DPT810 Clinical Neuro Mgmt I Final Exam

what is a major goal in neurologic rehab

improvement of walking

what are the 4 primary purposes of gait analysis

1. assist in understanding of gait characteristics
2. assist with mvmt dx
3. inform selection of interventions
4. evaluate effectiveness of tx

what are the 3 types of gait analysis

-kinematic qualitative
-kinematic quantitative
-kinetic analysis

what does kinematic qualitative analysis describe

uses observation to describe patterns of mvmts, deviations from normal postures, jt angles during gait cycle

What is an essential component of any PT exam?

-Identify & describe pattern/deviations

-Determine causes of deviation

-Develop interventions to treat deviation

OGA

what scales are used for kinematic qualitative analysis

-functional independence measure (FIM)
-DGI
-functional gait assessment (FGA)
-high-level mobility assessment tool (HiMAT)
-walking index for spinal cord injury II (WISCI II)

what does the FIM measure

level of A/dependent required for walking

what does the DGI measure

ability to adapt gait to changes in task demands

what does the FGA (modification of the OG DGI) measure?

addresses the ceiling effect DGI had for pt's w/ vestibular & balance d/o's

what does the HiMAT measure

high level skills for employment, social roles, leisure, sports

What outcome measure assesses extent & nature of A to walk 10m at self selected speed? (observes how much help they need & nature of that help (via PT, AD, orthoses)

WISCI II

what does kinematic quantitative analysis measure & provide?

-measures spatial & temporal variables
-provides quantifiable data important to 3rd party payers when discussing pt function, progress, & outcomes
-consists of simple methods or complex expensive methods

How are temporal variables measured in kinematic quantitative analysis & its goal?

-captured using a stopwatch
-Gait speed as a goal! → if improving walking as a goal for your pt, then gait speed is also a goal
-Quantifies cadence velocity, etc.
-Ex. 2 or 6 MWT, 10mWT

what are examples of complex methods when using kinematic quantitative analysis

-accelerometers (activity monitors)
-video based motion analysis

What determines & analyzes forces involved in gait?

-use of force plate technology & torque measurement systems

-more common in labs but can be available clinically

kinetic analysis

what do improvements in locomotor function result in?

-↓ burden of care
-facilitates participation in social roles & recreational activities
-increases QOL
-improves overall health status & physical functioning

what are the 5 requirements for successful walking

1. Support of body mass by LE's (functional strength)
2. Production of locomotor rhythm (reciprocal stepping)
3. Dynamic postural control of moving body (maintain posture control in dynamic mvmt)
4. Propulsion of body in intended direction (force production)
5. Adaptability of locomotor response to changing environmental & task demands (dual-task)

what must be done to maximize the effectiveness of locomotor interventions?

principles of motor learning & neuroplasticity must be incorporated

What are the general principles of neuroplasticity?

-Maximize repetitions→ Practice A LOT
-Make activity task specific
-Increase pt choice/ autonomy
-High intensity (inc HR & BP→ Use RPE scale (beta blockers)
-Challenging/ engaging
-Goal-directed & meaningful/salient

describe the general principles of practice

-Variable & random practice are ideal to address walking impairments → but recognize pt's fatigue/attention
-Improve retention & motor learning
-More closely resemble real-world task
-Variable → different variants in varying contexts
-Random → different tasks in random order

describe the general principles of feedback

-Knowledge of results (KR): give summary of their performance at end & then have faded schedule (gradually decrease amount of feedback given OT)
-Increase use w/ successful trials, decrease use w/ unsuccessful trials
-Feedback is helpful for motivation (provides pre-task for confidence)
-External focus of attention → helpful to promote motor learning

what are the benefits of BWSTT (10)

-Facilitates standing & stepping w/ more symmetry in a more natural way
-↓ need for excessive UE support/compensatory motion
-Facilitates automatic walking mvmts & reciprocal stepping
-PT can facilitate mvmt & provide sensory cues
-Earlier initiation of gait training
-↓ fear of falling
-Prevents learned non-use (in relation to compensatory strategies)
-Promotes dynamic balance
-Facilitates hip ext (often seen lacking in people who have difficulty walking)
-Can change parameters to make high intensities by varying speeds, ↑ incline, ↓ level of A

what are the benefits of treadmill training (5)

-Can provide a sensorimotor environment to facilitate recruitment for CPG's (central processing generators (innate))
-Helps produce rhythmic, reciprocal muscle activity needed for gait
-Task-specific training w/ increased intensity (via increased speed, increase incline)
-External pacemaker → Improves rhythm, cadence, symmetry of stride length
-Provides motor skill practice + aerobic conditioning

describe the 4 categories of overground training

1. Propulsion problem (difficult getting themself forward) → Weighted sled push, walk on incline, ↑ speed
2. Swing (difficulty advancing or clearing limb)
→ Obstacle avoidance, foot clearance/placement, stairs
3. Stance (difficulty accepting their BW)
→ Stairs, walk on uneven ground & compliant surfaces)
4. Postural stability problems (difficulty maintaining balance)
→ Simulation of community tasks (perturbations, carrying objects)

describe virtual reality & exergaming as an adjunct intervention to promote locomotor recovery

-Use of video or other gaming systems
-Evidence for small, but significant improvements in gait speed, stride, & step length
-Challenging, allow for random practice, motivation, & provide an external focus of attention

describe force production interventions as an adjunct intervention to promote locomotor recovery

-Use of functional strengthening in the context of tasks that are specific to the positions & modes of contraction that are limited in gait
-Endurance (difficulty maintaining stability in stance phase) vs. power dependent upon limitation (inadequate PF)

describe balance & dynamic postural control as an adjunct intervention to promote locomotor recovery

-LOS training → weight shifting & perturbation
-COM control while decreasing/changing BOS
(Heel raise, toe off, transition b/t limbs)
-Changing BOS, support surfaces, visual input, load
-Walk w/ changes in vision, stops/starts, speed changes, obstacles

circuit training as an adjunct intervention to promote locomotor recovery via

variable, random practice
-Manipulate tasks thru speed, added load, added cognitive challenge

describe motor imagery as an adjunct intervention to promote locomotor recovery

-Mental rehearsal w/o mvmt
-Activates similar cortical structures as actual mvmt
-Generally in addition to physical practice

what are the 2 types of motor imagery techniques

-Visual: visualize activity from 3rd person (like you are watching it)
-Kinesthetic: imagine exp from 1st person (you are feeling exp of the activity)

what are the 3 variables that determine WC needs

1. Balance/ postural control in sitting
2. Ability to achieve neutral sitting posture
3. Degree of postural support required

describe basic WC needs

-Good sitting balance (hands-free sitter)

-Neutral posture without support or A

-Ex. Older adults w/ decreased strength or weakness

describe intermediate WC needs

-Fair sitting balance (needs hands for support in order to keep balance)

-Achieves close to neutral posture (but not full neutral)

-Needs postural supports

-Do not need to be custom

-Ex. Mild CP, TBI w/ mild tone, maybe 1 contracture

describe complex WC needs

-Poor sitting balance
-Unable to achieve neutral posture
-Needs custom supports
-Could be to either correct OR accommodate for posture
-Ex. progressive disease or declining function OT or has tone associated w/ CP or multiple contractures

the seating & mobility procurement process starts w/ identifying

need & make a referral
-Assessment
-Funding/ ordering
-Product preparation
-Fitting
-User training
-Maintenance, repairs, follow up

what are the primary principles of sitting posture

-neutral sitting posture
-optimal postural alignment

describe the principle of neutral sitting posture

-pelvis & trunk alignment, neutral LE alignment, neutral head positioning
-Importance of pelvic alignment= foundation of a stable & neutral sitting posture

pelvic position to achieve a neutral sitting posture should be level. Neutral position OR in

slight anterior pelvic tilt (important to allow for trunk, head, & extremities to be positioned optimally)
-Have normal spinal curves & symmetrical WBing

What is the principle of optimal postural alignment?

-increase or decrease tone, weakness, ROM limitations, influence of gravity, habitual mvmts
-GOAL= get pt as symmetrical & balanced as possible

what are the benefits of optimal postural alignment?

-Less work for muscles
-Supports healthy body functions (CV, Respiratory, digestion, integumentary)
-↓ risk for pressure injuries
-↓ risk for deformities (contractures or problems that arise from asymmetrical sitting)
-Improve use of extremities (better core & trunk control= better stability)
-improved comfort (facilitates participation)

what 5 factors impact posture

-tone
-strength
-ROM
-gravity
-habitual patterns of mvmts (spasms)

describe posture when a patient can passively achieve alignment?

= posture considered FLEXIBLE (can be corrected via muscular effort)

describe posture if pt is unable to achieve alignment passively

= fixed posture (accommodate for fixed posture thru external supports)

pressure injuries as a principle of WC seating are areas of damaged skin over bony prominence due to excessive/prolonged

pressure, friction, shear, heat &/or moisture

-MAJOR health concern for those who use wc (esp pt w/ poor sensation or difficulty repositioning themselves)

-Can develop w/in hrs

-Can take months to heal

what 8 factors influence/contribute to the development of pressure injuries

-Decreased sensation
-Decreased mobility
-Excessive heat or moisture
-Poor sitting posture
-Previous or current pressure injury
-Poor diet/ fluid intake
-Aging
-Underweight (not a lot of cushioning around bony prominences) or overweight (excessive pressure on bony prominences)

what are 3 linear adjustments for MWC frames/bases

-Depth: allows for potential growth, determines turning radius (deeper chair= larger turn radius), ability to move in small spaces
-Height: determines ability to clear head if travel in a van, determines ability to self propel w/ feet
-Width: allows for potential growth (for children), allows us to clear doorways/narrow hallways

what happens if seat depth is too long

can lead to posterior pelvic tilt & kyphosis

what happens if seat width is too wide or too narrow

-too wide: can cause wheel access/self-propel challenging & poor shoulder alignment/biomechanics
-too narrow: increased pressure on hips from arms rests & leg rests

describe angular adjustments for MWC frames/bases

-Seat to back angle→ can accommodate for decreased hip flexion ROM & can create "dump" if needed (< 90 deg → places their COM into back of WC for better stability
-Seat to lower leg support angle → allows for LE elevation (pt w/ edema)

what are different types of foot support assembly and how is it determined

-fixed, lift off, swing in/out
-transfer style & final foot position placement will determine the style

what are different types of arm support assembly and how is it determined

-single or dual post, flip up, adjustable height, full or desk length
-determine based on transfer style, pressure relief method, durability

the non-adjustable MWC frame type is often called "transport chair" → used to get from point A to B. Most basic w/

no adjustability & limited sizing
-Sling seat & back
-Standard arm rests w/ fixed height (full or desk, removable or not) standard foot rests
-Population: Rental or temporary, often cannot self-propel, transfers to other surfaces quickly, requires w/c intermittently

describe the minimally configurable MWC frame type

-Some adjustability → more widths, depths, heights
-Population: may allow for hemi-height propulsion (pt who spends more time in chair), adjustability assists w/ maximizing safety & independence in transfers/mobility

describe the fully configurable MWC frame type

-Most complex
-Lighter w/ smaller profiles
-Better propulsion & maneuverability
-Often rigid, but w/ removable parts for disassembly
-Population: very active individuals who place a lot of demands on chair, generally safe & independent negotiating environments

describe the tilt position in MWC

-Angular position to assist w/ posture, pressure relief & weakness

-Gravity assisted positioning for rest (if pt does not have trunk control or cannot keep their head up)

-Disadvantage: Big & hard to transport→ unable to be propelled by w/c user

describe the recline position in MWC

-Allows for pressure relief, accommodate contracture, gravity assisted positioning

-Disadvantage: Big, bulky, limited sizing, often unable to self propel

describe the tilt & recline MWC position

-Combo of both

-Disadvantage: big & bulky

-Sometimes will be able to self propel

describe the standing MWC position

-Allows for WB & pressure distribution
-Must have adequate strength to utilize standing feature→ for someone who wants to be independent

what population of pt's are users of power mobility

pts who are unable to independently & functionally use a manual wc for all mobility needs
-Adequate cognition→ need intact cognition since maneuvering a power w/c is challenging

describe front wheel drive configuration in a PWC

-excellent stability, incline transitioning, maneuverability, obstacle handling
-feet close to body = close access to tables/ sinks
-learning curve for driving = need adequate posterior clearance (pt's COM infront of PWC COM)

describe the mid wheel drive configuration in a PWC

-Smallest turning radius**
-Intuitive to drive → pt's COM is close to COM of PWC
-LE positioned closer to body than RWD

describe the rear wheel drive configuration in a PWC

-Good control & drive predictability, can see feet while driving in different environments
-Feet far from body = hard to get close to objects in front

what are the benefits of a power tilt positioning feature in a PWC

-Provides a resting position can be helpful for repositioning
-Provides comfort, pressure relief
-Improves posture & head positioning

what are the benefits of a power recline & elevating leg rest positioning feature in a PWC

-Helpful for someone who needs a hoyer transfer
-Can recline into supine while in PWC
-Assists w/ pressure relief, stretching, bowel/bladder care, orthostatic hypotension, clothing mgmt, rest/ comfort

what are the benefits of a power seat elevation positioning feature in a PWC

-Seat can go up or down
-Can improve reach, function & safety→ improves access to environment
-Can improve transfers by creating level surface

what are the benefits of a power standing positioning feature in a PWC

allow for independent standing & frequent position change

describe joystick drive control

-Conventional (at hand) or non-conventional (anywhere the person has control)
-Use for someone w/ control of head, foot, or hand

describe head controls as a drive control

-Utilizes various switches on either side of head to control chair features
-MUST have good head control→ for someone w/o UE or LE control

describe sip n puff as a drive control

-Use of straw to provide different commands to chair
-Use for someone who is unable to control any other way

define "simulation" in context of a WC assessment

-process using your hands &/or equipment to determine pts tolerance to recommended angles & linear measurements identified in physical assessment
-provides opportunity to determine if suggested configuration will achieve desired goals

what is the epidemiology of a stroke

-5th leading cause of death
-leading cause of LT disability
-high in women >85
-high in men <85
-higher rates in African Americans, Mexican Americans, American Indians, & Alaskan Natives
-increased risk w/ increasing age (dbl risk > 65)
-recurrence is common (5-8% post 1yr after original stroke; 16% chance after 5 yr)

what are the determinants of mortality

-hemorrhagic > ischemic
-increased age
-HTN, heart disease, diabetes
-LOC at onset
-Lesion size (bigger lesion generally higher risk)
-Extent/ amount of deficits
-hx of CVA

what are major risk factors for any type of stroke

-HTN
-DM
-arrhythmias
-hypercholesterolemia
-smoking/ tobacco use
-heart disease
-sleep apnea

describe an ischemic stroke

-accounts for 80% of strokes
-3 types
-lack of blood flow to brain leading to cell death

what are the 3 types of an ischemic stroke

-thrombus: clot w/in brain or circulation to brain
-embolism: particle of matter breaks off & travels in circulation leading to blockage via plaque
-low systemic perfusion: not enough blood getting to brain due to cardiac failure or significant blood loss

what are the risk factors for an ischemic stroke

-atrial fibrillation
-cardiac disease & cardiac surgeries

describe the etiology of a hemorrhagic stroke

-intracerebral or subarachnoid
-via aneurysm or arteriovenous malformation (AVM) causing excess blood in or around the brain (BV rupture)
-closely linked to chronic HTN
-c/c of severe HA accompanied by vomiting

what are the early warning signs of stroke

-Face drooping
-Arm weakness
-Speech difficulty
-Time to call 911

why is early time to treat very important in stroke

-early CT can be used to determine etiology and guide tx
-tPA can be given in first 3-4.5 hrs IF artherothrombotic (ischemic) resulting in significant better recovery
-tPA can not be given if stroke is hemorrhagic or if outside the 3-4.5 hr window

what does cell survival depend on

largely on severity & duration of ischemia, 20-25% of BF is required for cells to survive

what is cerebral edema and its consequences

-Due to tissue necrosis, widespread rupture of cell membranes→ fluid moves into brain tissue (fluid inside cell moves out of cells into brain)
-Most frequent cause of death in acute stroke
-Characteristic of large infarcts of MCA & ICA
-consequences: increased ICP, intracranial HTN, midline shift of brain causing uninvolved hemisphere to get squished

what are the clinical sxs of cerebral edema

-decreased consciousness
-increased HR
-irregular respiration
-vomiting
-unreactive pupils & papilledema (swelling of optic discs)
-widened pulse pressure (very big span between systolic & diastolic BP)

what is a transient ischemic attack (TIA)

-temporary interruption of BF
-sxs → mins to hrs but no longer than 24 hrs
-increases risk for CVA & MI

what does a major stroke cause

severe impairments but pt is usually stable

what is the result of a deteriorating stroke and why

Neuro status declines following admission→ due to systemic or cerebral changes

what is a young stroke classified as

stroke occurred < 45 y/o

what are the determinants of severity and sxs of CVA

-location of lesion
-size of lesion
-nature of lesion
-body structures involved
-availability of collateral BF

describe an anterior cerebral artery (ACA) sydnrome

-Contralateral hemiparesis & sensory loss (LE > UE)
-Urinary incontinence
-Apraxia→ someone has strength, but not able to carry out the task or motor plan

what is the difference between ideational apraxia & ideomotor apraxia

-ideational: inability to produce mvmt on command or automatically w/ complete breakdown in conceptualization of task
-ideomotor: unable to produce mvmt on command but can move automatically; can perform habitual tasks when NOT commanded to do so

describe a middle cerebral artery (MCA) syndrome

-Contralateral hemiparesis & sensory loss (UE >LE)
-Left hemisphere lesion→ aphasia (difficulty comprehending & expressing language)
-Right hemisphere lesion→ perceptual deficits
-Homonymous hemianopsia (field cut/ do not have vision in visual field)
-Most common site of occlusion

describe a posterior cerebral artery (PCA) syndrome

-Contralateral sensory loss (thalamic branches)
-Homonymous hemianopsia, visual agnosia (vision intact but not able to identify common objects), cortical blindness if bilateral (occipital branches, have lost vision but can respond to light)
-Amnesia= memory loss

describe internal carotid artery (ICA) syndrome

-Massive infarction to areas supplied by the MCA (MCA branches off the ICA)
-Can lead to infarction of ACA territory if collateral blood flow isn't present through Circle of Willis
-Significant edema possible due to blocking off BF to MCA → herniation (brain starts to come down into SC), coma, death (a lot of cell death/ cell membrane rupture

describe a lacunar stroke

-strongly associated w/ hypertensive hemorrhage & diabetic microvascular disease (small cell)
-Caused by small vessel disease (DM, HTN) deep in cerebral white matter
-Presenting symptoms dependent upon impacted structures

describe a vertebrobasilar artery syndrome

-Many can occur due to small vessel disease→ can be small & discrete OR
-Larger infarcts→ very dangerous w/ high rate of mortality or multisystem dysfunction → Can lead to LOC, hemiparesis, disordered consciousness, vertigo, nystagmus, dysphagia, dysarthria, syncope, ataxia

what are the neurologic sequelae's of a stroke

-altered consciousness
-aphasia
-dysarthria: difficulty figuring out language plan causing slurred speech due to lesion in primary cortex, primary sensory cortex, or cerebellum
-dysphagia: inability/difficulty to swallow
-language & swallowing considerations (establish reliable communication via gestures, single commands)
-seizures (most common acutely & w/ hemorrhagic cVA)
-bowel/bladder function
-cardiopulmonary function (increased fatigue/decreased endurance = can inhibit rehab potential)
-DVT/pulm embolism
-osteoporosis/fx risk

describe the 3 types of aphasia

-fluent (wernick's/receptive): speech flows smoothly but auditory comprehension is impaired
-non-fluent (broca's/expressive): comprehension is good, but speech production is labored or completely lost
-global: severe presentation w/ impairments in comprehension & production of language

what are neurologic sequelae of a stroke regarding cognition

-Alertness/ arousal
-Orientation
-attention
-Memory
-Confusion
-Perseveration (continued repetition of words, thoughts or acts not related to current context)
-Executive function (engagement in purposeful behavior, planned behavior)

what are neurologic sequelae of a stroke regarding affect (emotional changes) due to lesions of the frontal lobe, hypothalamus, or limbic system

-Pseudobulbar affect (emotional lability or dysregulation (pt could have emotional outbursts not consistent w/ their mood or situation)
-Apathy
-irritability/ frustration
-social appropriateness
-Depression

what occurs if the left hemisphere is affected during a stroke

-Difficulty w/ communication (aphasia), info processing
-Cautious, anxious, disorganized
-Hesitant to try new things, benefits from support & feedback
-Realistic appraisal of current limitations

what occurs if the right hemisphere is affected during a stroke

-Difficulty w/ spatial/perceptual tasks (usually no language issues)
-Quick, impulsive, poor insight/ judgment/ safety
-Overestimates ability, unaware of deficits
-Often will need frequent feedback to slow down & think things through