Neuromuscular Exam 1

Facial palsy

Arm weakness

Speech impairment

Time (call immediately)

What does FAST stand for?

IV alteplase ((tPA), tenecteplase

What medication is used in someone with acute ischemic CVA?

1. >80 y.o

2. previous CPA

3. diabetic

4. NIHSS score >25 (very severe)

5. taking anti-coagulates

What are the 5 exceptions to tPA

brainstem lesions, large infarcts, edema resulting in herniation

Top causes for death in first few days (stroke)

pneumonia (25%), PE, cardiac disease

Top causes for death in first week (stroke)

1. urinary continence

2. young age

3. mild CVA

4. rapid improvement

5. good perceptual abilities

6. no cognitive disorders

What are some characteristics that show a probable outcome returning to independence post-stoke?

1. urinary continence

2. poor comorbid functioning

3. delayed rehab

What are some characteristics that show a negative outcome returning to independence post-stoke?

younger patients, men

Which population is at an increased risk of having a post-CVA seizure

want to encourage profusion t o area

Why do clinicians allow for a more elevated blood pressure in those that had a ischemic CVA?

88.9%

FAST has identified ____% of cases of CVA or TIA

4.5 hours (ideally, 3)

How quickly must tPA or tenecteplase be administered from onset of symptoms

180-200 mmHg

What is a common SBP cap for ischemic CVA?

140 mmHg

What is a common SBP cap for hemorrhagic CVA?

want to prevent further bleed

Why does hemorrhagic stroke have more strict parameters for blood pressure?

first 3-5 days

When does cerebral edema peak post-CVA?

BP management, medications, intraventricular drains, surgery (burr holes/ craniectomy)

what are the medical management of cerebral edema post-stoke?

large hemispheric stroke, basilar thrombosis, brainstem infarct, cerebellar stroke

What are risk factors for requiring mechanical ventilation post-stroke

true (food, water, dusk, etc.)

T/F patients on mechanical ventilation are at higher risk for aspiation?

Passy Muir Valve (can breath in)

Trach Cap (in and out)

Decannulation

What are the steps towards removing trach?

1. brainstem CVA

2. weak voice/ cough

3. poor oral hygine

4. difficulty swallowing oral secretions

What are 4 risk factors for aspiration?

Dysarthria

difficulty forming words

causes increased HR, decreased endurance

Why is dehydration dangerous for those post-CVA

body needs calories to heal

Why is malnutrition dangerous for those post-CVA

1. poorer functional mobility

2. increased medical complication

3. lower self care scores

Malnourishment predicts lower functional status following CVA. What is affected as a result?

1/3

(associated with poor functional outcomes, higher mortality)

Approximately _____ of all stroke survivors suffer from depression.

early mobilization, medications, neuropsychology

How can we prevent depression in post-CVA patients?

14%; 24%

____% of patients who had a CVA will exerience a fall in acute care

____% of patients who had a CVA will experience a fall inpatient rehab

50-75%; 9-15%

Without anticoagulation _______% of patients who had a CVA will have a DVT

______% will have a PE

2-7 days

When is peak onset for DVT/ PE post-CVA?

early mobilization

What can be done to help prevent DVT/ PE in patients post-CVA

pneumonia

(UTI very common in patients who are incontinent)

What is most common infection post-CVA?

bladder schedule (every 2-4 hours), foley (short term)

What can be done to help with urinary innocence?

1. spastic muscle imbalance (contracted shoulder)

2. muscle weakness

3. neglect

4. trauma (pulling on patient arm)

5. structural changes (loss of ER, flexion)

What are 5 factors that hemiplegic shoulder pain may be associated with?

early mobilization, proper positioning, turning schedule

How to reduce pressure injuries?

sacrum, ischial tuberosity, heels

Common areas for pressure injury?

all patients should be assessed by rehab professionals ASAP (within first 48 hours)

What did the canadian "best practice recommendations for stroke care" find?

serious stoke (hemorrhagic) had reduced less favorable outcomes with early mobilization; ischemic had favorable outcomes

What did the AVERT trial (2015) find?

1. functional ability

2. cognition

3. safety

4. support

5. prior roles

What are 5 factors to consider when making discharge recommendations?

timing matters

Principle that suggests the earlier stroke rehab was initiated, the better the outcomes, regardless of severity of stroke

gait training in first 3 hours of therapy

What is the most important predictor of gait outcomes

aggressiveness matters

Principle that suggests the earlier paticipation in hgiher-level, more advanced activities is associated with better outcomes

(even in "low level" patients)

true

T/F Participation in higher level actibities results in improvement of lower level activities without direct practice of these activities

Inpatient rehab

Facility with intense multidiscipilinary care; licensed as a hospital; 3 hours of therapy at least 5 days/ week; 24 hour nursing care; daily physician supervision

Skilled Nursing Facility (SNF)

Facility with minimal guidelines regarding care; no therapy requirement, MD supervision not daily, nursing care ~8 hours

older, female, hospitalized 6 months prior to CVA, higher CVA severity, longer stay

What kind of patients are usually admitted to a SNF?

false (IPR was lower)

T/F risk of mortality and readmissions was lower for those who went to SNF over IPR after acute hospitalization for CVA

gait activities, UE motor control, home management, problem solving (SLP)

What activities were found to increase FIM scorre? (minutes of therapy being spent on)

bed mobility, sitting activities, auditory comprehension (SLP), orientation (SLP)

What activities were found to have lower FIM score (minutes of therapy being spent on)

1. lower mortality

2. less likely to be institutionalized

3. improved independence

4. no longer of a hospital stay

What are benefits of organized CVA programs?

1. decreasing edema

2. improved circulation

3. spontaneous neural reorganization (influenced by rehab/ functional movements)

4. functional recovery (improving independence)

How may patients recover quickly following CVA?

1. genetics

2. co-morbidities

3. age

4. initial severity

5. mechanism of CVA

6. location/ size

What are 6 factors that impact recovery from stroke?

3 months

(can continue up to 6 months, but slower.... functional recovery can continue long past that)

When does neurological recovery peak?

inital stroke severity and age

(also pre-morbid health, physical abilities, presence of depression, level of social support, urinary continence, biomarkers)

What are the strongest predictors of rehab outcomes following CVA?

compensatory approach

Focus on skill based training augments by environmental adaptations (utilized more as time passes)

restorative approaches

focus on skill-based training augmented by strategy training and physical exercise program (utilized more early on)

C. He had his stroke less than three hours before getting to the emergency department

Patient X, a 71-year-old male, was at home when his wife noticed that he was slurring his words and having difficulty moving his left arm. She immediately called 911 and he was taken to the emergency room. He received tPA.

What do we know if he received tPA?

A. He has had a hemorrhagic stroke

B. He had his stroke more than three hours before getting to the emergency department

C. He had his stroke less than three hours before getting to the emergency department

D. We do not have enough information to determine anything at this time

B. The patient has a history of a stroke

Which of the following risk factors would indicate the higher risk for another stroke?

A. The patient has been a pack a day smoker for the last seven years

B. The patient has a history of a stroke

C. The patient has a history of uncontrolled hypertension

D. The patient has a history of controlled diabetes

E. All the above

A patient had a brainstem CVA. Which of the following complications as a clinician would we be worried about him developing?

A. Pneumonia

B. DVT

C. Seizures

D. Pressure injuries

E. All the above

B. Home with outpatient PT

CVA patinet's initial evaluation demonstrated that he has weakness in his right hemibody in both his Upper and Lower extremities, he has some cognitive concerns, and requires maxA for sitting balance and bed mobility.

Which of the following discharge recommendations would NOT be appropriate?

A. Inpatient Rehabilitation

B. Home with outpatient PT

C. Sub acute skilled rehab

D. Long term care facility

Rood

Which clinician used developmental sequence to obtain motor responses

flexion, adduction, ER, supination, wrist/finger flexion

What is the UE D1 flexion pattern?

extension, abduction, IR, pronation, wrist/finger flexion

What is the UE D1 extension pattern?

flexion, abduction, ER, supination, wrist/finger flexion

What is the UE D2 flexion pattern?

extension, adduction, IR, pronation, wrist/finger flexion

What is the UE D2 extension pattern?

hip flexion, adduction, ER, DF, Inversion, toe extension

What is the LE D1 flexion pattern?

hip extension, abduction, IR, PF, eversion, toe flexion

What is the LE D1 extension pattern?

hip extension, abduction, ER, PF, inversion, toe flexion

What is the LE D2 extension pattern?

hip flexion, abduction, IR, DF, enversion, toe extension

What is the LE D2 flexion pattern?

Knott and Voss (PNF)

Who came up with D1/D2 patterns?

medial aspect of cerebral hemispheres

(frontal and parietal)

What part of brain does anterior cerebral artery (ACA) supply blood to?

basal ganglia, anterior 4/5ths corpus callosum

What subcortical structures does the anterior cerebral artery (ACA) supply blood to?

yes

(executive functioning, memory, basic/ complex mental features, pattern recognition, matching)

Would you expect any COGNITIVE impairments with Anterior Cerebral Artery Syndrome ?

left hemisphere (frontal lobe)

What side of the brain might present with aphasia?

right hemisphere (frontal lobe)

What side of the brain might present with poor safety awareness/ impulsivity?

Wenicke's area (expressive)

lesion in auditory association cortex of left lateral temporal lobe;

Someone who has no issue producing language, although this language is nonsensical.

Broca's (receptive) aphasia

Lesion in premotor area of left frontal lobe

Someone who understands language, but has trouble producing language output and can only express 1-2 words

cognitive, balance, motor (LE), function

(no sensory or cranial nerves impairment)

What kind of impairments would you expect from Anterior Cerebral Artery Syndrome?

lateral aspect of hemispheres (frontal and parietal)

What part of brain does middle cerebral artery (MCA) supply blood to?

posterior internal capsule, globus pallidus, caudate nucleus, putamen

What subcortical structures does the middle cerebral artery (MCA) supply blood to?

MCA (50%)

What is the most common CV?

cognitive, sensory, motor (UE), balance, function

(not cranial nerve, coordination,

What deficits would be expected to be seen with MCA stoke?

Pusher's syndrome

Impaired perception of body posture in relation to gravity (mismatch of 18º towards side of lesion); usually damage to right thalamus from MCA stroke

Type II (loss of muscle cross-sectional area; greater on involved side)

Which nerve fibers progressively decline after stroke?

Apraxia

The inability to perform movements in the absence of motor and sensory types

constructional apraxia

Type of apraxia; inability to organize or arrange component parts into a final product; impairs setting table, making bed, dressing

ideomotor apraxia

Type of apraxia; Inability to carry out purposeful movement on command

ideational apraxia

Type of apraxia; Incorrect use of an object: using toothbrush to comb hair

posterior aspect of hemispheres

(occipital and medial/inferior temporal)

What part of brain does posterior cerebral artery (PCA) supply blood to?

upper brainstem, midbrain, posterior diencephalon (thalamus)

What subcortical structures does the posterior cerebral artery (PCA) supply blood to?

visual, balance, functional

(not cognitive, cranial nerves, sensory, motor, coordination)

What deficits would be expected to be seen with PCA stoke?

homonymous hemianopsia

Loss of the entire visual field on one hemisphere

cerebellum and brainstem

What part of brain does posterior inferior cerebral artery (PICA) supply blood to?

cranial nerves, sensory, coordination, balance, function,

(not cognitive, motor)

What deficits would be expected to be seen with PICA stoke?

trigeminal (V), vestibulocochlear(VIII), glossopharyngeal(IX), vagus (X), spinal accessory (XI)

Which cranial nerves may be affected in PICA stroke?

- dysarthria and dysphagia

- ipsilateral loss of pain/ temp (face)

- contralateral loss of pain/temp (trunk/ extremities)

- ataxia

- vertigo

- Horner's syndrome (miosis, ptosis, loss of sweating)

Symptoms of Wallenberg syndrome (PICA stroke)

cerebellum, medulla, pons, inner ear, cerebellum

What part of brain does vertebrobasilar artery supply blood to?

cranial nerves, sensory, motor, coordination, balance, function

(not cognitive)

What deficits would be expected to be seen with vertebrobasilar artery stoke?

CN 5-7; 9-12

Which cranial nerves would be affected with vertebrobasilar artery stroke?

DCML, spinalthalamic tract

(pain/ temp, light touch, proprioception)

Which pathways would be affected in vertebrobasilar artery stroke?

Locked-in syndrome

Large vertebrobasilar strokes;

the patient is cognitively intact, but the only movement the patient has is ocular movement, specifically vertical gaze. Cranial nerve 8 is spared, so patients do have preservation of hearing.