NPTE Studying Stroke and TBI

What are the two different types of CVA?

Ischemic - clock or blockage

Hemorrhagic - Rupture or leakage

The first ____ hours is critical to attend to for a ischemic CVA

72 hours

How does an Anterior Cerebral artery CVA present?

Contralateral motor and sensory loss greater in the LE > UE

Sensory loss LE > UE

Memory and behavioral impairments due to Frontal Lobe involvement

Problems with imitation and bi-manual tasks, apraxia

Urinary incontience

What is the most common ischemic stroke?

Middle Cerebral artery

How does a non dominant Middle Cerebral Artery CVA present?

Contra motor & sensory involving UE and face (UE > LE)

Contra Homonymous Hemianopsia

NonDominant Side (Right stroke)

Perceptual problem

Unilateral neglect, depth perception, spatial relations, agnosia, apraxia)

How does a dominant side middle cerebral artery CVA present?

Dominant Side (Left stroke)

Aphasia

Contra motor & sensory involving UE and face (UE > LE)

Contra Homonymous Hemianopsia

What would happen if you give a step up as a TherEx for a patient who had a non-dominant middle cerebral artery? What side of the brain is affected?

Right stroke

They do not know how much knee or hip flexion they will need in order to ambulate up the stairs

Will typically hear a stomp

What is Homonymous Hemianopsia?

loss of half of the field of view on the same side in both eyes

What is Hemineglect?

Patient may have distortions of the perception on the contralateral side. If drawn a clock, the numbers would be filled all on one side

What interventions would you use to treat those with Homonymous Hemianopsia or Hemineglect?

Strategies that encourage awareness and use of the environment on the hemiparetic side of the hemiparetic limb

Teach active visual scanning - active movement is important, need to turn head and axial trunk rotations to the more involved side

What is Aphasia?

loss of ability to understand or express speech, caused by brain damage

What is global aphasia?

Wernicke's and Broca's aphasia put together

Impairments in both production and comprehension of lanuage

Where would the lesion be if your patient has aphasia?

Dominant Hemisphere

Left hemisphere

What is Wernicke's Aphasia?

"Fluent Aphasia" - Word Salad

Lesion located in auditory associated cortex in the left lateral temporal lobe

Auditory comprehension is impaired with difficulty with comprehending spoken lanuage

What is Broca's Aphasia?

Nonfluent Aphasia - Broken Speech

Lesion in the premotor area of the left frontal lobe

Flow of speech is slow and hesitant, but comprehension is good

What is spatial perceptual Dysfunction?

Incorrect perception of self & illness

Incorrect perception of self in space (may neglect all input from the affected side (worsened by homonymous hemianopsia)

What is Agnoisa?

Unable to identify an object by sight, touch, or hearing

What is a huge part of treatment you need to be aware of with a spatial perceptual dysfunction?

Safety safety safety

A PT is ordered to examine a 76 year old patient who has suffered a recent stroke. The OT informs the PT that the patient has apraxia. She cannot drink from the bottle on command. However, she can point out the bottle and verbalize the purpose of the bottle. From this information, what sort of apraxia does this patient have? How should the PT approach treatment?

A. Ideomotor apraxia; The PT should speak in short concise sentences

B. Ideational apraxia; The PT should always give the patient 3-step commands

C. Ideomotor apraxia; The PT should always give the patient 3-step commands

D. Ideational apraxia; The PT should speak in short concise sentences

A. Ideomotor apraxia; The PT should speak in short concise sentences

The action of 3-step command is not going to change anything since they are unable to do the task on command

How does a Posterior Cerebral Artery present?

Contra Homonymous Hemianopsia

Memory deficits

Visual Agnosia

Prosopagnosia - difficulty naming people on sight)

Central post stroke (thalamic) pain

How does a Vertebrobasilar Artery: Locked in Syndrome present?

Basilar artery infarct of bilateral pons

Rapid progression from hemiparesis to tetraplegia

Cranial nerve paralysis (CN V-XII)

Rapid progression from dysarthria to anarthria

Result → Patient cannot move or speak but is alert and oriented

In PT session, the therapist commands the patient to wear a shirt, but the patient is unable to complete the task due to inability to find buttons on his shirt. Which of the following is MOST appropriate diagnosis and the best possible strategy to address this deficit?

A. Form discrimination, patient should be encourage to use touch to identify objects

B. Figure-ground discrimination, patient should be encourage to use touch to identify objects

C. Position in space impairment, orientating the patient with one object in relation to another

D. Ideational apraxia, having the patient perform one part of the task at a time, guiding the patient with the task if needed

B. Figure-ground discrimination, patient should be encourage to use touch to identify objects

A patient with right hemisphere damage would MOST likely have

A. Left unilateral neglect and difficulty reaching for objects presented on the Left side of the body

B. Left unilateral neglect and difficulty reaching for objects presented on the midline of the body

C. Difficulty crossing midline to reach objects on the right side of the body

D. Difficulty stabilizing gaze and locating objects on the right side of the body

A. Left unilateral neglect and difficulty reaching for objects presented on the Left side of the body

What are some Right side specific CVA symptoms?

Left side weakness/paralysis

Left neglect, spatial perceptual problems

Poor judgment, impulsivity

Short attention span and short term memory loss

Communication problems

Due to weakness of facial muscles

Cognitive problems

What are some Left side specific CVA symptoms?

Right side weakness/paralysis

Aphasia

Due to damage in Wernicke's and/or Broca's

Personality changes

Cautious, compulsive, disorganized

Difficulty with new information

Decreased memory

Difficulty generalizing or conceptualizing

What are the components of an UE flexor synergy?

Scap retraction, elevation, hyperextension

Should ABD, ER

Elbow flexion

Forearm supination

Wrist and finger flexion

What are the components of a LE extensor synergy?

Hip extension, ADD, IR

Knee Ext

Ankle PF, INV

Toe Extension

During the initial eval, PT asks the stroke patient to lift her left arm as high as she is able. Patient is able to lift her arm off of her lap; however, she is only able to move it with elbow flexion, shoulder elevation, and wrist flexion with significantly increased tone. Which of the following Brunnstrom's Stages Of recovery is MOST appropriate description for this patient?

A. Stage 3

B. Stage 4

C. Stage 5

D. Stage 6

A. Stage 3

What is the most important stage for therapy for Brunnstrom's Stages Of recovery?

Stage 4

Due to being able to create movements outside of the synergy patterns

What are the 7 stages of Brunnstrom's Stages Of recovery is

Stage 1 - Flaccidity, No active limb movement

Stage 2 - Beginning of minimal voluntary movement

In synergy, with associated reactions

Increase in tone

Stage 3- Voluntary control of movement synergy (spasticity at peak)

Stage 4 - Movement outside synergy

Decrease in tone

Stage 5 - Increased in complex movement, greater independence from limb synergies

Stage 6 - Individual join movement, coordinated movement

Stage 7 - Normal function

A PT is evaluating an 86 year old female, who sustained a Right CVA due to a MCA infarction 1 week ago. Patient has the classical signs and symptoms of MCA CVA. During the initial eval, the PT performs reflex testing on the patient. The PT would expect what?

A. Right side hyperreflexia and (-) Babinski

B. Right side hyporeflexia and (+) Babinski

C. Left side hyperreflexia and (+) Babinski

D. Left side hyporeflexia and (-) Babinski

Left side hyperreflexia and (+) Babinski

In a patient that has been Dx with a CVA, how would you position their UE affected side in supine?

Scapular protracted; shoulder forward and slightly ABD

Arm supported via pillow

Elbow extended with hand resting on pillow

Wrist neutral, fingers extended, thumb ABD

In a patient that has been Dx with a CVA, how would you position their LE affected side in supine to reduce common malalignments?

Hip forward (pelvis protracted)

Knee on small pillow or towel roll to prevent hyperextension

Nothing against soles of feet

In a patient that has been Dx with a CVA, how would you position them if they are side lying on the more affected side?

Head/neck: neutral and symmetrical

Trunk: aligned in midline

More Affected UE: Scapular protracted, shoulder forward, arm placed in slight abduction and ER, elbow extended, forearm supinated, wrist netural, fingers extended and thumb abducted

LE: Hip extended and knee flexed supported by pillows

In a patient that has been Dx with a CVA, how would you position them if they are side lying on the less affected side?

Want to elongate the hemiplegic side

Trunk: aligned midline; small pillow or towel can be placed under the rib cage to elongate the hemiplegic side

UE: Scapular protracted, shoulder forward; arm on a supporting pillow with elbow extended, wrist neural, fingers extended, thumb abducted

In a patient that has been Dx with a CVA, how would you position them if they are sitting in an arm chair or wheelchair?

Head/neck: neutral and symmetrical; head directly above pelvis

Trunk: spine extension

Pelvic: aligned in neutral with WB on both buttocks

More affected UE: Shoulder protracted and forward; elbow supported on arm through or lapboard; forearm, wrist neutrals, fingers, and thumb abduction (resting splint as needed)

Both LEs: Hips flexed to 90deg, positioned in neutral with respect to ration

What is Pusher's Syndrome?

Altered perception of body orientation in relation to gravity

-Lateral postural imbalance due to pushing with stronger UE/LE towards weaker side

-Believe they are upright but are actually leaning towards affected/weaker side

-Seen in 10% of people after stroke (usually thalamic stroke)

What is the intervention for Pusher's Syndrome?

Therapist can sit on the patient's LESS involved side and instruct the patient to "lean over to me."

OR

the patient can be positioned with the LESS involved side next to a wall and instructed to "lean" towards the wall

Patient should be fully involved in problem solving

What are the clinical signs and symptoms of "Pusher's Syndrome"?

Spontaneous body tilting toward the more-affected side

Abduction and extension of the less-affected extremities

A 82 year old patient suffered a right sided CVA about a week ago. The therapist is educating him on various positioning strategies. Which of the following is the MOST appropriate while lying on the left side?

A. Head/neck: Neutral, left scap protracted; L arm in slight abduction and ER; elbow extended, forearm supinated, wrist neutral, fingers extended, and thumb abducted

B. Head/neck: Neutral, left scap protracted; L arm in slight abduction and IR; elbow extended, forearm pronated, wrist neutral, fingers extended, and thumb adducted

C. Head/neck: Neutral, right scap protracted; L arm in slight abduction and IR; elbow extended, forearm pronated, wrist neutral, fingers extended, and thumb adducted

D. A. Head/neck: Neutral, left scap protracted; L arm in slight adduction and ER; elbow flexed, forearm supinated, wrist extended, fingers flexed, and thumb abducted

A. Head/neck: Neutral, left scap protracted; L arm in slight abduction and ER; elbow extended, forearm supinated, wrist neutral, fingers extended, and thumb abducted

What is the PNF UE D1 Flexion pattern?

Flex, adduction, ER

Forearm supination

Wrist - radially flexed

What is the PNF UE D1 Extension pattern?

Ext, Abd, IR

Forearm pronated

Wrist ulnarly extended

What is the PNF UE D2 Flexion pattern?

Flex, ABD, ER

Wrist radially extended

What is the PNF UE D2 Extension pattern?

Ext, Add, IR

Wrist ulnarly flexed

What are head/neck and trunk chop patterns?

Lead arm (weak arm) goes through the required pattern

Assist arm (strong arm) holds from the top of the wrist and moves into the opposite PNF pattern

Ex: Lead arm begins in D1 Flex and moves into D1 Ext while the assist arms moves into D2 Extension

The trunk and head needs to follow these movements

What is an UE thrust pattern?

What is the D1 lower extremity extension pattern?

Hip Ext, abd, IR

Knee flexion or extension

Ankle PF, eversion and toe flexion

What is the LE D2 Flex/Ext pattern?

Karate kick

Kick your leg up and out

Pull your leg down and behind

What is the LE D1 Flex/Ext pattern?

Soccer kick

Leg up and across

What is D2 Flexion pattern for LE?

Hip flexion, ABD, IR

Knee flex or extend

Ankle DF, eversion, Toe flexion

What is a D2 extension pattern for LE?

Hip extension, Add, ER

Knee flexion or extension

Ankle PF, inversion

Toe flexion

A patient diagnosed with Parkinson's disease exhibits a forward stooped posture. As part of the patient's care plan, the PT selects a number of active exercises that promote improved posture. Which PNF pattern would be the MOST appropriate to achieve the PT's objective?

a. D1 Extension

b. D1 Flexion

c. D2 Extension

d. D2 flexion

D. D2 Flexion Pattern

Helps open up the airway and helps eliminate the stooped posture

A therapist examines a 69 year old woman who has suffered a recent stroke. The therapist needs to focus on pre-gait activities. Which PNF diagonal best encourages normal gait?

A. D1

B. D2

C. PNF is contraindicated

D. Pelvic PNF patterns only

A. D1

This is very similar to walking

What is Decorticate posturing?

Abnormal flexor response, sustained contraction and posturing of the UE in flexion & LE in extension

What is Decerebrate posturing?

Abnormal extensor response

Sustained contraction and posturing of the trunk and limbs in full extension

What is opisthotonus posturing?

Strong sustained contraction of the extensor muscles of the neck and trunk

What are stages I-III in the Rancho Los Amigos Level of cognitive functioning scale?

I. No response, Completely unresponsive to any stimuli

II. Generalized Response Patients react inconsistently and non-specifically to stimuli

III. Localized response Patients react inconsistent but specifically to stimuli

What is Rancho Level IV?

Confused/Agitated:

Alert and in heightened state of activity with potential aggressive behaviors

Absent short term memory

Unable to fully cooperate with treatment

When treating a patient that is a Level IV on the rancho scale, how should you set up the treatment session?

Quiet room

Remove all possible distractions

Remove objects that can be thrown or used aggressively

What is Rancho Level V?

Confused, inappropriate, non-agitated

Unable to learn new information, but can listen/understand simple commands

Frequent brief periods, non-purposeful sustained attention

Intervention

How would you structure your intervention plan for someone who is a rancho level v?

Quiet environment

Highly structured functional tasks

Need a routine

Can use assistive devices

Give options

What is Level VI of the rancho los amigos scale?

Confused and Appropriate

little carry-over for new learning

MaxA for new learning or no carry over

Consistently follows simple directions

Unaware of impairments, disabilities, and safety risks

How would you structure your intervention plan for someone who was on the level VI Rancho Los Amigos scale?

Highly structured functional tasks

Decreases cues/external direction

Decrease use assistive devices

Increase speed and complexity of tasks as able

A physical therapist is called to assess a patient with traumatic brain injury. The therapist documents that the patient has a cerebrate posturing pattern. Which of the following is MOST likely to be seen in this patient?

A. Sustained contraction and posturing of the trunk and lower limbs in extension, and the upper limbs in flexion, fists clenched

B. Sustained contraction and posturing of the trunk and lower limbs in flexion, and upper limbs in extension, fists clenched

C. Sustained contraction and posturing of the trunk and limbs in position of full extension

D. Sustained contraction and posturing of the trunk and limbs in a position of full flexion

C. Sustained contraction and posturing of the trunk and limbs in position of full extension

A patient recovering from TBI is functioning at stage IV on the Rancho Los Amigos level of cognitive functioning scale. During the therapist's initial examination, the patient becomes agitated and tries to bite the therapist. The BEST course of action is to:

A. Postpone the examination until later in the day when the patient calms down

B. Postpone the examination for 1 week and then try again

C. Document the behaviors and engage in calming activities

D. Restructure the formal exam so the therapist can complete it in 3 very short sessions

C. Document the behaviors and engage in calming activities

Other answers are too passive and will not work in this specific scenario

Restructuring will not change any of the behavior that will occur with this type of client

What is Level VII of the rancho los amigos scale?

Automatic, Appropriate

Min supervision for new learning, with carryover

Initiation and follow through of basic ADLs

Minimal supervision for safety in routine home and community activities

Able to attend to highly familiar tasks in a non-distraction environment for at least 30 min with minA to complete tasks

How would you structure a treatment session for someone who is a Level VII on the rancho los amigos scale?

Structured functional tasks

Increase complexity of tasks

Work on coordination and fine motor control

What is Level VIII of the rancho los amigos scale?

Purposeful, Appropriate (stand by assistance)

Consistent orientation to person, place, and time

Independent with familiar tasks for an hour in distracting environment

Uses memory devices to recall schedules

Able to recall and integrate past and recent events

How would you structure an intervention session with someone who is a level VIII on the rancho los amigos scale?

Structured and unstructured functional tasks

Increase complexity of tasks

Work on coordination and fine motor control

Immediate steps you should take when someone is experiencing autonomic dysreflexia?

Sit them up to lower BP

Look for the noxious stimuli (bladder distension most common cause)

How to treat orthostatic hypotension for someone with SCI?

Gradual progression to vertical position

Use abdominal binder and compression stockings to minimise effects