Test #1 Rehab - Stroke & TBI

Ch 15 & 19

ischemic cascades

1. Blood flow stops: Lack of blood supply leads to cell damage.

2. Excess neurotransmitters: More neurotransmitters are released, which overstimulate brain cells.

3. Energy failure: Brain cells can't make energy (ATP) properly, disrupting function.

4. Calcium buildup: Calcium floods into cells, damaging them and breaking down membranes.

5. Free radicals form: Excess calcium causes chemical reactions that produce harmful free radicals.

6. More damage: Free radicals and chemicals like nitric oxide worsen cell damage and inflammation.

ischemic stroke

loss of blood flow to the brain

hemorrhagic stroke

bleeding in the brain

embolic stroke S&S

• sudden

• lacks S&S

• occurs anytime

• possible seizure

• neuro deficits can resolve

thrombotic stroke S&S

• TIAs

• warning S&S

• during sleep

risk factors for stroke

• atherosclerosis

• ethnicity: black, Mex, native american, alaskan

• 65 +

• recurrence

warning signs for stroke

BE FAST

• Balance - loss

• Eyes - vision impairment

• Face - uneven smile; droopy

• Arm - weakness, numbness, can’t lift

• Speech - slurred

• Time - hurryyyyyyyyy

ACA (Anterior Cerebral Artery) S&S

• contralateral hemiparesis → LE more than UE

• sensory loss → LE more than UE

• apraxia

• difficulty with bimanual tasks + imitation

PCA (Posterior Cerebral Artery) Stroke S&S

• thalamic pain

• homonymous hemianopsia

• memory deficits

• hemiplegia

MCA (Middle Cerebral Artery) S&S

• spatic hemiparesis

• sensory loss → face + UE more than LE

• homonymous hemianopsia: one sided vision

• aphasia

• spatial disorganization

homonymous hemianopsia:

visual field defect where there is loss of vision in the same side of both eyes, typically due to damage in the brain's visual pathways (often from stroke, brain injury, or tumors)

ICA (Internal Carotid Artery) S&S

• usually produces both major MCA + ACA effects

• uncal herniation

• coma

• death

• crucial for supplying blood

vertebrobasilar S&S

• facial paralysis

• deafness, tinnitus

• ataxia

medial medullary S&S

• ipsilateral half tongue paralysis

• contralateral paralysis → UE + LE

• impaired tactile + proprioception

Wallenburg’s (lateral medullary) S&S

• ipsilateral decreased pain + temperature sensation in face

• vertigo + nystagmus

• nausea/vomiting

Horner’s S&S

• miosis: pupil constriction

• ptosis: dropping eyelid

• decreased swelling

Locked in S&S

• complete paralysis

• upward gaze still intact

• normal cognition

Pusher’s S&S

• push themselves toward the side of their weakness and resist attempts to correct their posture

• impaired proprioception

• slouched posture

Which side of the hemisphere is affected:

• Visual-perceptual impairments

• quick, impulsive, poor judgement

• emotional deficits

• difficulty understanding the idea of tasks

• L side motor + sensory loss

R hemisphere affected

Which side of the hemisphere is affected:

• Broca’s (broken speech) + Wernicke’s (understanding) aphasia

• slow, cautious, easily distracted

• difficulty initiating tasks

• depressed

• R side motor + sensory loss

L hemisphere affected

acute phase for strokes

• monitor vital signs

• early mobilization, ROM

• ADL training

• splinting

• positioning

• sensory training: stroking, tapping, quick stretch, pressure

• tone reduction

ataxia

wide BOS, irregular movements

UE Flexion - synergy patterns

• elbow flexion

• scapular retraction + elevation

• shoulder abduction + ER

• forearm supination

• wrist + finger flexion

UE Extension - synergy pattern

• elbow extension

• scapular protraction

• shoulder adduction + IR

• forearm pronation

• wrist + finger flexion

LE Flexion - synergy pattern

• hip flexion + abduction + ER

• knee flexion

• ankle dorsiflexion + inversion

• toe extension

LE extension - synergy pattern

• hip extension + adduction + IR

• knee extension

• ankle plantar flexion + inversion

• toe flexion

TBI

an alteration in brain function caused by an external force

mild TBI (time)

• concussion

• loss of consciousness = 0 - 30 min

moderate TBI (time)

loss of consciousness = 30 min - 24 hrs

severe TBI (time)

24 hrs +

Glasgow Coma Scale - Activities:

Eye opening

1 - 4

Glasgow Coma Scale - Activities:

Best motor response

1 - 6

Glasgow Coma Scale - Activities:

verbal response

1 - 5

Glasgow Coma Scale - Interpretation:

Mild

12 - 15

Glasgow Coma Scale - Interpretation:

Moderate

9 - 11

Glasgow Coma Scale - Interpretation:

Severe

3 - 8

Glasgow Coma Scale → the higher the number…

the better the patient is

Mild (concussion) - clinical presentations

• dizziness

• headaches

• light sensitivity

• difficulty with memory or concentration

moderate - clinical presentations

• impaired balance

• cognitive deficits

• some motor control issues

severe TBI - clinical presentations

• significant motor impairments

• cognitive dysfunction

• altered consciousness

motor impairments with TBI

• paresis

• abnormal tone

• decreased postural control

• deceberate + decorticate posturing responses

cognitive impairments with TBIs

• arousal level

• memory

• concentration

• learning

• executive functions

• communication deficits (world-retrieval, inappropriate responses)

behavioral impairments with TBIs

• agitated, aggressive, irritable

• emotional lability

• mental inflexibility

• impulsive

declarative memory

ability to recall facts + previous events → explicit learning

procedural memory

• how to do a motor task → implicit learning

• long-term memory that involves the recall of motor skills and actions

acute interventions for TBI

• early mobilization

• preventing secondary impairments → positioning, casting

• sensory stimulation

• family education

post acute interventions for TBIs

• motor relearning strategies

• restorative + compensatory strategies

• constraint - induced therapy (forced use)

• dual - task performance

restorative strategies

get use back in affected limb

task oriented approach

• method that focuses on practicing functional tasks to improve movement and recovery

• locomotor training with body weight support

dual task approach

• performing two tasks simultaneously, typically combining a motor and a cognitive task

• training specific, walking on various terrains, walking while performing cognitive tasks, ambulate and scan for vehicles in parking lot

Rancho Los Amigos LOCF

descriptive scale in 3 categories of cognitive + behavioral recovery → treatment planning

Rancho Los Amigos LOCF:

1

no response

• Patient appears to be in deep sleep and completely unresponsive to stimuli

Rancho Los Amigos LOCF:

2

generalized response

• Reacts inconsistently/nonpurposefully to stimuli

• Limited responses and often the same no matter the stimulus

• May be gross body movements and/or vocalization

Rancho Los Amigos LOCF:

3

localized response

• Reacts specifically to stimuli, but inconsistently

• Responses directly related to stimulus presented

• May follow simple commands

Rancho Los Amigos LOCF:

4

confused-agitated

• Heightened state of activity

• Bizarre/nonpurposeful behavior

• Incoherent/inappropriate verbalizations

• Confabulation

• Gross attention is brief

• Lacks recall

Rancho Los Amigos LOCF:

5

confused-inappropriate

• Responds to simple commands consistently

• Highly distractible

• May converse on social automatic level for short periods

• Inappropriate/confabulatory verbalization

• Severely impaired memory

Rancho Los Amigos LOCF:

6

confused - appropriate

• Goal-directed behavior requiring external input/direction

• Follows simple commands consistently with carryover

• Incorrect responses due to memory

• More depth/detail for past memories

Rancho Los Amigos LOCF:

7

automatic - appropriate

• Appropriate/oriented

• Does automatic daily routine but robot-like

• Minimal to no confusion

• Shallow recall of activities

Rancho Los Amigos LOCF:

8

purposeful - appropriate

• Recall and integrate past and recent events

• Shows carryover and no supervision required

• Some decreased ability compared to PLOF

Acronym for Rancho Los Amigos LOCF

"No Green Lions Can Act Correctly And Purposefully"

Total Glasgow Coma Scale (GCS) Score =

E + V + M

GCS: Eye opening (E)

• 4: Spontaneous (eyes open on their own)

• 3: To speech (eyes open in response to voice)

• 2: To pain (eyes open in response to painful stimuli)

• 1: None (no eye opening)

GCS: Verbal response

• 5: Oriented (responds coherently and appropriately)

• 4: Confused (responds but disoriented)

• 3: Inappropriate words (random words or phrases)

• 2: Incomprehensible sounds (moaning, groaning)

• 1: None (no verbal response)

GCS: motor response

• 6: Obeys commands (follows simple commands)

• 5: Localizes pain (purposeful movement toward painful stimuli)

• 4: Withdraws from pain (pulls away from painful stimuli)

• 3: Abnormal flexion (decorticate posturing)

• 2: Abnormal extension (decerebrate posturing)

• 1: None (no motor response)

green

• Deceberate

• separate hands to side

• midbrain lesion

purple

• Decorticate

• diencephalon lesion

• “to the core”