[PT10117] [1T2S] [2] Second Shift Period (Stroke, TBI, Cognitive Dysfunction)

Sudden loss of neurological function caused by an interruption of the blood flow to the brain with neurological deficits persisting for >24 hours

Cerebrovascular accident (CVA) or stroke

List the signs of stroke (6)

1. Balance - Does the person have a sudden loss of balance?

2. Eyes - Is the person experiencing double vision or are they unable to see out of one eye?

3. Face - Is one side of the face drooping? Ask the person to smile.

4. Arm - Does one arm drift downward? Have the person raise both arms in the air.

5. Speech - Is the person slurring their speech or having difficulty getting the words out right? Have the person repeat a simple phrase.

6. Time - Call 911 and get the person to a certified stroke center immediately.

[BE FAST]

True or False: RIND impairments may resolve spontaneously as brain swelling subsides generally within 3 weeks

True

Refers to the temporary interruption of blood supply to the brain.

Transient ischemic attack (TIA)

Stroke is the ____ leading cause of disability worldwide

first leading cause

Stroke is the _____ leading cause of death in the Philippines

second leading cause

How much were the former and now increased reimbursement coverage values of PhilHealth for acute ischemic stroke?

Former: P28,000

Increased: P76,000

How much were the former and now increased reimbursement coverage values of PhilHealth for acute hemorrhagic stroke?

Former: P38,000

Increased: P80,000

What is the Stroke National Policy?

A policy that aims to ensure timely referral of patients to Acute Stroke Ready Hospitals (ASRH) by:

1. Facilitating the referral pathways

2. Utilizing healthcare provider networks

When was the Stroke National Policy approved? And who approved this?

2020 - DOH

Six Problems Post-Stroke

1. Sensation

2. Motor function

3. Postural control & balance

4. Speech, language, & swallowing

5. Perception & cognition

6. Emotional status

PROBLEMS POSTSTROKE

Sensory problems include: (4)

1. Sensory deficits (on affected) (superficial & deep)

2. Pain

3. Shoulder hand syndrome (SHS)

4. Visual problems (hemianopsia & blindness on one side)

PROBLEMS POSTSTROKE

Motor function problems include: (7)

1. Weakness (PRIORITY)

2. Edema

3. Abnormal tone

4. Shoulder subluxation

5. Synergies

6. Incoordination

7. Motor planning concerns

[WEASSIM]

PROBLEMS POSTSTROKE

True or False: Subluxation must be prioritized over weakness

False: Weakness must be prioritized over subluxation (since weakness leads to the subluxation)

PROBLEMS POSTSTROKE

What muscles are prioritized in strengthening to prevent shoulder subluxation?

1. Posterior and middle deltoid

2. Supraspinatus

PROBLEMS POSTSTROKE

Why is edema a possible problem poststroke?

Since there is weak muscle pumping action, fluids accumulate in the distal extremities

PROBLEMS POSTSTROKE

Syndrome where there is ipsilateral pushing of the arm on the affected side & ipsilateral trunk listing

Pusher’s syndrome

PROBLEMS POSTSTROKE

True or False: Emotional status is not something we can modify but is something that we should recognize in poststroke patients

True

IMPAIRMENTS (HEMISPHERE)

Which hemispheric side is damaged with the following presentation?

• Difficulty in communication and in processing information in a sequential, linear manner

• Cautious, anxious, & disorganized

• Realistic in their appraisal of their existing problems

(L) hemisphere damage

IMPAIRMENTS (HEMISPHERE)

Which side is hemiplegic with the following presentation?

• Difficulty in communication and in processing information in a sequential, linear manner

• Cautious, anxious, & disorganized

• Realistic in their appraisal of their existing problems

(R) sided hemiplegia

IMPAIRMENTS (HEMISPHERE)

Which hemispheric side is damaged with the following presentation?

• Difficulty in spatial-perceptual tasks and in grasping the whole idea of a task or activity

• Quick and impulsive

• Safety is a far greater issue where poor judgement is common

• Also require a great deal of feedback when learning a new task

(R) hemisphere damage

IMPAIRMENTS (HEMISPHERE)

Which side is hemiplegic with the following presentation?

• Difficulty in spatial-perceptual tasks and in grasping the whole idea of a task or activity

• Quick and impulsive

• Safety is a far greater issue where poor judgement is common

• Also require a great deal of feedback when learning a new task

(L) sided hemiplegia

What are the complications & direct impairments associated with cardiovascular/pulmonary system? (5)

1. Thrombophlebitis

2. DVT

3. Impaired cardiac output, cardiac decompensation, & serious rhythm disorders

4. Decreased lung volume, pulmonary perfusion, and vital capacity

5. Altered chest wall excursion

What are the complications & direct impairments associated with integumentary system? (3)

1. Pressure sores (in acute stage)

2. Skin breakdown

3. Decubitus ulcers

What are common sites of pressure sores in supine position? (3)

1. Elbows

2. Sacrum

3. Heel

What is the most common site of pressure sore formation in supine?

Sacrum

What is the second most common site of pressure sore formation in supine?

Heel

What is the intervention in preventing pressure sores formation?

Proper positioning and turning

What are the complications & direct impairments associated with musculoskeletal system? (3)

1. LOM and contractures

2. Disuse atrophy

3. Muscle weakness

What are the recommended interventions in preventing disuse atrophy and muscle weakness? (2)

1. Provide strengthening exercises

2. Encourage use of affected arm

What are the complications & direct impairments associated with osteoporosis? (1)

1. Loss of bone mass per unit volume (in chronic stages)

What are the complications & direct impairments associated with neurological system? (2)

1. Seizures

2. Hydrocephalus

True or False: The examiner must ask the stroke pt for any history of seizures

True

True or False: All people with stroke will benefit from rehabilitation and therefore it should be made available

True

True or False: We must adhere to person-first policy in stroke rehabilitation

True

True or False: Every person with a stroke must strictly adhere to the given management techniques provided by the PT, whether they like it or not (provider-centered).

False: Every person with a stroke has the right to choose their goals, activities, and priorities (client-centered)

True or False: Rehabilitation should adopt a impairment-based approach, only focusing on the patient’s clinical presentation.

False: Rehabilitation should adopt a whole-person approach, which includes addressing physical, social, and spiritual dimensions

True or False: Stroke care should be evidence-based

True

True or False: Rehabilitation should be provided only by physicians and nurses in a general hospital

False: Rehabilitation should be provided by a specialized interdisciplinary team of health professionals throughout the care continuum

True or False: Rehabilitation should be provided in an optimal amount to promote maximum recovery

True

True or False: Rehabilitation should be offered in a culturally safe and appropriate environment

True

True or False: Service providers have a responsibility to ensure that the resources and environment facilitate maximum recovery

True

True or False: The parameters of the treatment are dependent on whether the patient wants to stop already.

False: The parameters of the treatment must be optimal to what is needed for maximum recovery. Just proceed with caution or implement adjustments to carry out safety in fulfilling these parameters.

What phase of stroke recovery is the duration below:

• 0-24 hours

Hyperacute or acute phase

What phase of stroke recovery is the duration below:

• 24 hours-3 months

Early rehabilitation phase

What phase of stroke recovery is the duration below:

• 3-6 months

Late rehabilitation phase

What phase of stroke recovery is the duration below:

• >6 months

Chronic phase

True or False: A suspected stroke patient can be brought to the hospital beyond 24 hours.

False: The first 24 hours of a stroke attack is very important.

What are the problems associated with hyperacute or acute/early rehabilitation phases? (8)

1. Hemiplegia

2. Risk for contractures

3. Orthostatic hypotension

4. Cognitive deficits

5. Abnormal tone

6. Dependence in transfers & ADLs

7. Bed sores

8. Decreased balance & tolerance

What are the problems associated with late rehabilitation phase? (8)

1. Hemiplegia

2. Tightness & contractures

3. Balance problems

4. Difficulty in bed mobility & transfers

5. Abnormal tone

6. Shoulder subluxation

7. Difficulty in walking

8. Incoordination

What are the problems associated with chronic phase? (11)

1. Hemiplegia

2. Tightness & contractures

3. Balance problems

4. Hemiplegic arm

5. Dependence in ADLs

6. Risks for fall

7. Sensory deficits

8. Poor endurance

9. Postural deviatins

10. Risk for another stroke

11. Gait deviations

What are the target goals for hyperacute or acute/early rehabilitation phases? (7)

1. Maintain available ROM

2. Prevent the occurrence of bed sores

3. Prevent muscle atrophy

4. Prevent hemineglect

5. Improve balance & tolerance

6. Get the pt out of bed ASAP (p 1-2 wks)

7. Maintain (increase) strength

What are the target goals for late rehabilitation phase? (7)

1. Increase ROM

2. Minimize shoulder subluxation

3. Improve bed mobility & transfers

4. Enhance balance control

5. Improve coordination

6. Increase walking ability

7. Improve muscle strength

What are the target goals for chronic phase? (9)

1. Increase use of hemiplegic arm

2. Increase endurance

3. Improve gait

4. Strengthen weak muscles

5. Fall prevention

6. Improve balance control

7. Correct posture malalignment (prevent Pusher’s syndrome)

8. Enhance independence and function

9. Attain functional ROM

What are the interventions for hyperacute or acute/early rehabilitation phase? (7)

1. ROM exercises (PROM-AAROM-AROM)

2. Functional training

3. Gradual backrest elevation

4. Proper breathing

5. Proper positioning and turning

6. Sitting and standing balance and tolerance

7. Light PREs

What are the interventions for late rehabilitation phase? (7)

1. AROM, PNF, & coordination exercise

2. Strengthening & functional training

3. Static & dynamic balance training

4. Proper bed mobility & transfer techniques

5. ES (for muscle re-education)

6. Stretching & flexibility exercises

7. Gait training

What are the interventions for chronic phase? (9)

1. Stretching & ROM exercises

2. Strengthening & functional training

3. Constraint-induced movement therapy (CIMT)

4. Postural control strategies

5. Fall prevention strategies & balance training

6. Sensory re-education

7. Gait training

8. Patient education

9. Lifestyle modification

EVIDENCE – HYPERACUTE OR ACUTE PHASE

True or False: Among adult patients with acute stroke, we recommend admission to a stroke unit compared to the general ward.

True

EVIDENCE – HYPERACUTE OR ACUTE PHASE

True or False: Among acute stroke patients, we allow very early mobilization with constant monitoring within 24 hours by trained staff (i.e., physical therapists, nurses).

False: Among acute stroke patients, we recommend against very early mobilization within 24 hours by trained staff (i.e., physical therapists, nurses).

EVIDENCE – HYPERACUTE OR ACUTE PHASE

True or False: There is strong evidence that patients should be referred for early rehabilitation as early as possible even without medical stability within 24 hours of stroke symptom onset.

False: There is strong evidence that patients should be referred for early rehabilitation as early as possible once medical stability is reached preferably within 24 hours of stroke symptom onset unless contraindicated.

EVIDENCE – EARLY REHAB PHASE

True or False: All patients with stroke should receive clinically relevant therapy defined in their individualized rehabilitation plan, appropriate to their needs and tolerance level once medically stable.

True

EVIDENCE – EARLY REHAB PHASE

True or False: Better results can be obtained if physical therapy takes place once a day (patient’s preferred time) for 15 – 30 minutes, depending on the patient’s tolerance.

False: Better results can be obtained if physical therapy takes place twice a day (morning and afternoon) for 45 – 60 minutes, depending on the patient’s tolerance.

EVIDENCE – EARLY REHAB PHASE

True or False: There is some evidence that spasticity and contractures should be treated or prevented by antispastic pattern positioning (Bobath, RIPs), ROM exercises, and/or stretching.

True

EVIDENCE – EARLY REHAB PHASE

True or False: There is strong evidence on the use of splints in treating or preventing spasticity and contractures.

False: There is conflicting evidence on the use of splints in treating or preventing spasticity and contractures.

EVIDENCE – LATE REHAB PHASE

True or False: Strength training is endorsed for improving muscle strength and has no adverse effect on spasticity.

True

EVIDENCE – LATE REHAB PHASE

How many hours and days of outpatient therapy should be provided to patients?

HOURS: 45 mins – 3 hours/day

DAYS: 3–5 days/wk

This should be modified according to individual patient needs and goals.

EVIDENCE – LATE REHAB PHASE

True or False: Hospital-based outpatient stroke rehabilitation programs are better compared to home-based rehabilitation in achieving modest gains in ADLs following inpatient rehabilitation.

False: Home-based and hospital-based outpatient stroke rehabilitation programs are equally effective in achieving modest gains in activities of daily living following inpatient rehabilitation.

EVIDENCE – LATE REHAB PHASE

True or False: The use of an overhead pulley for the prevention of post-stroke shoulder pain is not endorsed.

True

EVIDENCE – LATE REHAB PHASE

True or False: The use of surface NMES (supraspinatus, middle/posterior deltoid) prior to 6 months post-stroke for preventing and/or reducing shoulder subluxation is endorsed.

True

EVIDENCE – LATE REHAB PHASE

True or False: The use of surface NMES for preventing shoulder pain is endorsed.

False: The use of surface NMES for preventing shoulder pain is not endorsed.

EVIDENCE – LATE REHAB PHASE

True or False: The use of US for post-stroke patients who have shoulder subluxation with shoulder pain is not recommended.

False: The use of US for post-stroke patients who have shoulder subluxation with shoulder pain is suggested.

Parameters: Continuous deep US

EVIDENCE – CHRONIC PHASE

True or False: Task-specific balance training programs and virtual reality training are endorsed as options to improve balance, gait, and functional recovery post-stroke.

True

EVIDENCE – CHRONIC PHASE

True or False: The use of CIMT is endorsed in post-stroke patients who have the following to improve dexterity, perceived use, and quality of arm and hand movements.

True

EVIDENCE – CHRONIC PHASE

What are the requirements for post-stroke patients before they can undergo CIMT? (4)

1. At least 10° active finger extensions

2. At least 20° active wrist extensions

3. Limited sensory and balance problems

4. Intact cognition

EVIDENCE – CHRONIC PHASE

True or False: The use of FES on the wrist and forearm is strongly endorsed to reduce motor impairment and improve functional motor recovery of stroke survivors

True

EVIDENCE – CHRONIC PHASE

True or False: Community Reintegration and long-term recovery; follow-up services are strong evidence recommendations to support not only risk factor management but management of physical and psychological complications.

True

EVIDENCE – CHRONIC PHASE

True or False: There is strong evidence that repetitive practice of walking improves gait speed, functional ambulation and walking distance.

True

EVIDENCE – CHRONIC PHASE

True or False: There is strong evidence that FES may improve gait, improve muscle force, strength and function in selected patients, guaranteeing permanent effects.

False: There is strong evidence that FES may improve gait, improve muscle force, strength and function in selected patients, but the effects should not be assumed to be sustained.

Neuromuscular impairments of TBI (5)

1. Abnormal tone

2. Sensory impairments

3. Impaired balance

4. Motor function

5. Paresis

[A SIMP]

Cognitive impairments of TBI (8)

1. Altered level of consciousness

2. Memory loss

3. Altered orientation

4. Attention deficits

5. Impaired insight and safety awareness

6. Problem-solving/reasoning impairments

7. Perseveration

8. Impaired executive function

Behavioral impairments of TBI (8)

1. Disinhibition impulsiveness

2. Sexual inappropriateness

3. Physical and verbal

4. Irritability

5. Egocentricity

6. Aggressiveness

7. Apathy

8. Impaired drive

Goals of acute care in TBI patients (4)

1. Improve respiratory function and prevent respiratory complications

2. Prevent secondary brain damage

3. Preserve musculoskeletal integrity

4. Facilitate arousal and active engagement

POSSIBLE ATTACHMENTS

This attachment only lets the patient make sounds but cannot speak

Intubation

POSSIBLE ATTACHMENTS

What are the two kinds of intubation attachments for breathing?

1. Endotracheal tube

2. Tracheostomy

POSSIBLE ATTACHMENTS

What level is the tracheostomy tube attached to the patient?

Hyoid level

POSSIBLE ATTACHMENTS

What is the purpose of a tracheostomy tube?

Allows easier breathing and drains secretions of pt

POSSIBLE ATTACHMENTS

Provides nutrition to pts from nose to esophagus

Nasogastric tube (NGT)

POSSIBLE ATTACHMENTS

Drainage for fluids (excess) within the lung parenchyma

Chest tubes

POSSIBLE ATTACHMENTS

True or False: A chest tube attachment is a precaution when moving the thorax.

True

POSSIBLE ATTACHMENTS

Tube through IVC to get blood sample and for administering medicines

Central venous line

POSSIBLE ATTACHMENTS

Goes through the vein to administer medicines

Swan-Ganz catheters

POSSIBLE ATTACHMENTS

From the scalp, it pierces the bone and enters the dura to monitor ICP

Intracranial pressure monitors

POSSIBLE ATTACHMENTS

Attachment that checks important VS (ex. HR, PR, BP)

Heart rate monitors

POSSIBLE ATTACHMENTS

This is inserted to either a vein or artery on the forearm to facilitate exchange of fluids and nutritional support to the blood

IV line/Arterial line

What respiratory problems are amenable to PT treatment? (4)

1. Hypoventilation impaired

2. Mucociliary clearance

3. Hyperventilation

4. Ventilation/perfusion mismatch

What are the two indications for ventilation?

1. Hypoxemia

2. Hypercapnia

Partial pressure value indicative of hypoxemia?

PaO2 < 60 mmHg

Partial pressure value indicative of hypercapnia?

PaCO2 > 45 mmHg

Rate at which the brain is perfused by blood

Cerebral perfusion pressure

Formula in calculating the CPP

CPP = MAP - ICP