Intro to CVA (Left and Right Hemispheres)

Mentation/Orientation Review

Levels of consciousness

•Alert
•Lethargic
•Obtunded
•Stupor
•Coma

Alert

•Patient is awake and attentive to normal stimuli

•Able to interact with people

Lethargic (somnolent)

•Patient arouses with stimuli (tapping, shaking)
•Able to stay awake for a time but falls asleep when not stimulated enough
•Decreased awareness
•Patient may have difficulty focusing on task or losses train of thought
•Oriented and not confused

Obtunded

•Patient is difficult to arouse

•Confused when awake

•Needs constant stimulation to keep awake

Stupor (semi-comatous)

•Patient responds only to strong, noxious stimuli then immediately returns to unconscious state if stimulus stops

•Patient is unable to interact with clinician

Coma

•Patient cannot be aroused by any type of stimulus

•May or may not have reflexes

Cognitive testing

•Includes:
•Assessment of attention
•Orientation
•Memory
•Abstract thought
•Ability to perform calculations or construct figures
•Judgement

Delirium

•Severe confusion that can develop in a few hours or days

•Caused by metabolic imbalance (low Na), medication, infection, alcohol or drug intoxication/withdrawal, severe illness

•Pt demonstrates offensive, loud, and talkative behaviors
•
•State of disorientation characterized by:
•Irritability
•Agitation
•Paranoia
•Hallucinations

•State of disorientation characterized by:

•Irritability
•Agitation
•Paranoia
•Hallucinations

Lecture Objectives

•List the differences in normal functions of the left and right hemisphere
•Understand how damage to the different hemispheres present in patients
•Compare different language problems that arise from injury to the brain
•Understand different strategies to use during treatment to improve function

Left and Right Brain Myth

Left and Right Hemispere Facts

•
•Work together and communicate - corpus collosum
•Circle and square test

•Some parts of the brain have more functions than others

•Individuals have preferences of what interests them and then develops that skill more

Normal Left Hemisphere Functions

•Analytic thought
•Problem solving
•Reasoning
•Deductive and inductive
•Logic
•Facts
•Details
•Based on validity
•Number skills
•Calculations
•Science skills

•Curiosity
•Impulsiveness
•Verbal communication
•Language
•Comprehension, expression, reading, writing
•Right sided visual field
•Controls the right side vision of each eye
•Right sided motor control
•Controls the right side of the body

Left Hemisphere Injury

•Impaired analytical thought, reasoning, logic, mathematical skills

•Visual problems (field cuts to the right, tunnel vision or blurred)

•Easily frustrated because they are misunderstood

•Inappropriate use of yes/no

•Perseveration/echolalia

•Inability to name objects but knows what to do with them

•Inappropriate laughing/crying

•Language
•Broca's aphasia
•Wernicke's aphasia
•Global aphasia

Broca's aphasia

•Aka Expressive aphasia

•Brodmann's areas 44, 45

•Usually good comprehension with poor verbalization

•Intelligence intact

•May use 1-2 words

•Switch letters in words like sloon for spoon

•May use main words and leave out conjunctions like but, and, or

•Apraxic speech - messages from the brain aren't getting to the tongue and other facial muscles to help form words

•Patients with expressive aphasia are aware of their deficits

•https://www.youtube.com/watch?v=JWC-cVQmEmY (3:59)

Strategies to use for patients with Broca's aphasia

•Eliminate distractions in the room

•Give the patient multiple choice options

•Ask yes/no questions

•Encourage the patient to use gestures and communication devices

•Give the patient time to answer (try not to finish his sentence)

Wernicke's aphasia

•Aka receptive aphasia

•Brodmann's area 22, 39, 40

•Poor auditory comprehension

•Verbalization is fluent and grammatically correct; however, the content is unintelligible

•Perseverates

•Patients are unaware that they have a deficit

•https://www.youtube.com/watch?v=3oef68YabD0 (1:30)

Strategies to use for patients with Wernicke's aphasia

•Eliminate distractions in the room

•Get the patient's attention

•Simplify your commands

•Give one step commands at a time

•Allow the patient time to process the info and respond

•Use gestures and emphasize key words

•Demonstrate the task you want the patient to do

Global aphasia

•Injury to the areas of the brain that result in both expressive and receptive aphasia

•May say the same words or phrases over and over like "I know" and "ok"

•May use varying intonation to have different emphasis and tone based on the situation

•https://www.youtube.com/watch?v=1Xlu0TUPaQI (1:53)

Strategies to use for patients with Global aphasia

•Eliminate distractions

•Get the patient's attention

•Allow the patient time to process the info

•Don't speak for the patient

Strategies to use for patients with Left Hemisphere Injury

•Use adult language, normal tone and volume of voice

•May have the patient write to assist in communication

•Give immediate feedback

•Simplify commands
•
•Use gestures or picture boards

•Yes/no questions

•Check for patient comprehension by: repeating back what you think the pt is saying, asking him to repeat or showing you the steps

Normal Right Hemisphere Functions

•Attention
•Sustained
•Divided
•Alternating
•Visual and auditory

•Reasoning
•Deductive and inductive
•Memory
•Immediate
•Short term
•Long term
•Working

•Problem solving
•Daily living problems

•Creativity
•Imagination
•Visualization
•Daydreaming
•Music
•Abstract concepts
•Spatial awareness
•Inhibition
•Deciding what is appropriate or safe behavior

•Initiation
•Beginning a task
•Asking for help
•Starting a conversation

•Orientation
•Name, date, time, place, situation

•Organization
•Thoughts
•Information

•Emotions
•Holistic approach

•Non-verbal communication
•Left sided vision field
•Left sided motor control

•Attention

•Sustained
•Divided
•Alternating
•Visual and auditory

•Reasoning

•Deductive and inductive

•Memory

•Immediate
•Short term
•Long term
•Working

•Problem solving

•Daily living problems

•Creativity

•Imagination
•Visualization
•Daydreaming

•Inhibition

•Deciding what is appropriate or safe behavior

•Initiation

•Beginning a task
•Asking for help
•Starting a conversation

•Orientation

•Name, date, time, place, situation

•Organization

•Thoughts
•Information

Right Hemisphere Injury

•Impaired attention

•Hemi-anopsia

•Difficulty recalling info from memory

•Difficulty with solving problems of everyday life

•Impaired inhibition
•Inappropriate language and blurting out whatever comes to mind, perseveration, putting a lot of food in mouth, poor safety awareness, impulsive, poor judgement

•Decreased initiation
•Difficulty asking for help or initiating a task

•Impaired orientation


•Difficulty with organization

•Impaired orientation

•Inability to recall time, place, situation, and other personal info
•Impaired left/right discrimination
•Left side neglect or inattention
•Unable to navigate in unfamiliar areas

•Difficulty with organization

•Impaired ability to stay on topic in a conversation
•Difficulty getting thoughts verbalized into an intelligent speech
•Difficulty understanding and relating to incoming info

Strategies to use for patients with Right Hemisphere Injury

•Eliminate distractions and get the patient's attention

•Set up a routine

•Simplify directions

•Ask patients to repeat instructions

•Slow pt down if impulsive or moving too fast

•Redirect the patient back to the task at hand

•Have patient return gaze to a point on the left side of his visual field to establish a point of reference and get him to attend to that side

•Work on initiation by sabotaging a task and see how patient responds

•Practice, practice, practice