case study 5 - CVA

Question 1

What is the circle of willis

Answer 1

A ring of blood vessels connecting the anterior and posterior circulations of the brain and providing important communication between them.

Question 2

what are the arteries of the brain

Answer 2

• right and left carotid arteries
• Anterior + posterior cerebral artery
• Middle cerebral artery
• Anterior communicating artery

Question 3

what is diabetes melititus

Answer 3

• known as diabetes where the insulin in your body is affected (can be type 1 or 2)

Question 4

what is type 1 diabetes

Answer 4

– a lifelong condition where the body’s immune system attacks and destroys the cells that produce insulin.

Question 5

what is type 2 diabetes

Answer 5

– where the body does not produce enough insulin, or the body’s cells do not react to insulin properly.

Question 6

symptoms of diabetes mellititus

Answer 6

• Increased urination often at night
• Blurry vision
• Lack of energy/fatigue
• Tingling/numbness in hands/feet
• Delayed wound healing.

Question 7

where is insulin produced

Answer 7

• in the pancreas

Question 8

what is the glasgow coma scale

Answer 8

• used to objectively describe the extent of impaired consciousness in all types of acute medical and trauma patients
• score of 13-15 = mild
• score of 3-8 = severe
• looks at visual, verbal and motor reponse
• could also use AVPU method

Question 9

what are the phases of gait

Answer 9

• initial contact
• loading response
• mid stance
• terminal stance
• pre swing
• initial swing
• terminal swing

Question 10

what is the middle cerebral artery

Answer 10

• allows for oxygenated blood to glia cells (important for movement)
• branches directly from the internal carotid artery and consists of four main branches, M1, M2, M3, and M4.

Question 11

risk factors of stroke

Answer 11

• smoking
• obesity
• high blood pressure
• decreased physical acitivity
• diabetes

Question 12

name for high blood pressure

Answer 12

hypertension

Question 13

what is normal blood pressure

Answer 13

120/80

Question 14

risk factors of high blood pressure

Answer 14

• poor diet
• family history
• obesity
• lack of exercise
• increase salt in diet

Question 15

what is postural hypertension

Answer 15

an increase in the blood pressure upon assuming an upright posture.
- may cause fatigue
- fainting

Question 16

what is tone

Answer 16

• steady state of tension in muscles even at rest
• high tone = stiffness in movement
• low tone = muscles are floppy /flaccid

Question 17

what is hypertonia

Answer 17

• high muscle tone
• stiffness to movement
• can lead to contractures

Question 18

what is hypotonia

Answer 18

• low muscle tone
• flaccid/ heavy to move
• may affect their balance

Question 19

what controls muscle tone

Answer 19

• cerebellum
• extraperimidal asecnding tracts (rubrospinal tract)

Question 20

what is the reason for decrease in muscle strength following stroke

Answer 20

due to disruption in communication between brain and muscles, corticospinal tract is disrupted, decreasing strength and tone as stroke is an upper motor neurone disease.

Question 21

what medication is given for hypertension

Answer 21

most common is pistril

Question 22

what muscles may be affected on his upper and lower left side

Answer 22

upper:
- bicep, tricep, deltoids, pectoralis major, wrist flexors +extensors
lower:
- quadriceps, hamstrings, hip flexors (psoas major, iliacus), glutes, gastrocnemius, tibialis anterior

Question 23

what causes foot drop

Answer 23

• perineal nerve affected by stroke
• low tone in tibialis anterior and gastrocnemius

Question 24

what is shoulder sublaxation

Answer 24

• occurs when the humerus partially slides in and out of place quickly
• when assessing ROM shoulder joints, check for sublaxation by performing flexion and holding inferior angle scaupla so it moves with joint.

Question 25

How would you assess left upper limb weakness?

Answer 25

- using Oxford Grading Scale will assess the muscle strength - likely to be 5/5 for right upper limb - likely to be 3/5 (against gravity) for left upper limb - also assess tone whilst doing this, palpating muscle - likely to feel softer muscle in left side - ensure to take into account shoulder sublaxation, checking for pain

Question 26

How would you treat left upper limb weakness?

Answer 26

- begin with active assisted exercises grasping hands performing extension, flexion - use weight bearing techniques - start with placing hands either side of body shifting weight onto each side - progress to all four kneeling shifting weight

Question 27

How would you assess left lower limb weakness?

Answer 27

- using Oxford Grading Scale will assess the muscle strength - likely to be 5/5 for right lower limb - likely to be 3/5 (against gravity) for left lower limb - also assess tone whilst doing this, palpating muscle - likely to feel softer muscle in left side

Question 28

what evidence is there for treatment of upper limb weakness?

Answer 28

- Zisi et all 2022 - Explain aims, experiment, findings and conclusions - weight bearing exercises shown to help increase upper limb movement and grasping strength (particuaraly extension). - active assisted grasping - sit on edge of bed and perform sit and reach

Question 29

How would you treat lower limb weakness?

Answer 29

- use a ball and ask patient to roll it with their foot up and down, if finding easy then ask them to bridge up and do the same - sit and reach also helping with balance, task specifity (mention Hasset 2023) - weight bearing techniques - progress to standing holding onto edge of plinth shifting weight from left to right

Question 30

what evidence is there for treatment of lower limb weakness?

Answer 30

- Kim et al - Explain aims, experiment, findings and conclusions - weight bearing exercises shown to help increase upper limb movement and grasping strength (particurly extension). - if this helps with upper limb it should be benificial for lower limb. HASSET ET AL - task specific excerises once 3/5 strength Chang et al - 5STS test good rather then 30STS AND 6MW when looking at breathlessness and imrpoved strength of lower limb

Question 31

how would you assess left foot drop?

Answer 31

- sensation, proprioception and coordination in foot. - manual muscle testing: dorsiflexion (Hislop et al. 2013) - get patient to sit on edge of plinth with feet hanging down - sit on stool opposite and palpate tibialis anterior, other hand resistance onto dorsal foot - ask patient to dorsiflex (tests with gravity as resistance 3/5) - if able then move to 4/5 - if 5/5 the full ROM should be done or end range held. - likely to be 3/5 - assess patients gait using WZF progress to stick

Question 32

how would you treat left foot drop?

Answer 32

- 3/5 perform dorsi flexion, foot pumps hourly - progress prescribe strengthening exercises for tibialis anterior to increase rom in dorsi-flexion - provide patient with a foot brace for extra support then splint and assess gait with this using stick.

Question 33

how would you assess sensation

Answer 33

use a peice of tissue and lightly brush the area of skin, patient closes eyes and tells you where do unaffected side first

Question 34

how would you assess proprioception

Answer 34

holding onto the distal region of toes or finger laterally, bring it up and down and patient closes eyes telling whether it is up or down

Question 35

how would you assess coordination

Answer 35

touch your nose then my finger rub your heel onto your contralateral shin

Question 36

what evidence is there supporting the importance of task specificity

Answer 36

Hasset 2023 - says mobilization with task specifity is important once patient can move against gravity

Question 37

what are the risk factors of strokes

Answer 37

- high blood pressure - heart disease - smoking - diabetes - poor diet - gender (most common/higher risk in females) - brith control

Question 38

what is spactsity

Answer 38

muscles excitability, involuntary

Question 39

what do NICE guidelines say about stroke

Answer 39

- NICE guidelines (2023) stroke patient should be offered rehab 3 hours a day, on at least 5 days of the week, and cover a range of multidisciplinary therapy including physiotherapy, occupational therapy and speech and language therapy.

Question 40

ischemic stroke

Answer 40

ischaemic – where the blood supply is stopped due to a blood clot

Question 41

haemorrhagic

Answer 41

haemorrhagic – where a weakened blood vessel supplying the brain bursts.