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N Exam 2

CVA, TBI, balance, perception

when do you use a RIP pattern? when pt has spasticity or rigidity- use to break up tone
most common orthodic for people with stroke AFO
when shd is subluxed... make sure shd is supported- wt bearing or open chain w/arm supported
if you do parts to whole... put it all together at end
different types of CVA ischemic, hemorrhagic, TIA
ischemic CVA thrombus, embolus
thrombus:atherosclerosis decrease artery size (slowly gets smaller)
embolus:cardiac event or disease, blood clot to brain, quick onset
hemorrhagic CVA AVM, HTN, aneurysm (SAH), ICH
AVM you're born with this, abnormality that affects circulation in brain arterial venous
HTN hypertension, causes decrease in integrity of vessels in brain
aneurysm SAH- subarachnoid space
ICH intracerebral hemorrage
TIA CVA transient ischemic attack, mild stroke, mini stroke, temporary
ischemia leads to necrosis-ischemic penumbra:surrounding area @ risk
edema leads to increased intercranial pressure
decreased blood flow toxic to neural tissue, increased intercranial pressure
stroke extension stroke is in one area- but there will be results in other areas due to damage to cells that control calcium & glutomate & their levels will increase
modifiable risk factors HTN, heart dx, hyperlipidemia, cigarette smoking, ETOH, sedentary, obesity, oral contraceptive
non modifiable risk factors prior TIA, CVA- gender, more likely for males- race, African Americans- Family hx- age
prevention identify high risk groups-lifestyle modification-regular screenings
medical dx hx & PE, dx tests- CT, MRI
using CT for stroke (computed tomography) cheaper & easier, won't show up if too early, small or embolitic, can ID hemorrhagic, you can r/o tumor and it's more common
using MRI for stroke better in acute, costs more
immediate medical rx monitor & regulate- cardiopulmonary function, BP, ICP, blood glucose, kidney. prevent secondary complications- sz, infection. dissolve clot-heparin, tPA (tissue plasminogen activator). Sx- to remove hematoma or fix vessel
CVA rehab av. hospital stay 5-6 days, team approach, most effective 1st 6-18 months, in about any setting, assessed with FIM score & Fugl-Meyer
stroke syndromes ACA, MCA, vertebrobasilar artery, PCA, lacunar infarct
ACA- anterior cerebral artery more effect in LE, pt typically incontinent, aphasia, some memory & behavior deficits
MCA- middle cerebral artery UE & face, aphasia, homonymous hemianopia- most common
vertebrobasilar artery often fatal-ataxia, effects cranial nerve & cerebellum- feel trapped in body, can't communicate
PCA-post cerebral artery sensory loss & vision
lacunar infarct deep in brain, usually result from DM & HTN
L CVA/ R hemi aphasia, alexia, agraphia, apraxia, negative, anxious, realistic about situation
R CVA/ L hemi perceptual deficits, neglect, Pusher syndrome, dysarthria, dysphagia, impulsive, indifferent, overestimates ability
cognitive problems memory, confabulation, impaired judgment, poor insight, won't get humor, confused, impaired orientatino, decreased attention & arousal
behavior problems lability, flat effect (no emotion), decreased motivation, irritable
visual problems homonymous hemianopsia
sensory problems thalamic pn- pn perseveration- even tho stimulus is removed
perceptual problems unilateral neglect, pusher syndrome, apraxia
communication problems aphasia-expressive (from motor broca, can't say what they mean), receptive (from wernike, when you speak they don't understand), global. dysarthria
oralfacial problems unilateral facial weakness-one side drooping, probs eating/drinking. w/dysphagia increase the HOB. watch for inadequate nutrition
mm problems hypotonus, spasticity, synnergies (strongest components), Brunnstrom: stages of recovery, typical posture of stroke pt. mm weakness. reemergence of primitive reflexes
couple other problems cardiopulmonary deconditioning, bowel & bladder dysfunction
secondary problems contractures, shd pn & subluxation (flaccid or spastic), RSD, shd-hand syndrom, decrease balance, falling, DVT's, pn, stress, go thru stages of loss, pressure sores
how PT helps with communication posture control (sitting balance, head control), eye contact, inhibiting abnormal tone, improve respiration, UE control to use assistive tech (like computer)
typical posture of adult hemiplegic: head lat flexion toward involved side, rotation away from involved side
typical posture of adult hemiplegic: UE scap: depression, retract. shd: add, IR. elbow: flex. forearm:pronation. wrist: flex, ulnar dev. finger: flex
typical posture of adult hemiplegic: trunk lat flex toward involved side
typical posture of adult hemiplegic:LE pelvis: elevation, retraction. hip: IR, ADD, ext. knee: ext. ankle: plantarflex, supination, inv. toes:flexion
synergy patterns Brunnstrom, when pt attempts mvmt, these occur.
UE flexor scapula retraction, elbow flexion, wrist/hand flexion
UE ext shd IR & ADD, forearm pronation
LE flexor hip flex
LE ext hip add, knee ext, ankle plantarflex
looking for tone w/ PROM, what do you feel? will feel like they are pulling against you, like they're stuck
typical sitting posture pt might lean fwd or bkwd, feet apart, sit on affected side & lean to other side, post pelves, kinda scared
balance COG over BOS & auto postural adjustments
2 components of balance 1)anticipating 2)on-going/concurrent
systems needed for balance sensory, perceptual & motor
sensory touch & proprioceptive pressure-somatosensory, visual-visual accuity & peripheral vision, vestibular-can resolve postural dilema
perceptual cognitive, if not paying attention or not able to understand it can cause problems
motor standing strategies-ankle/hip/step
in which stage of motor dev do we start working on balance? controlled mob
common probs with static balance wt distribution (putting wt on 1 side in sitting or standing), BOS (wide BOS is usually compensating for balance prob), sway (increase in sway is another compensation)
common probs with dynamic balance fear (causes stiffness), changes in LOS, changes in balance reactions (if speed or timing of reactions are delayed- intensity of reaction can also cause probs whether too much or too little)
M-CTSIB modified clinical test for sensory interaction in balance- tells us abt sensory conflict- separates different parts of balance so we can see what the problem is
balance efficacy pt evaluates self
where do more falls occur... ECF/hospitals or home? 3x more in ECF/hospitals
intrinsic factors that cause falls impaired cognition, vision, & sensation, postural changes, balance problems, loss of flexibility & strength, poor endurance, fatigues quickly, loss of mobility, gait changes, pain
hypotonia low tone (ex. Downs syndrome)
dysmetria problem judging distances
dysdiadokinesis inability to control rapid alternating movements
intentional tremor trying with effort to do something, constant throughout movement
postural tremor only happens in certain position
movement decomposition generalized weakness so movement not as good
ataxia gait, wide base, high guard, stagger
dysarthria speech, motor problem
scanning (speech) looking for words- speech not fluid
asthenia decrease strength
key structures of vestibular dysfunction 3 semicircular canals (SCC), saccule & utricle
3 semicircular canals fluid + hair cells, angular acceleration/deceleration, velocity
saccule & utricle fluid + hair cells + Otolithes, linear movement, gravity dependent, static head tilt
VOR (cerebellum) vestibular occular reflex, gaze stability w/head mvmt, extrinsic eye mm control, smooth pursuit, scanning, saccade: quick eye reposition (compensatory, functional-reading)
vertigo body/environment is moving/spinning Vestibular
dysequilibrium sensation of being off-balance
oscillopsia vibrating motion of objects in visual environment that are known to be stationary
lightheadedness may faint, pre syncope, brain ischemia, orthostatic hypotnesion, VBI (vestibrobasilar insufficiency), hypoglycemia
vertigo nausea
nystagmus oscillating eye movement
frenzel lenses special glasses that magnify pt eyes
BPPV benign paroxymal positional vertigo- vertigo brought on by diff positions
meds for vestibular dysfunction antihistamines, antianxiety, anticholinergic (motion sickness)
habituation ex reduce symptoms with provoking activities/positions
dynamic gait index developed to assess the likelihood of falling in older adults. designed to test 8 facets of gait. total score 24. greater than 19/24 is predictive of falls risk in community dwelling elderly
perception integration of sensory impressions into information that is psychologically meaningful. memory + sensation
transfer of training approach practice tasks with similar perceptual requirements will carry over to other tasks
SI (sensory integration) approach controlled sensory input to facilitate desire motor response, CNS processing (ex: rubbing w/ different textures, ice, wt bearing, spinning)
somatagnosia impairment of body scheme
position in space inability to perceive special concept: up/down, under/over, in/out
ideomotor apraxa inability to perform a task on command or imitate gestures, even tho the pt understands the task. pt is able to perform previously learned tasks automatically
ideational inability to perform a purposeful motor task either automatically or on command. the pt has no concept of taks
tinetti assessment tool balance and gait portions
Berg lots of sitting, standing, EO, EC, turning, std on one leg
vestibular rehab evaluation sheet. oculomotor & vestibulo-ocular exam, physical status, positional vertigo/nystagmus, motion sensitivity quotient
dizzy feelings circle feelings you are calling dizziness
habituation ex Brandt-Daroff, sit EOB feet flat, turn head, lie down, sit up, turn head other way... no symptoms count to 30. symptoms wait until they are gone then count 30. 3x session... 3 sessions day
standing balance ex feet apt, feet together, feet in half tandem, feet in full tandem. firm or foam.
Vestibular-ocular ex once every hr or 2 shake your head side to side and read one list of words
causes of TBI MVA (motor vehicle accident), falls, violence, war, sports & recreation (child-bicycle)
main people getting TBI men 15-24
TBI prevention helmets, seatbelts, dont get DUI, use protective equipment with sports
EDH- epidural hematoma "talk & die"
SDH- subdural hematoma
obstructive hydrocephalus enlarged ventricle as a result of impaired CSF-decreased response, impaired concentration, HA, vomiting, sudden irritability, increase BP & decrease HR- rx with mannitol or shunt
TBI dx tests EEG, evoked potentials, MRI, CT scan, PET scan, PE, glasgo coma scale (less than 8 =coma), Ranchos Los Amigos Levels of Cognitive Function (LOCF)
coma vs vegetative state vegetative state is several months- some brain stem reflexes return, may occasionally open eyes, sleep & waking cycles, response to pn sometimes, but still basically unconscious. coma-EC, no volitional mvmt, 3-4 wks
complications, secondary problems of TBI infection, mm atrophy, pneumonia, contractures, DVT's pressure sores
PT interventions in acute phase of TBI PROM, positioning, mm setting, bed mob, EOB & OOB ASAP, tilt table
medications for TBI sz meds (phenytoin-dilatinin, phenobarbitol-luminol, carbamazepine-tegretol), tylenol, NSAIDs, wk narcotics, antidepressants, antipsychotics, botox, phenol, baclofin, valuim, dentrilene for spasticity.
heterotrophic ossification abnormal bone formation is soft tissue of mm as result of immobility-most common in hip
LOCF Levels I, II, III comatose
LOCF Levels IV, V, VI confused
LOCF Levels VII, VIII appropriate
LOCF Levels VIII, IX, X purposeful, appropriate
LOCF Level I no response/total assist
LOCF Level II generalized response/total assist, response with gross body mvmt (ex roll in bed), physiological changes, &/or vocalization, response delayed
LOCF Level III localized response/total assist, specific response consistent w/stim, strongest response to pain & bad odors
LOCF Level IV confused-agitated (bizarre world)/max assist, attention: brief, general. memory: no STM. learning:none. behavior: agressive/flight, mood swings. no purpose, no cooperation, egocnetric. speech: confabulating, incoherent
LOCF Level V confused-inappropriate-nonagitated/max assist. alert, wandering-"go home". brief w/structure, more specific. memory: impaired, some return of old learning. no new learning. behaves without structure, random/ nonpurposeful. no prob solve. confused speech
LOCF Level VI confused-appropriate/mod assist. may realize in hospital. incr in attn & memory. new learning. simple commands, poor awareness of limits, speech appropriate w/structure
LOCF Level VII- robot phase auto appropriate/min assist. realize what happened to them. depression. irritable, uncooperative
LOCF Level VIII, IX, X purposeful appropriate/stand by assist to Mod I. doing better. figuring out how they will be from now on
Created by: jessigirrl4
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