15. Neuro stroke and TBI

middle cerebral artery location

largest

supplies lateral side of the brain

anterior cerebral artery location

inner/medial

posterior cerebral artery location

posterior

Anterior cerebral artery syndrome S/S

ACA = ABCDE (kid/child)

• Contralateral hemiparesis LE

• Contralateral hemisensory loss LE

• Urinary incontinence

• Problems with imitation, bimanual tasks, apraxia (inability to do known tasks)

• Slowness, delay, motor inaction

• Contralateral grasp reflex, sucking reflex

middle cerebral artery syndrome S/S

• MCA = MPH (Miles Per Hour)

• Contralateral hemiparesis (UE and face)

• Contralateral hemisensory loss (UE and face)

• L MCA = Language speech impairments - brocas wernicke global aphasia

• R MCA = Perceptual disorders - unilateral neglect

• L/R MCA = Contralateral homonymous hemianopsia

MCA lesion to different branches

• superior = brocca

• inferior = wernike

• stem = both

posterior cerebral artery syndrome

MOST VISION PROBLEMS

S/S peripheral territory:

• Contralateral homonymous hemianopsia

• Visual agnosia - PROSOPagnosia (difficulty remembering familiar face)

• Dyslexia WITHOUT agraphia (difficulty writing)

• Color discrimination

• Memory deficits

• Topographical disorientation - gets lost easily

S/S central territory

• Thalamus: central post stroke thalamic pain syndrome

• All sensations become painful because the thalamus is the center for sensation everything passes through here.

Right vs left stroke: Right

Presents like a baby

left hemiparesis/hemisensory loss

visual - perceptual impairments:

- neglect

- difficulty with visual cues

quick and impulsive

rigidity of thought

difficulty with negative emotions

homonymous hemianopsia

Right vs left stroke: left

presents like an old person

right hemiparesis/hemisensory loss

language:

- aphasia

- difficulty with verbal cues

slow cautious

highly distractible

difficulty with positive emotions

homonymous hemianopsia

spasticity vs synergy

spasticity - at rest; increase in tone, passive ROM, velocity dependent

synergy: combined movement pattern, AROM

^^ think about how synergy rhymes with energy and need energy for AROM

upper limb spasticity

scapula: retraction, doward rot

shoulder: adduction, IR, depression

elbow: flexion

forearm: pronation

wrist: flexion, adduction

hand: finger flexion, clenched fist thumb, adduction in palm

THINK OF THE CHICKEN DANCE

Lower limb spasticity

pelvis: retraction (hip hike)

hip: adduction (scissoring), IR, extension

knee: extension

foot and ankle: PF, inversion, equinovarus, toes claw, toes curl

THINK OF A BALLERINA

flexion synergy UE

scapula retraction/elevation or hyperextension

shoulder ABD, ER

elbow flexion

wrist and finger flexion

THINK OF JOHNNY BRAVO

Flexion synergy LE

hip flexion, abduction, ER

knee flexion

ankle DF, inversion

toe DF

extension synergy of UE

scapular protraction

shoulder ADD, IR

elbow extension

forearm pronation

wrist and finger flexion

THINK OF JOHNNY BRAVO

extension synergy LE

hip extension, adduction, IR

knee extension

ankle PF, inversion

toe PF

(similar to spasticity) ballerina position

brunnstrum stages of recovery

• 1 = flaccid

• 2 = start of spasticity; minimal synnergy; involuntary/associated reactions

• 3 = max spasticity/synnergy; voluntary reactions

• 4 = less spasticity/synnergy; start to move outside of limb synnergies

• 5 = less spasticity/synnergy; move outside of all limb synnergies, but uncoordinated

• 6 = no spasticity/synnergy; coordinated outside of limb synnergy

• 7 = normal

brunnstrom stage 1

flaccidity

no active limb movement

brunnstrom stage 2

beginning of minimal voluntary movement

in synergy with associated reactions

increase tone

brunnstrom stage 3

voluntary control of movement synergy (spasticity is peak)

further increase tone to peak level

brunnstrom stage 4

movement outside of synergy

decrease tone

brunnstrom stage 5

increase complex movement, greater independence from limb synergies

brunnstrom stage 6

individual joint movement

coordinated

brunnstrom stage 7

normal function

positioning strategies for patients

• opposite of spasticity presented (since this is PROM/presented at rest)

• ER/abd/extension extremities; protract shoulder, neutral wrist/ankle; extend fingers; abd thumb

TBI ranchos levels 1-3

• 1 = no responsive - coma

• 2 = generalized response

  • non-purposeful whole body

  • vocal

  • inconsistent

• 3 = localized response

  • purposeful, local, specific

  • inconsistently respond to simple commands (close eyes, squeeze hand)

• txt = PROM, positioning, caregiver education, respiratory care

TBI ranchos level 4

• 4 = confused agitated

  • heightened activity

  • does not cooperate, verbalization is incoherent, confabulations (make up stories)

  • no selective attention

  • no memory

• txt =

  • consistent

  • orient the patient

  • calm behavior and do not confront if pt is agitated; just redirect pt

  • closed environment

  • NO yes/no or open ended questions

TBI ranchos level 5-6

• 5 = confused inappropriate

  • 100% respond to simple commands

    • inconsistently to complex commands

  • socialize for short periods

  • still has memory issues

    • innappropriate use of objects so cant learn new task

• 6 = confused appropriate

  • goal directed behavior with external input

  • memory better

  • group sessions

• txt = goal directed; option A or B exercise

  • avoid complex commands and open complex environments

  • same as level 4

TBI ranchos level 7-8

• 7 = automatic appropriate

  • oriented in home/hospital

  • daily routine robot like

  • judgement impaired

  • able to initiate socialization

• 8 = purposeful appropriate

  • impaired judgement in emergency situations only

• txt =

  • focus on skills for work

  • problem solving skills

  • trial living on own

  • adaptation to work