PTE 753: exam 2

neuro-developmental treatment, cerebrovascular accident, and cerebral palsy

what is neuro-developmental treatement (NDT)?

a holistic and interdisciplinary clinical practice model that emphasizes individualized therapeutic handling based on movement analysis for individuals with neurological pathologies

how does a therapist develop an NDT for a patient?

by continuously observing movement of the patient to make an assessment: typical or atypical?

• information gathering

• examination

• evaluation

• intervention

what are the factors of NDT that emphasize the characteristics of normal movement?

1. based on normal tone

2. flexible postural control which supports normal movement

3. ability to shift weight with elongation on weight-bearing side

4. emphasizes transitional patterns not static holding

in what position should a therapist place a patient with high tone so that he can learn and move functionally?

in whichever position the patient experiences reduced tone

what is the key factor for an NDT approach to therapy?

postural control

what does “emphasize transitional patterns” mean within an NDT approach?

always analyze the patient while he is moving in and out of positions to get a solid understanding of his movements

T or F: NDT is a stand alone treatment since it focuses on a patient’s movement patterns.

F; always add functional activities and/or sensory training too

what are the five principles of intervention for an NDT approach?

1. tone and movement patterns can be influenced by handling, positioning, and sensory information

2. active movement is required

3. repetition with variability is required

4. evaluation and intervention are continuous

5. work at all levels of the adult or child’s capabilities

why is variability in treatments important?

bc it stimulates life

T or F: NDT evaluations and interventions are always continuous.

T

list some techniques used in an NDT approach to reduce arousal and tone.

• perform low intensity, slow rhythm, repetitions of stimuli

• apply firm pressure

• stimulate antagonist

• apply/use warmth

list some techniques used in an NDT approach to increase arousal and tone.

• perform brisk, irregular, and high intensity stimuli

• perform in upright positions

why do upright positions increase arousal and tone in a patient?

must control more degrees of freedom → more awake/alert → more aware of tone and postural control

how does one normalize tone in an NDT approach?

• weight bear in appropriate alignment

• elongation and rotation of trunk

• active movement

what are the key points of control when facilitating an NDT approach?

wherever the therapist places her hands to stimulate/control the ideal functional movement pattern

what’s the difference between proximal and distal points of control?

proximal points: provide more sensory input and allows for less trial and error; place hands at head, shoulders, trunk, and hips

distal points: provide less sensory input and allows for more trial and error making carry-over higher; place hands at extremities

T or F: an NDT approach should be responsive to the child’s or adult’s ability and mood.

T

an NDT approach places emphasis on ____ of movement by facilitating appropriate movement patterns as needed.

quality

the “as needed” appropriate movement patterns used in an NDT approach should never be _____ because the patient is moving towards her functional independence.

compensatory

T or F: equipment, bracing, and surgery do not replace intervention for an NDT approach.

T

when aiming for whole body alignment during NDT, what should a therapist focus on?

focus on deficits from top to bottom and in all three planes of motion (sagittal, frontal, and transverse)

what is a cerebral vascular accident (CVA)?

a medical emergency where blood flow to the brain is interrupted, either by a blockage or a rupture in a blood vessel, leading to cell damage and potential long-term disability or even death

what are the two classifications of a CVA?

1. pathologic type: ischemic (thrombosis/ embolism) or hemorrhagic

2. temporal factors: complete, stroke-in-evolution, transient ischemic attack (TIA)

T or F: a cerebral infarction or ischemic stroke (thrombosis/embolism) is the most common form of stroke.

T

what’s the difference between an ischemic and a hemorrhagic stroke?

ischemic: caused by blockage

hemorrhagic: caused by vessel rupture

what are the four types of ischemic strokes?

1. embolism: clot from body (usually the heart or lungs) travels to the brain

2. thrombotic: blockage from plaque buildup in large cerebral vessels

3. lacunar: blockage from plaque buildup in small cerebral vessels

4. transient ischemic attacks: temporary blockage resulting in a “mini” stoke

what are the two types of hemorrhagic strokes?

1. intracerebral: bleeding within brain tissue

2. subarachnoid: bleeding into subarachnoid space from surface vessels

list some examples of the most common risk factors for a CVA.

• hypertension

• diabetes mellitus

• heart disease

if a patient presented with these risk factors, what could a therapist do to care for this patient?

check vitals; educate and manage PMH/comorbidities; advise for diet and exercise

what are some characteristics and behaviors that increase blood pressure?

• high serum cholesterol levels

• obesity

• diabetes mellitus

• heavy alcohol consumption/ elicit drug use/ smoking

why has healthcare seen a drop in mortality rates from stroke in recent decades?

a rise in education and use of hypertensive drugs and more screening and treatment referral centers

where does a thrombotic infarction usually occur?

where plaques form around junctions of branching arteries

• these plaques form locally! (do not travel to brain)

where does a embolic infarction usually occur?

where an embolus from the heart, internal carotid artery, or carotid sinus occludes in the brain

• usually in branches of the MCA

why does an embolic infarction most commonly occur in the middle cerebral artery (MCA)?

bc it’s branches are a secondary direct continuation of the internal carotid artery making it a straight path for an embolus to travel through

why does healthcare see such a variability in stroke symptoms and outcomes?

• strokes affect different brain regions depending on which blood vessel is involved

• the brain’s blood supply has individual differences in vascular anatomy

50% of cardioembolic strokes are caused by ___ ____ due to the irregularity of blood flow.

atrial fibrillation

why is surgery to remove a cardiac blood clot risky for a patient on blood thinners?

bc the patient will have to stop taking the blood thinner medication for the surgery which increases the risk of a cardioembolic stroke occurring

what are the four locations for brain hemorrhages?

1. epidural hematomas

2. subdural hematomas

3. subarachnoid hemorrhages

4. intracerebral hemorrhages

why are subarachnoid hemorrhages the most deadly location for a hemorrhagic stroke to occur?

bc its everywhere and specifically within the ventricles-→ backs up CSF causing elevated pressure in and around the brain

would a hemorrhagic stroke cause focal or global deficits?

both! depends on the artery and amount of blood in affected area

what’s the difference between focal and global deficits?

focal: specific, localized damage leading to problems in a distinct area or function.

global: diffuse, widespread damage impacting multiple brain regions, leading to more general and widespread impairments. 

what is a saccular aneurysm?

a type of aneurysm characterized by a sac-like bulge on the side of a blood vessel

• usually found at branchings of major cerebral arteries-especially in the anterior circulation

what is the anterior circulation supplying blood to the brain?

carotid artery system:

• internal carotid artery

• anterior cerebral artery

• anterior communicating artery

• middler cerebral artery

• posterior communicating artery

what is the posterior circulation supplying blood to the brain?

vertebral-basilar system:

• vertebral arteries

• basilar artery

• anterior inferior cerebellar artery

• superior cerebellar artery

• posterior cerebral artery

• posterior inferior cerebellar artery

what is an arteriovenous malformation (AVM)?

an abnormal tangle of blood vessels connecting arteries and veins, bypassing the capillaries

• the developmentally weak vessels of an AVM are prone to rupture

an ______ _______ is the most common cause of CVA in a young person (10-35 years of age).

arteriovenous malformation (AVM)

which vessel is mostly commonly affected in strokes?

middle cerebral artery (MCA)

an acute inpatient therapist has a new patient s/p ACA CVA 2 days ago. what symptoms should the therapist prepare for?

• motor deficits- specifically LE on affected side

• lack of initiation and decision making

• urinary incontinence

• contralateral neglect!!

an acute inpatient therapist has a new patient s/p MCA CVA 2 days ago. what symptoms should the therapist prepare for?

• slurred speech

• tingling or numbness in face, arm, or leg on affected side

• loss of movement on affected side

an acute inpatient therapist has a new patient s/p PCA CVA 2 days ago. what symptoms should the therapist prepare for?

• visual field deficits

• possible sensory loss

• memory and emotional disturbances

PICA and AICA strokes are rare due their anastomoses, but what symptoms will arise if a patient does have an occlusion within these arteries?

coordination issues, vertigo, and cranial nerve symptoms

an occlusion of the _____ artery results in a pure sensory stroke. why?

thalamic-proliferating

• this branch from the PCA supplies the thalamus where sensory pathways synapse before traveling to the somatosensory cortex

an occlusion of the _____ artery results in a pure motor stroke. why?

lenticulostriate

• this branch of the MCA supplies the internal capsule where the motor pathways travel

T or F: a stroke within the MCA superior division will cause the greatest amount of paralysis due to the homunculus layout.

F; a stroke within the internal capsule’s division

during an acute thrombosis and TIAs, the goal is to improve cerebral circulation as quickly as possible to prevent ischemic tissue from becoming infarcted tissue. which drug helps with this?

TNKase tenectepase

• strong breaker of clots (reduces or eliminated clots) but may still have deficits following dosage

_____ _____ are used to prevent TIAs and may stop a stroke-in-evoultion.

anticoagulant drugs

what type of stroke are individuals with sickle cell anemia likely to experience and why?

ischemic

• abnormal red blood cell shape gets hung up at branch points, leading to clots

describe an ischemic core and a penumbra

ischemic core: where most decrease in blood flow within tissue occurs; may be dead tissue and show no improvement

penumbra: area around ischemic core where potential for recovery is possible; area for neuroplasticity

T or F: aphasia and dysarthria are the same.

F; aphasia is difficulty understanding and processing speech and dysarthria is difficulty speaking due to motor issues

an injury within the ___ lobe may lead to Broca’s aphasia and an injury at the ____ ____ intersection may lead to Wernicke’s aphasia.

1. frontal

2. parietal-temporal lobes

Broca’s aphasia (expressive)

a language disorder that primarily affects the ability to produce fluent speech, characterized by difficulty forming complete sentences and finding the right words

• usually aware of their communication struggles and comprehension of language is intact

Wernicke’s aphasia (receptive)

a language disorder characterized by difficulty understanding spoken and written language, despite that ability to produce fluent speech

• speech often lacks meaning and may include random words; may not realize their speech is incomprehensible

as a physical therapist treating stroke patients, why is it important to emphasize combining movement with speech?

dual-tasking with speech and movement can seem “natural”, making recovery come easier to the patient

the prefrontal cortex allows us to be visually attentive to the contralateral visual field. what treatment strategies could a therapist use to help a patient visually scan to the affected side?

enhance sensory stimulus to that side (physical, auditory, visual) and allow patient to learn via making errors and problem-solving

• use things that patient loves to keep activity engagement up

pusher syndrome

a condition following a stroke or TBI where the patient pushes away from the non-paretic side towards the paretic side, leading to a tilted posture and a loss of balance

a stroke or TBI to what specific area would result in pusher syndrome?

damage to the ventroposterolateral thalamus (VPL); believed to be responsible for gravioception (perception of one’s body relative to gravity)

T or F: a patient with pusher syndrome usually has an intact perception of upright but he cannot feel that his body is tilted.

T; (perception of) visual vertical is always preserved

why wouldn’t physically helping a patient move into a more vertically aligned position be helpful?

the patient will fight back, making it (balance and alignment) worse

• rehab stays are generally ~2-3 times longer because of this

a lot of patients lean toward a weak side in the early stages of recovery. how does a therapist know if a patient has pusher syndrome?

bc the patient fights against/pushes back if the therapist tries to passively move them

pusher syndrome is a frontal plane deficit so a therapist will want to work on balance with _____ into the frontal plane.

perturbations

describe the gait deficits seen in a patient with pusher syndrome following a right medullary infarct.

longer stride length with L foot and shorter stride length with R foot

what is the biomechanical effect on posture by carrying a weight on the side to which the patient pushes?

forces the patient to correct and counter the weight by leaning/shifting center of mass to other side

what is one of the best treatment options for a patient with pusher syndrome?

mirror therapy! never use parallel bars

on which side would a therapist guard someone with pusher syndrome?

Dr. Shaw’s answer: on weak side to act as protection

boards’ answer: on strong side to act as a target

why is it important to include divided attention (dual-tasks) to a stroke patient’s recovery process?

most of our movements and the control of our posture occur without much thought. when the pathways that control autonomic movement are damaged, then intact cortical pathways try to compensate, leading to inefficient methods. we want to correct that as best as possible.

list an example of a motor-motor and a motor-cognitive divided attention (dual-task) activity.

motor-motor: walking while holding a cup of water

motor-cognitive: walking while reading street signs aloud

what is learned non-use?

a phenomenon where individuals, often after a neurological injury, suppress the use of a limb even though they have the capacity to use it

list some examples of effective strategies to prevent learned non-use.

• ask the patient to “help” you

• transfer to/from using both sides

• use affected side during activities

what is constraint-induced movement therapy (CIMT)?

focuses on increasing use of the paretic limb post-stroke by restricting the non-paretic limb

patient must have an intact ____ ____ to use and see the benefits of FES and NEMS.

reflex arc

per this class, what is the difference between FES and NMES?

FES: passive and active motions; activate muscle during context of use (best for gait training)

NMES: passive and active motions; solo contraction of an isolated muscle

how is FES like a “neuroprosthesis”?

assists in muscle stimulation to achieve a desired response like when using an AFO

is FES considered a compensatory or recovery intervention?

sike its both again!; it depends on the patient’s preference and his/her ability to recover/improve

• for FES to be considered recovery, it needs to show benefits and improvement in a specific and desired task

while the ultimate end-goal is _____ movement that is coordinated and not synergy bound, often after a stroke the first purposeful movement that can be elicited is _____ movement.

1. voluntary

2. facilitated

describe Ramistes.

the movements of hip abduction and adduction are neurologically coupled, such that greater effort in one extremity will “overflow” to the other

• “yoked” together → cue at same time to get a synergistic response

T or F: when treating hemiparesis and neglect syndrome, always start with the safety issues related to neglect.

T

describe a good cue given to a stroke patient when working on sit to stands.

“lean over your bad side to shift, bringing your nose over your toes, and weight bear on bad side to stand” → works on head hip relationship and avoids learned non-use of paretic side

what are two key components when working with patients suffering from hemiparesis and neglect syndrome?

1. want to enhance all senses on neglect side- visual, auditory, physical/self, touch

2. give little feedback to allow patient to respond to environment

what are the ten principles of neuroplasticity to treatments?

1. use it or lose it

2. use it and improve it

3. specificity

4. repetition matters

5. intensity matters

6. time matters

7. salience matters

8. age matters

9. transference

10. interference

what is cerebral palsy (CP)?

a group of permanent disorders of the development of movement and posture, causing activity limitations that are attributed to non-progressive disturbances that occurred in the developing fetal or infant brain

what are the top three associated disabilities of CP?

1. language disability

2. visual disability

3. cognitive delays; seizure disorders

what are the two ways to define CP?

1. types of signs and symptoms present

2. limb involvement

what are the types of CP that are categorized by their signs and symptoms?

• spastic: stiff muscles and exaggerated reflexes

• dyskinesia

  • athetoid: involuntary, fluctuating muscle movements, often described as slow, writhing, or twisting

  • dystonia: sudden, uncontrollable movements

• ataxia: problems with balance and coordination

• mixed

what are the types of CP that are categorized by their limb involvement?

• hemiplegia: one side of the body

• diplegia: lower extremities more than upper extremities

• quadriplegia: all limbs

what are the five levels/classifications of CP (12-18 yrs old)?

1. youth walk at home, school, outdoors, and in the community

2. youth walk in most settings but environmental factors and personal choice influence mobility choices

3. youth are capable of walking using a hand-held mobility device

4. youth use wheeled mobility in most settings

5. youth are transported in a manual wheelchair in all; self mobility is severely limited

list the body function impairments associated with CP.

• muscle tone and extensibility

• strength

• skeletal structure

• selective and postural control

• motor learning

• pain

why do patients with CP develop arthritic pain earlier in life?

they experience limited movement through the full range resulting in decreased diffusion of nutrition to the joint cartilage

muscle tone

a muscle’s typical resting tension

extensibility

resistance of muscle to passive movement or muscle lengthening (stretching)

T or F: persistence of hypotonicity changes the muscle fibers leading to extensibility (stiffer).

F; hypertonicity