Neuro 2

a CVA/TIA affecting the motor cortex would cause what symptoms

weakness

a CVA/TIA affecting brocas/wernickes area would cause what symptoms

brocas - speech production

wernickes - language comprehension (interpretation of speech)

a CVA/TIA affecting the occipital lobe would cause what symptoms

visual deficits

a CVA/TIA affecting the cerebellum would cause what symptoms

ataxia/dizziness

describe how a stroke occurs

vascular occlusion or bleed in the brain causes rapidly developing focal ± global signs of cerebral dysfunction

Compare onset and timing of stroke vs TIA

Both stroke and TIA are sudden unexpected onset however, stroke symptoms are >24hrs or cause death whereas, TIA symptoms typically last <10mins but are always <24hrs

Most common stroke impairment

Limited ability to undertake physical activities

Identify the 3 most common function losses following a stroke

Motor impairment (70-99%), Sensory impairment (66%), Visual inattention (58%)

Most common MOTOR impairment that limits function in stroke patients

weakness

What are the FAST signs of stroke

Face drooped?

Arms cant be raised?

Speech slurred or confused?

Time is critical, call 000!

Thrombolysis

IV medication to dissolve an ischaemic clot

Endovascular thromboectomy

Mechanical clot retrieval via catheter

A pt has had a thrombolysis, what is the physio relevance in regard to influencing management

Follow post-thrombolysis protocols, monitor BP/neurological change, mobilise only after clearance

A pt has had a endovascular thrombectomy, what is the physio relevance in regard to influencing management

Check groin site, monitor haemodynamics, mobilisation guided by medical protocol

General guidelines for physiotherapy following TPA <12hrs post thrombolysis

Respiratory assessment only - gentle respiratory therapy if required, NO suctioning, NO positive pressure

NO mobilisation

General guidelines for physiotherapy following TPA >12hrs post thrombolysis

Medical clearance required for mobility, consult with medical team to ensure understanding of procedure and outcomes (esp complications), mobilise with caution taking extra precautions to minimise risk of any injury, alert medical team to any bleeding during/following treatment

whta factors should be considered when planning an acute functional assessment

-is the pt medically stable

-is pt alert/cooperative

-does pt have pain

-physical capability to move

-what medical adverse event is pt most at risk of

-is pt at risk of injury

-pt risk factors for falling

-what is goal of assessment

-what level of assistance are you planning to provide

-are there any supportive/protective/safety devices required

minimum requirements for standing in acute stroke management

-medically stable and cleared for mobility

-cooperative with some comprehension

-pain managed

-DVT screen NAD

-strength grade >/= 3 in hip F/E, knee E, ankle PF/DF in at least one LL

-attachments managed

-clinical protocols adhered to

identify an acute measurement tool for coordination

finger nose test

identify an acute measurement tool for tone and spasticity (seperate tools)

Tardieu spasticity

Modified ashworth scale for muscle tone

identify an acute measurement tool for coordination

Ritchie Articular Index (RAI) joint tenderness with PROM of hemiplegic shoulder

What is identified as the strongest predictor of functional outcome following a stroke

Initial stroke severity on admission

Based on the AVERT trial, when should most stroke patients ideally commence out-of-bed mobilization

Between 24 and 48 hours

Which impairment is considered the most significant contributor to reduced physical function post-stroke?

Weakness

List the "4Ds" typically associated with a Vertebrobasilar system stroke.

Diplopia, dysphagia, dysarthria, dizziness

What specific muscle groups should be targeted when using E-stim to prevent or reduce shoulder subluxation

supraspinatus + posterior deltoid

Identify some clinical indicators that suggest poor functional outcomes for a stroke patient

Worse stroke severity on admission

Prior stroke

Older age

High degree of motor loss

Prolonged unconsciousness

Urinary incontinence > 1/52

Cognitive deficits, sensory inattention, neglect

What is the minimum total scheduled daily therapy time (PT and OT combined) recommended for rehabilitation

3 hours total scheduled therapy, with at least 2 hours of active task practice.

List 2 complications associated with bleeding into the subarachnoid space (often from ruptured aneurysm)

Blood mixing with CSF leading to rapid rise in ICP

Blood irritates the meninges causing headache, photophobia and weakness

Define the "Ischaemic Penumbra" and explain its significance in acute medical management

Ischaemic Penumbra is the salvageable brain area surrounding the ischaemic core (tissue destined to die). Restoring blood flow to this area is the goal of rapid medical intervention.

Explain the rehabilitation recommendations for Progressive Resistance Training (PRT) for stroke patients. Include the recommended repetitions, sets, and how it should be combined with other therapy types

Progressive resistance training should be provided for reduced strength. Target 8-12 repetitions maximum (RM) for at least 2 sets. Because it is unclear if PRT alone improves activity, it must be combined with repetitive task practice.

A stroke patient in the sub-acute phase of recovery exhibits a flaccid upper limb with a palpable gap at the glenohumeral joint. They are beginning to experience dull, aching shoulder pain.
-What complication is this patient likely developing?

-Propose a management plan

Use firm support when sitting and a sling during walking

Use E-stim for 30-60 mins/day targeting supraspinatus/posterior deltoid.

Provide education on manual handling to protect the joint.

Cardiorespiratory fitness targets for stroke patients

The recommendation is to aim for 3–5 days per week, for 20–60 minutes per session, at a perceived exertion (RPE) of 11–14

What is the amount of STS repetitions required for effective motor learning

more than 60 reps per day

What must we include in rehabilitation of stroke patients who have difficulty sitting and how can we ensure functional integration, list ways to progress as well

Practice msut include sitting and reaching beyond arms length with supervision/assistance

To ensure functional integration we can make it specific such as reach for cup and take sip etc, key for driving motor learning

Progress trunk control via pertubation and reducing BOS

Vary distance and direction

What must we include in rehabilitation of stroke patients who have difficulty standing and how can we ensure functional integration

Challenge standing balance by weight shifting or reaching as well as incorporating functional training such as stepping, squats or obstacles

When should spasticity be addressed in stroke patients

Not a main driver or activity limitation so only address when it impacts function

Stroke patient contracture prevention/management

Active motor training combined with estim (get them to do what they can while estim working)

Stroke patient has swelling of extremities, what is the recommended management, as well as who is most at risk of swelling

Passive mobilsiation (PROM) and elevation of limb whilst resting

Immobile patients with limbs in gravity dependent positions are at most risk

When does rehabilitation of TBI patient commence

As soon as medically stable

Describe TBI

Single event physical injury to the brain from an external mechanical force that results in permanent or temoporary impairment of cognitive, physical and psychosocial functions with diminished or altered state of consciousness

Contrast primary, secondary and associated injuries in regard to TBI’s

The primary injury refers to damage done at time of impact and is caused by mechanical forces (acceleration/deceleration/rotation) whereas, secondary injury occurs after initial impact and refers to the physiological and biomolecular aftermath of the primary injury (e.g. elevated icp.

Associated injuries are peripheral injuries that occur during the same incident that caused the TBI (e.g. chest, spine etc)

Identify key features associated with secondary injury TBI

Occurs after inital impact

Disrupted autoregulation

Compression

Reduced blood flow

Elevated ICP hypotension

Hypoxia

Identify common somatic complaints in TBI

Headaches, dizziness, pain, sleep disturbances

How is severity outcome of TBI predicted

Using GCS and PTA

Identify how DEPTH is measured on GCS for predicting TBI severity

Depth is scored in the first 24hrs:

Mild = 13-15

Moderate = 9-12

Severe = 3-8

Identify how DURATION is measured on GCS for predicting TBI severity

Duration is scored based on how long GCS is greater than or equal to 8:

Mild = <15mins

Moderate = 15mins to 6hrs

Severe = 6-48hrs

Very severe = >48hrs

Identify how duration is measured on PTA for predicting TBI severity

Duration of posttraumatic amnesia:

Very mild = <5mins

Mild = 5-60mins

Moderate = <24hrs

Severe = 1-6days

Very severe = 7-28days

Extremely severe = >28days

Definition and features of coma

Coma = </=8GCS

Not obeying commands, uttering words, or opening eyes

What are the 2 best predictors of functional outcome in those who have suffered a TBI

Duration of coma (GCS <8) and length of PTA

Define PTA

Post traumatic amnesia is period from accident until person is oriented to surroundings

Describe ‘vegetable state’ includign features

Wakeful, reduced responsiveness, intermittent periods of wakefulness

Post traumatic confusion or clouding of consciousness in those who have suffered a TBI is often a sign of improvement, identify what features we would see in these individuals

awake most of time, confused, easily distracted, faulty memory, slow consistent responses to stimuli, functional communication emerges in this state

Identify some autonomic changes that occur in someone who has suffered a TBI

HR and RR variability

Temerature and BP changes

Excessive sweating

Dialted pupils

Vomiting

Anxiety, panic disorder, PTSD

Identify some sensory and perceptual changes that occur in someone who has suffered a TBI

Hypersensitivity to light or noise

Loss of hearing or sight

Visual field changes

Numbness and tingling (peripheral nerve injury)

Loss of somatosaensory functions

Dizziness or vertigo

Agnosia

Apraxia

Identify some motor changes that occur in someone who has suffered a TBI

paralysis/paresis - monoplegia/hemiplegia

cranial nerve injury - facial paralysis, dysarthria, dysphagia

poor coordination of movement

abnormal reflexes and muscle tone

loss of selective motor control

poor balance

loss of bowel/bladder control

Identify how a TBI patient may present differently to a CVA patient

Higher prevalence of behavioural, cognitive and perceptual impairments

Disorders of consciousness influence early rehab

More communication issues, agitation, low arousal

Greater likelihood of diffuse injury than focal deficits

Fatigue, headaches, sleep disturbances and sensory hypersensitivity more common

What must be included in patient interview when assessing a TBI patient

Description of TBI event and time period following\

Perception of perceived functional ability

Associated injuries

Falls screen

What must be included in physical assessment for a TBI patient

Associated/concurrant injuries and pain

Posture and balance

Voluntary movement - active, muscle strength, coordination

Involuntary movement (through observation)

Flexibility, tone, spasticity, reflexes

Sensation and visual deficits

Vestibular function

Functional tasks analysis including balance and gait

Cognitive and perceptual deficits e.g. dyspraxia, inattention, neglect

Why do we try to advocate for outpatient or community based rehab for those who have suffered a TBI (applies to any impairment really)

Enables the patient to practice and learn activities in the environment in which they will be applied

Identify common interventions for muscle paresis as the problem

Strength training targetted toward key muscle groups responsible for improved function to optimsie translation to functional gain

Common interventions for movement disorders

Task specific practice (structured practice, mvoement specificity, feedback)

Identify common strategies to optimise physiotherapy outcomes

Practice whole functional tasks

Set concrete goals

Demonstrate the exercises and tasks

High reps

Short frequent sessions

Remove distractions

Reward appropriate behaviour

Simple orders, clear tasks

Whilst testing visual acuity, visual fields and eye mvoements (CN3, 4, 6) you have identified new visual deficits in a patient who has suffered a TBI, what is your next plan of action

Refer for comprehensive assessment by relevant health professional

What occurs in tetraplegia and what deficits would we see

C1-T1 injury - reduction or loss of motor/sensory function in arms, trunk, legs and pelvic organs

What occurs in paraplegia and what deficits would we see

Below T1 injury - reduction or loss of motor/sensory function in trunk, legs and pelvic organs

contrast complete and incomplete SCI

complete has no motor or sensory function below the level of injury whereas incomplete will have some function preserved below the injury

Describe anterior cord syndrome as an incomplete spinal injury

Damage toward front of spinal cord via flexion/dislocation/protrusion

Loss/impairment ability to sense pain, temeprature and touch below level of injury

Motor impairment

Describe central cord syndrome as an incomplete spinal injury

Damage in centre of cervical spinal cord, common moi is hyperextension

Loss of function in the arms

Function MAY be preserved in legs and bladder/bowel

Describe brown-sequard syndrome as an incomplete spinal injury

Damage is on one side of spinal cord

Impairment or loss of movement and proprioception on injured side

Impairment of pain, temperature and touch sensation on opposite side

Describe conus medullary syndrome as an incomplete spinal injury

Trauma that affects the spinal cord in the sacral area and lumbar nerve roots

Bladder bowel significantly impaired

Minimal lower extremity impairment

Sensory impairment are symmetrical in saddle area

A person suffers an SCI that is accompanied by respiratory impairments, whta complications could these respiratory impairments cause

Ability of breath compromised from partial paralysis of diaphragm, intercostals and/or abdominals

Difficulty coughing and sneezing means icnreased risk of chest infection

Respiratory failure, pneumonia and pulmonary embolus

Increased risk of atelactasis

spinal cord injuries at what level can cause autonomic dysreflexia

Lesions at or above T6

Autonomic dysreflexia (AD) signs/symptoms

Hypertension, headache, bradycardia, flushed appearance, unusual sweating, shivering, nasal congestion, goosebumps, nausea

Common causes of autonomic dysreflexia

UTI, blocked urine catheter, pressure ulcers, constipation, infection

Management of autonomic dysreflexia

Move pt into upright sitting

Check BP every 5 mins

Loosen tight clothing

Search for cause

Seek medical attention

Autonomic Dysreflexia

-at what level lesion can AD begin to present

-signs/symptoms

-common causes

-management

Lesions at or above T6

symptoms - HTN, headache, bradycardia, flushed appearance, unusual sweating, shivering, nasal congestion, goosebumps, nausea

causes - UTI, pressure ulcers, blocked urine catheter, constipation, infection

management - move pt into upright sitting, check BP every 5 mins, loosen tight clothing, check for cause, seek medical attention

SCI lesion at C1-C3, identify key muscles still functioning, mobility use, and ADL independence

SCM, trapezius, some/no diaphragm

Powerchair for mobility

Fully dependent, ventilator dependent, needs 2A

SCI lesion at C4, identify key muscles still functioning, mobility use, and ADL independence

Full diaphragm function, small shoulder control

Powerchair for mobility

Dependent for all ADL’s

SCI lesion at C5, identify key muscles still functioning, mobility use, and ADL independence

Biceps and deltoids now wokring

Powerchair for mobility, hand control so can drive but no transfer

Independent eating, shaving and grooming with adaptive devices

SCI lesion at C6, identify key muscles still functioning, mobility use, and ADL independence

Wrist extensors, rotator cuff, tendonesis grip

Manual WC possible, often power WC, can drive with modifications

Modified independence in accessible environment

DO NOT STRETCH FINGER FLEXORS

SCI lesion at C7-C8, identify key muscles still functioning, mobility use, and ADL independence

Triceps, finger flexors and extensors

Manual WC, independent transfers

All self care tasks independently

SCI lesion at T1, identify key muscles still functioning, mobility use, and ADL independence

Full UL innervation, trunk paralysis remains

Manual WC, independent transfers

All self care tasks independent

SCI lesion at T2-T12, identify key muscles still functioning, mobility use, and ADL independence

Intercostals (T6+), abdominals (T12), trunk stability

Manual WC, bilateral AFO’s + cane for short distances

Fully independent, some modified ambulation possible

SCI lesion at L2-S5, identify key muscles still functioning, mobility use, and ADL independence

Hip flexors, knee extensors, dorsiflexors, plantarflexors

Community ambulation possible with aids

Fully independent in any environment, rapid recovery

Treatment objectives for those with SCI in acute phase

Manage cardiorespiratory conditions/complications, achieve independent respiratory status if possible

Early mobilsiation, orientation to vertical

Prevent neurological deterioration and facilitate neurological recovery

Prevent and manage secondary complications

Maintain and strengthen all innervated muscle groups

Facilitate functional patterns of activity

When would surgery be indicated in an SCI

If there is displacement or loss of stability in spinal column

Conservative management of SCI in acute phase

4-6 weeks of bracing when mobilised

recumbence (laying down) due to absence of vasomotor reflexes

passive ROM, active exercises for unaffected muscles

cervical injury - traction, assisted cough, arms elevate to prevent edema

before mobilising use tilt table whilst monitoring BP, vital signs, and neurological function every 10 degrees until 80 deg

mobilisation after 4-6 weeks

aim is to protect spinal cord until restoration of biomechanical stability

What should we do before mobilising a pt with an SCI who hasnt orientated to vertical yet

Tilt table whilst monitoring BP, vital signs, and neurological function every 10 degrees until 80 deg

Conservative management of SCI in restoration/subacute phase

Usually in spinal cord injury unit

Interventions following ICF framwork - prevent impairments, activity limitation and participation restrictions

Improve independence in ADL’s

Achieve and maintain community reintegration

Conservative management of SCI in long term/chronic phase

Long term management via coordinated community rehab services

Long term support to meet ongoing needs

Achieve high level mobility goals for community participation

Monitor recovery of function

Physiotherapy interventions for respiratory care in those with SCI

Targeted postural drainage to improve secretion clearance

Combination of mechanically assisted cough and manually assisted cough for those with ineffective cough

People with newly acquired SCI with respiratory muscle weakness should be assessed by a physiotherapist within 24 hours of admission

Physiotherapy interventions for strength training in those with SCI

Shoulder exercises to prevent shoulder pain

People prescribed exercise should receive a hard or electronic copy of individualised program

Focus on upper back, posterior shoulder - lat pulldowns, rowing, incline bench

Dosage = 2-4days a week, 2-3 sets of 8-12 reps, 50-80% 1RM

Physiotherapy interventions for motor skills and mobility in those with SCI

Power wheelchair skills training for those dependent on powerWC for mobility

Walking training should be provided to people with SCI who have lower limb function

Empower those with SCI to manage their injuries and physical rehab

Dosage and modalities of cardiovascular fitness for those with SCI

2-3 days a week, 20-60min sessions, 60-80% peak HR, avoid overuse issues in UL

Arm cranking, wheelchair ergometry, swimming sports, vigorous ambulation

Physiotherapy interventions for pain management in those with SCI

Educate to avoid shoulder overuse and trauma to prevent and treat shoulder pain

Shoulder exercises

Pressure injury and management

Routine skin check, reposition every 2 hours in lying, pressure relief every 30mins in sitting (weight shifting), clean skin from urin/fecal leakage

Pressure mapping and sitting assessment to individualise type and duration of relief, WC tilt, NMES to increase blood flow and reduce ischial pressure, edcuate pt

How should a tetrapelgic be postioned in bed in regard to UL and LL

shoulder abduction, elbow extension, wrist extension 45deg, fingers slight flexion

hips extension and slight abduction, knee extension (avoid hyperext), ankle and toes in dorsiflexion

what are the 5 most common secondary complications in SCI

UTI, AD, pressure ulcers, bone and soft tissue injuries, bowel problems

Describe a grade A SCI on the AIS scale

Complete - no motor or sensory function preserved in S4/S5