Neurologic PT Evolution & Clinical Reasoning Framework in Stroke Rehabilitation

What has been the primary shift in Neurologic PT over the last 60 years?

From reflex-based, therapist-driven techniques to motor-learning, neuroplasticity-driven, and participation-focused care.

What is the Clinical Reasoning Framework (CRF)?

A cyclical decision-making process used to guide neuromuscular patients from intake to outcomes.

What model connects diagnosis to real-world impact in Neurologic PT?

The International Classification of Functioning, Disability and Health (ICF).

What are the 4 P's of the IV STEP in Neurologic PT?

Prediction, Prevention, Participation, Plasticity.

List the 8 steps of the Clinical Reasoning Framework in order.

Intake → Hypothesis → Physical Exam → Evaluation → Diagnosis → Prognosis → Intervention → Outcomes.

What are the components of the ICF model?

Body Function/Structures, Activity, Participation, Personal & Environmental contextual factors.

What does 'Use it or lose it' mean in the context of neuroplasticity?

Failure to drive specific brain functions can lead to functional degradation.

What does 'Repetition matters' signify in neuroplasticity principles?

Induction of plasticity requires sufficient repetition.

What is the significance of 'Intensity matters' in neuroplasticity?

Induction of plasticity requires sufficient training intensity.

What does 'Time matters' refer to in neuroplasticity?

Different forms of plasticity occur at different times during training.

What is the meaning of 'Salience matters' in neuroplasticity?

The training experience must be sufficiently salient to induce plasticity.

How does age affect training-induced plasticity?

Training-induced plasticity occurs more readily in younger brains.

What does 'Transference' mean in the context of neuroplasticity?

Plasticity in response to one training experience can enhance acquisition of similar behaviors.

What is the meaning of 'Interference' in neuroplasticity?

Plasticity in response to one experience can interfere with acquisition of another.

What is the first step in the Clinical Reasoning Framework?

Intake: Gathering patient history, patient-identified problems, and symptom identification.

What happens during the 'Hypothesis' step of the CRF?

Generate a hypothesis about which body system(s) are driving the problem.

What is evaluated during the 'Physical Exam' step of the CRF?

Hands-on tests and measures across various categories to confirm or refute the hypothesis.

What does the 'Evaluation' step entail in the CRF?

Clinical judgment synthesizing exam findings to determine what the objective data means for the patient.

What is the purpose of the 'Diagnosis' step in the CRF?

To frame a movement-system diagnosis through the ICF model.

What is the goal of the 'Prognosis' step in the CRF?

To predict the level of improvement and expected timeframe for recovery.

What does the 'Intervention' step involve in the CRF?

Treatment combining impairment-level and activity-level components tied to long-term and short-term goals.

What is the final step in the Clinical Reasoning Framework?

Outcomes: Re-measurement against baseline, which feeds back into the next cycle's intake.

What are the 10 categories tested in the Physical Exam?

Movement Analysis, Mental, Cranial Nerves, Autonomic, Motor, Somatosensory, Coordination, Reflex, Posture, Gait & Mobility.

What is the significance of the 2020s in the evolution of Neurologic PT?

Focus on de-implementation of low-value care and integrating high-value practices like intensity and assistive technology.

What are the key features of the '4 D's' in brainstem stroke?

Dysphagia, Dysarthria, Diplopia, Dysmetria

What is the primary function of the ACA?

Supplies blood to the frontal lobe, affecting contralateral LE weakness and sensory loss.

What deficits are associated with an MCA stroke?

Contralateral arm and face weakness, sensory loss, and homonymous hemianopsia.

What is the definition of a TIA?

Transient ischemic attack — a temporary neuro deficit from brief interruption of blood flow that resolves without permanent infarction.

What are the distinguishing features of Ischemic stroke?

Blockage of blood flow due to thrombus or embolus, leading to an infarcted core and surrounding ischemic penumbra.

What is the primary difference between hemorrhagic and ischemic strokes?

Hemorrhagic stroke involves bleeding into or around brain tissue from a ruptured vessel, while ischemic stroke is due to blockage.

What does the F.A.S.T. acronym stand for in stroke assessment?

Facial weakness, Arm weakness, Speech difficulty, Time to call 911.

What is the time window for administering tPA in acute ischemic stroke?

Within 3 to 4.5 hours of symptom onset.

What are the BP targets for tPA candidates?

Keep BP

What is the role of the ischemic penumbra?

It is the surrounding tissue that is salvageable and receives just enough oxygen to survive temporarily.

What are common risk factors for stroke?

Non-modifiable: Age, Gender, Genetics/Ethnicity; Modifiable: Blood pressure, Cardiac disease, Diabetes, Smoking.

What are the symptoms of cerebellar stroke?

Symptoms are always ipsilateral to the lesion, including ataxia and potentially brainstem signs.

What is the main symptom of a stroke affecting the Superior Cerebellar Artery (SCA)?

Pure unilateral ataxia.

What distinguishes Broca's aphasia from Wernicke's aphasia?

Broca's aphasia is nonfluent with comprehension spared; Wernicke's is fluent but meaningless with impaired comprehension.

What is the primary role of a Speech-Language Pathologist (SLP) in stroke management?

To address dysphagia and communication impairments.

What are the key features of dysarthria?

Muscle weakness leading to decreased strength, rate, and range of motion of speech muscles.

What is the purpose of the bedside exam in dysphagia assessment?

To evaluate swallowing function and identify potential risks.

What is the significance of the CT scan in acute stroke management?

CT is the current imaging standard, done within 30 minutes of ED arrival to assess for hemorrhage.

What are the common nursing management strategies for stroke patients?

Prevent dehydration, malnutrition, and aspiration; screen for DVT, seizures, and cardiac complications.

What are the symptoms of a stroke affecting the Posterior Cerebral Artery (PCA)?

Contralateral homonymous hemianopsia and potentially alexia without agraphia.

What is the role of assistive technology in stroke rehabilitation?

To enhance recovery and support patient participation in activities of daily living.

What is the impact of stroke on participation and activity levels?

Stroke can severely limit participation in daily activities and affect the ability to engage in work and play.

What are the implications of having a supportive family for stroke recovery?

A supportive family can enhance recovery through emotional support and assistance with rehabilitation activities.

What is the typical recovery pathway for stroke patients post-acute care?

Discharge to inpatient rehab, skilled nursing facility, or home with ongoing therapy.

What characterizes Broca's aphasia?

Labored, slow speech with spared comprehension.

What are common errors in Broca's aphasia?

Paraphasic errors, lack of grammar, mainly uses nouns.

What is Wernicke's aphasia characterized by?

Fluent but meaningless speech with impaired comprehension.

What type of errors are common in Wernicke's aphasia?

Neologisms and circumlocution.

What is the primary difference between dysarthria and apraxia of speech?

Dysarthria involves muscle weakness; apraxia involves difficulty with purposeful planning of speech movement.

What are the main features of dysarthria?

Reduced strength, rate, and range of motion of speech muscles.

What is a common assessment method for dysphagia?

Videofluoroscopic swallow study (VFSS).

What interventions can be used for dysphagia?

Exercises and EMG biofeedback.

What is astereognosis?

Inability to recognize object form through somatosensation.

What is the role of the left parietal lobe in sensory processing?

It is involved in interpreting and attaching meaning to sensory input.

What deficits are associated with right parietal lesions?

Neglect and attentional disturbances.

What is Pusher Syndrome?

A condition where the patient actively resists correction to midline due to a lesion in the posterior lateral thalamus.

What interventions are effective for neglect syndrome?

Prism adaptation, patching, and mirror therapy.

What are the three types of apraxia?

Sequencing errors, conceptual errors, and spatial-temporal errors.

What is the significance of extinction testing?

It reveals neglect, where a patient identifies one side but ignores one side when touched bilaterally.

What is the expected incidence of apraxia in left-hemisphere stroke patients?

25-46%.

What does the Barthel Index measure?

Activities of daily living (ADL) performance.

What is the purpose of auditory cues in neglect intervention?

To sustain attention.

What is the role of proprioceptive input in neglect treatment?

To help the patient orient their body and improve awareness of the neglected side.

What does the Contraversive Pushing Scale measure?

The severity of tilt and pushing behavior in patients with Pusher Syndrome.

What is the prognosis for patients with Pusher Syndrome?

Similar long-term outcomes to non-pusher patients, but takes about 3.6 weeks longer in rehab.

What are common movement patterns for bed mobility in hemiplegic patients?

Upper-extremity, head-trunk, and lower-extremity sequencing patterns.

What is a common patient-identified problem during bed mobility intake?

Difficulty rolling or scooting in bed.

What is the impact of hemiplegia on rolling mechanics?

It disrupts normal sequencing due to weakness and abnormal tone.

What is the significance of environmental adaptations in communication interventions?

They help facilitate better communication in patients with speech impairments.

What is the preferred pattern for rolling left in bed?

RUE lifts/reaches across body above shoulder; shoulder girdle leads with head turning left and trunk flexing/rotating left.

What is a common patient report when trying to roll in bed?

"I get stuck when trying to roll" or "My legs are heavy."

What is a common deviation in head movement during abnormal rolling in hemiplegia?

Head is laterally flexed toward the hemiplegic side and rotated toward the less-involved side.

What is a typical arm presentation in a hypertonic hemiplegic arm?

Held in flexion synergy with difficulty combining shoulder flexion and elbow extension.

What is the primary movement mechanics for scooting up in bed?

Start in hooklying with bilateral weight-bearing, arms push, and legs extend to move the body up.

What is a common impairment observed when coming to sit from lying down?

LEs lag behind due to weakness in hip abductors and hip flexors.

What is the difference between anticipatory postural adjustments (APA) and reactive postural adjustments (RPA)?

APA is feedforward and prepares for movement, while RPA is feedback and reacts to perturbations.

What are the three orientation components required for normal sitting?

Body segments, support surface, and vertical orientation.

What is Pusher Syndrome in hemiplegic patients?

Active pushing away from the unimpaired side with increased weight-bearing toward the impaired side.

What is a common trunk presentation in hemiplegia during rolling?

Laterally flexed on the hemiplegic side with shoulder and pelvic girdles retracted.

What is a typical leg presentation in a hypotonic hemiplegic leg?

Floppy or heavy with abnormal hip abduction and external rotation.

What are the therapeutic considerations for patients with mental impairments during bed mobility?

Use demonstration, write instructions, and speak slowly and clearly.

What is the role of cranial nerves in bed mobility?

Patients may not attend to the environment and look toward one side.

What is the significance of trunk control in bed mobility?

Trunk control is crucial for effective movement and transitions between positions.

What are standardized outcome measures for assessing bed mobility?

Trunk Control Test and GMFM (Gross Motor Function Measure).

What is the impact of poor trunk/UE/LE sequencing on coming to sit?

It may lead to difficulty lifting the trunk or using the upper extremities for assistance.

What is the mechanism for shifting the pelvis into full weight-bearing?

Requires proper trunk, upper extremity, and lower extremity sequencing.

What are common abnormal static sitting postures in hemiplegia?

Spinal flexion with posterior pelvic tilt and weight shifted to either side.

What is the purpose of using cues and slowed pacing in therapy?

To compensate for systems that cannot reliably interpret instructions or their own position.

What is the role of proximal stabilization in therapy for hemiplegic patients?

It steadies the base from which a dysmetric limb moves, allowing for coordinated movement.

What does the term 'abnormal bridging' refer to in the context of scooting?

Difficulty flexing hip/knee to weight-bear the foot, leading to ineffective movement.

What are the three mechanisms that maintain orientation to vertical in sitting?

Optical righting, head righting, and equilibrium reactions.

What is the clinical presentation of motor impairments in bed mobility?

Inability to move against gravity and difficulty isolating joint movement.

What is the significance of the Trunk Impairment Scale (TIS)?

It is used to assess trunk control and balance in patients with hemiplegia.

What are common mental impairments in movement-system interventions?

Difficulty following directions; head down, not attending to the environment.

What therapeutic considerations are used for mental impairments?

Demonstration, writing, and speaking slowly/clearly.

What cranial nerve presentation might indicate a movement-system impairment?

Not attending to the environment; looking to one side.