poorly articulated, hesitant with limited vocab

    good comprehension, reading

    poor writing
  44. what is global aphasia?
    • all aspects of language affected
    • unable to speak, comprehend, write, read
  45. what is dysarthria?
    • impaired speech due to damange to PNS or CNS
    • causes weakness, paralysis, or incoordination of motor-speech system
  46. what is dysphagia?
    • swallowing dysfunction
    • imparied oral muscle activity
  47. behavior associated with L CVA
    negative, anxious, hesitant, and depressed, cautious, insecure, uncertain
  48. behavior associated with R CVA
    impulsive, poor awareness of deficits, poor judgement of own abilities, uncooperative, unmotivated, overly dependent, confused
  49. 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
  50. what is emotional lability?
    • lose emotional control
    • laughing to crying for no reason

    treatment: redirect or distract
  51. 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
  52. what is dementia?
    faulty judgements, poor memory, mood alterations
  53. 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
  54. 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
  55. what are some internal memory aids to help with memory?
    • rehersal
    • elaborating-pt works on details and relate to what they already know
    • visual imagery
    • self-reference-how info relates to them
  56. what are some external memory aids to help with memory?
    • cues: be specific
    • memory notebook
    • alarms/watches
    • labels: color coding

    generalization-once skill remembered practice in multiple settings

    retention span-how many pieces of info remembered
  57. what is attention?
    active process that determines which sensations and experiences are relevant to the individual
  58. what is sustained attention?
    maintain attention to taks
  59. what is selective attention?
    screen and process relevant info while screening out irrelevant info
  60. what is divided attention?
    perform two tasks at same time

    example walking and talking
  61. what is alternating attention?
    go back and forth between two different tasks
  62. treatments for attention issues
    • nondistracting environment
    • structured environment
    • keep it simple
  63. 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
  64. how do mental flexibility and abstracting fit into CVA?
    • experiences and behavior is interpreted by pt at most obvious value
    • linked with memory problems
  65. what is confabulation?
    • stories or words that are used to fill in gaps in memory
    • patient believes they are true
  66. how does depression tie into CVA?
    • due to psychological reaction to loss
    • occurs in 1/3 of all cases
  67. 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
  68. 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
  69. what is agnosia?
    inability to recognize sensory stimuli
  70. what is visual agnosia?
    inability to recognize objects when seen but can recognize when touched
  71. what is tactile agnosia?
    • (asterognosis)
    • parietal lobe
    • inability to recognize objects by touch , but can recognize visually
  72. what is auditory agnosia?
    inability to recognize sounds
  73. 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
  74. 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
  75. 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
  76. 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
  77. 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
  78. what are superficial sensations?
    • light touch
    • sharp/dull
    • temperature
    • pressure
  79. what are deep sensations?
    • movement sense
    • position sense
  80. what is visual neglect?
    inattention to visual stimuli on involved side
  81. what is hyperasthesia?
    increased sensitivity to sensation
  82. what is hypesthesia?
    decreased sensitivity to sensation
  83. what is anesthesia?
    loss of feeling or sensation
  84. what is dyesthesia?
    unpleasant or abnormal sesnation produced by normal stimuli
  85. what is paresthesia?
    abnormal sensation: burning, prickling, formication
  86. what is hyperalgesia?
    excessive sensitivity to pain
  87. what is hypalgesia?
    decreased sensitivity to pain
  88. what is analgesia?
    absence of sense of pain and noxious stim
  89. how is paresis involved in CVA?
    • UE usually more affected than LE
    • distal more than proximal
    • changes in motor unit
    • changes in muscle
  90. how is ROM impacted in CVA?
    • decreased AROM due to decreased strength
    • decreased ROM due to contractures, increased muscle tone
  91. what is hypotonia/flaccidity?
    • lack of resistance to movement
    • present immediately after stroke
  92. what is hypertonia?
    • increased above normal resting levels
    • ROM limited
    • mmt requires effort
    • deformities results
  93. what is dystonia?
    • disordered tone
    • repetitive involuntary movements
    • basal ganglia lesions
  94. what is spasticity?
    • increased resistance to passive stretch
    • in anti-gravity muscles
    • leads to contractures
  95. where is spasticity likely to occur in UE?
    • scapular retractors
    • shoulder adductors
    • internal rotators
    • depressors
    • elbow flexors
    • forearm pronators
    • wrist and finger flexors
  96. where is spasticity likely to occur in LE?
    • pelvic retractors
    • hip adductors
    • internal rotators
    • hip and knee extensors
    • ankle PF
    • ankle supinators
    • toe flexors
  97. 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
  98. 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
  99. 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
  100. 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
  101. 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
  102. 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
  103. what is grade 0 on modified ashworth scale
    no increase in muscle tone
  104. 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
  105. 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
  106. what is grade 2 on modified ashworth scale
    more marked increase in muscle tone throught most of the ROM but affected parts easily moved
  107. what is grade 3 on modified ashworth scale?
    considerable increase in muscle tone; passive movement difficult
  108. what is grade 4 on modified ashworth scale?
    affected part rigid in flexion or extension
  109. 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
  110. 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
  111. 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
  112. 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
  113. what is homolateral limb synkinesis?
    flexion of hemiplegic UE elicits flexion of hemiplegic LE
  114. what is apraxia?
    inability to carry out purposeful movements despite lack of motor, sensory, cognitive or behavioral deficits
  115. 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
  116. what is reactive postural control?
    reacting to destabilizing external force
  117. what is anticipatory postural control?
    self-initiated movements

    • unable to:
    • maintain sitting
    • maintain standing
    • move in WB posture
  118. what is asymmetrical posture?
    most of weight in sitting or standing shifted to nonparetic side
  119. 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
  120. urinary incontinence is due to?
    • bladder hyperreflexia or hyporeflexia
    • sensory loss
    • loss of sphincter control
    • UTI
  121. bowel function impairments because?
    • diarrhea
    • constipation
  122. 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
  123. contractures and CVA
    flexibility of CT is lost

    UE: limitations in shoulder motion, elbow flexors, wrist and finger flexors, pronators

    LE:plantarflexors and hamstrings
  124. 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
  125. 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
  126. 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
  127. what are the functional limitations associated with CVA
    • bed mobility
    • transfers
    • ambulation
    • ADLs and functional tasks
    • w/c mobility and management
    • stair ambulation
    • sit to stand
  128. what is ataxia?
    • loss of muscular coordination
    • associated with cerebellar stroke
  129. what does ataxic gait look like?
    • uneven step length
    • irregular step width
    • even more tremoring with increased effort
  130. treatment for ataxia
    • postural stability
    • slow weight shifts
    • PNF
  131. what is a cerebral aneurysm?
    • weak point in blood vessel in brain
    • artery bulges outward and fills with blood
  132. cause of cerebral aneurysm?
    • trauma
    • infection
    • hardening of arteries
    • congenital (most common)
  133. 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
  134. treatment of cerebral aneurysm
    • prior to rupture :
    • may do nothing depending on location and surgical risks
    • may clip it or remove it
  135. 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

    cause: congential
  136. what is the risk of AVM?
  137. what are symptoms of AVM?
    headache, seizures, dizziness, neuro symptoms

    prior to rupture:worst headache ever
  138. 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
  139. what is the most defining characteristic of a pusher?
    they push toward their hemi side
  140. what is thalamic antasia?
    • -Unable to sit up/ fall to hemiplegic side
    • –Fail to use axial or trunk muscles
    • –do not resist correction
  141. 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
  142. what is listing phenomenon?
    –Lose balance due to hemiparesis and fall to hemi side but:

    • •Recognize
    • loss of balance

    • •do
    • not resist correction

    • •Cling
    • onto something with non-paretic hand to prevent fall
  143. what are vestibular cortex lesions?
    tilt of visual vertical without pushing behavior
  144. what is the cause of pushing?
    • neglect: R sided problem
    • 40-50% of all pushers are L CVA
  145. left or right lesions are to the posterior........?
  146. less frequently affected are .......?
    insula and post central gyrus
  147. what do thalamus, insula and post central gyrus do?
    • process the afferent sensory signals that mediate graviceptive information about upright body
    • orientation in humans
  148. besides the visuo-vestibular system what else is a graviceptive system?
    sensory from skin and tendons
  149. 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
  150. what causes pushing? vestibulo-visual system
    lesions of vestibular cortex DO NOT cause contraversive pushing
  151. 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
  152. what is the prognosis for pushers?
    • there are treatment techniques
    • when it subsides in 1 side it doesnt mean it starts on other side
  153. treating a "pushy" patient
    • visual input that corresponds to
    • reality!
    • Midline orientation/ weight shift =
    • learn movements needed to reach midline
    • –Strength
    • –Balance
    • –Gait
    • –Transfers
    • –Bed Mobility
    • –Endurance
    • -weight shift activities
  154. first step in pusher treatment
    • draw patients attention to problems
    • -use vision
    • -vestibular system-allow them to safely lose balance
  155. second step in pusher treatment
    • encourage them to use correct posture
    • shifting weight
    • use vision to align up
    • reaching to nonparetic side
  156. third step in treatment of pusher
    • internalize newly learned compensation
    • perform other tasks while maintaining posture
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