1
Q
Stroke Death Prevelence
A
- stroke kills almost 130,000 americans each year
- 1 out of every 19 deaths
- every year, more than 795,000 people in the US have stroke
- 185,000 strokes (1 in 4) are people who have had previous stroke
- stroke is a leading cause of serious long-term disability
2
Q
Risk factors of Stroke that CANNOT be changed
A
- age: risk doubles for each decade of life after age 55
- gender: more common in men than women, women use of birth control pills and pregnancy pose stroke risks though
- prior stroke, TIA, or heart attack: person with 1+ TIA is 10X more likely to have a stroke than someone of same age/gender. if patient has had heart attack, 3X higher risk of having a stroke
3
Q
TIA
A
- transient ischemic attack
- aka “mini stroke’
4
Q
Can stroke risk be influenced by race and ethnicity?
A
- YES
- risk of first stroke is nearly twice as high for African Americans and African American’s are more likely to die following a stroke than caucasians
- hispanic americans’ risk for stroke falls between caucasians and african americans
5
Q
CVA Risk Factors that CANNOT be changed but CAN be TREATED or controlled
A
- sickle cell anemia
- african american and hispanic children more common
- sickle cells tend to stick to blood vessel walls, which block arteries and cause a stroke
6
Q
CVA Risk factors that CAN be CHANGED, TREATED, AND CONTROLLED
A
- high blood pressure
- cigarette smoking
- diabetes mellitus
- carotid or other artery disease (peripheral)
- atrial fibrillation
- high blood cholesterol
- poor diet
- physical inactivity/obesity
7
Q
Carotid artery
A
- narrowed by atherosclerosis
- plaque builds up in artery walls
- may become blocked by blood clot
8
Q
Peripheral Artery Disease
A
- narrowing of blood vessels carrying blood to leg and arm muscles
- plaque in artery walls
- higher risk of artery disease and therefore stroke
9
Q
Poor Diet that increases stroke risk
A
- high in saturated fat and cholesterol
- high sodium (salt)
- diets with excess calories > obesity
- 5+ servings of fruits and vegetables per day may reduce the risk of stroke
10
Q
Physical inactivity and obesity effects on stroke
A
- being inactive, obese, or both can increase risk of high blood pressure, high blood cholesterol, diabetes, heart disease, and stroke
- recommendation: at least 30 minutes of activity on most or all days
11
Q
Ischemic Prevelence with strokes
A
- ischemic: lack of blood
- 83-87% of all strokes are ischemic strokes, when blood flow to brain is blocked
12
Q
Two types of ischemic strokes
A
- cerebral thrombus
- cerebral embolism
13
Q
Cerebral Thrombus
A
- type of ischemic stroke
- blood vessel narrows
- from atherosclerosis
- thrombosis = blood clot
14
Q
Cerebral embolism
A
- type of ischemic stroke
- clot from heart, upper body, or neck dislodges and move to brain and blocks artery
15
Q
DVT
A
- deep vein thrombosis
- expect swelling, red and warm to touch, paon
- don’t vigorously exercise with DVT!
16
Q
Hemorrhagic Stroke
A
- 17% of all strokes
- weakened vessel that ruptures and bleeds into the surrounding brain
- blood accumulates and compresses the surrounding brain tissue
- weakened blood vessels are from aneurysms or arteriovenous malformations (AVMs)
17
Q
Aneurysm
A
- ballooning of a weakened region of a blood vessel
18
Q
Arteriovenous Malformation (AVM)
A
- a cluster of abnormally formed blood vessels
- the vessels can rupture, causing bleeding into the brain
19
Q
MCA
A
- middle cerebral artery
- most common stroke location
20
Q
Areas affected by a MCA stroke
A
- optic radiation = homonymous hemianopia (contralateral visual fields cut)
- broca’s and wernicke’s area = expressive and receptive aphasia
- motor and sensory homunculus
21
Q
Broca’s Area #
A
44
22
Q
Wernicke’s Area #
A
22
23
Q
Homonymous Hemianopsia
A
- due to a stroke involving the optic tract or radiations on the opposite side
- usually from MCA
- homonymous hemianopsia is when you cannot see the same 1/2 of each eye (i.e. both eyes lose their field of vision of the R side)
24
Q
Unilateral optic field loss
A
- i.e. left optic nerve compression
- this is when you can see completely out of one eye but not at all out of the other
- eye that is blind is one with nerve compression
25
Bitemporal hemianopia
- chiasmal compression from "pituitary tumor"
| - means both the outside/lateral visual fields are blinded/blocked
26
Contralateral Hemiparesis and Sensory impairment due to MIDDLE Cerebral Artery affects what areas first
- arm > leg
27
Apraxia
- can be caused by MCA stroke
- inability to plan or carry out a motor plan
- ideomotor apraxia
- ideational apraxia
28
What does the MCA supply?
- supplied internal capsule and basal ganglia
- damage will result in both UE and LE involvement
- remember: internal capsule deals with a lot of motor output
29
Contralateral Hemiparesis and Sensory impairment due to ANTERIOR cerebral artery affects what areas first
- leg > arm
30
Anterior Cerebral Artery Stroke impairments
- contralateral hemiparesis
- contralateral sensory impairments
- loss of bowel/bladder control
- apraxia
- mental impairment with perseveration, confusion, memory loss
31
Perseveration
- do the same thing or say the same words repeatedly
32
Posterior Cerebral Artery Stroke Impairments
- contralateral homonymous hemianopia
- Dyslexia
- Memory deficits
- Topographical disorientation
- cranial nerve III Palsy (oculomotor)
- contralateral hemiparesis
- Thalamic Syndrome
33
Thalamic Syndrome
- can be due to posterior cerebral artery stroke
- sensory impairments in all modalities
- pain
- paresthesias
- pain and temperature sensory loss
- ataxia, athetosis, choreiform movement
- visual agnosia: not recognizing familiar object with vision
- tactile agnosia: not recognizing object based touch
34
Dyslexia
- learning disorder characterized by difficulty reading due to problems identifying speech sounds and learning how they relate to letters and words
- also called specific reading disability
- common learning disability with children
- can be from posterior cerebral artery stroke
35
Patesthesia
- an abnormal sensation such as tingling, tickling, pricking, numbness or burning of a person's skin
- can be symptom of thalamic syndrome due to posterior cerebral artery stroke
36
Athetosis
- slow, characterized by slow, involuntary, convoluted, writhing movements of the fingers, hands, toes, and feet
- in some cases arms, legs, neck and tongue
- can be symptom of thalamic syndrome post posterior cerebral artery stroke
37
Choreiform movements
- involuntary, forcible, rapid, jerky movements which are mostly manifestations of basal ganglia diseases (relatively small amplitude)
- can be from thalamic syndrome from posterior cerebral artery
38
Carotid Arteriogram
- arteriogram of the R carotid artery showing a severe narrowing (Stenosis) of the internal carotid artery just past the carotid fork
- there is enlargement of the artery after the stenosis
39
Basilar Artery Stroke Impairments
- brainstem
- coma
- quadriplegia
- "locked in" syndrome
- bilateral cerebellar ataxia
- thalamic pain syndrome
- diplopia or other visual field deficits including blindness
40
Locked-in syndrome
- can be from basilar artery stroke
- pure motor
- can't move but they might be able to move their eyes and possibly communicate through the movement of their eyes
- intact consciousness
41
Vertebral Artery Stroke Impairments
- ataxia
- vertigo
- nausea
- vomitting
- nystagmus
- impaired pain and temperature sensation in ipsilateral face
- Horner's syndrome (sympathetic dysfunction causing ptosis)
- dysphagia
- sensory impairment in contralateral arm, trunk, and leg
42
Vertebral Artery Test
- rotating away from side that testing, and extending of cervical vertebra
- look for pupil to dilate, for dizziness of individual
- can also check for nystagmus
43
Muscle Fiber type I
- slow, oxidative
| - motor unit is slow
44
Muscle fiber type IIA
- fast, oxidative glycolytic
| - motor unit is fast, fatigue-resistant
45
Muscle fiber type IIB
- fast, glycolytic
| - motor unit fast, fatigable
46
Slow oxidative muscle fiber info (SO, Type I)
- motor units: many
- muscle fibers: few
- axon diameter: small
- tetanic tension: low
- fatigability: low
- speed of contraction: slow
- muscle fiber diameter: small
- capillarization: rich
- mitochondria: many
- ATPase: low
- oxidative enzymes: high
47
FF Motor Unit/FG Muscle Fiber Info (Type IIB)
- motor units: few
- muscle fibers: many
- axon diameter: large
- tetanic tension: high
- speed of contraction: fast
- muscle diameter: large
- capillarization: poor
- mitochondria: few
- ATPase: high
- Oxidative enzymes: low
48
Henneman Principle
- there exist an order to motor unit recruitment when GRADUAL CONTROL OF TENSION is important
- small motor units are recruited 1st and larger last
- large motor units are de-recruited 1st and small de-recruited last
* *THIS ORDER IS VIOLATED WHEN ONE IS PERFORMING BALLISTIC OR RELATIVELY FAST MOVEMENTS
49
Henneman Principle slope
- shows the control of speed of muscle force generation (graded)
50
Tactile Sensation
- identify pattern of sensory loss
- glove-like or sock-like loss = cortical lesion
- cortical lesion
51
Scapula Subluxation
- common occurrence after stroke
- humerus subluxes inferiorly out of glenoid fossa
- due to weakness or spasticity
- weight of humerus causes upward rotation of inferior angle of scapula
- abnormal position of scapula
- flaccid or low tone or weak muscles at shoulder and trunk lead to altered alignment of scapula and humerus
- dynamic stabilizers not present
- reliance on static stabilizers which overstretch due to weight of arm in dependent position
- inferior subluxation is most common
- assume due to low tone, but also hypertonicity pullin scap up that may not even be related to RCM
- best to position sidelying or with table/armrest under
52
Impairment if have an optic nerve lesion
- blind in one eye
53
Impairment if have an optic chiasm lesion
- Bilateral temporal field deficit
| - i.e. blind in the outside/lateral of both eyes
54
Impairment if have an optic tract, optic radiations, and/or occipital lobe lesion
- L homonymous hemianopsia
| - cannot see the L half of the visual field for BOTH eyes
55
Temporal lobe lesion eye impairment
- L upper quadrant homonymous hemianopsia
| - Cannot see the upper left 1/4 in BOTH eyes
56
Parietal lobe lesion visual impairments
- L lower quadrant homonymous hemianopsia
| - cannot see in the lower left 1/4 of visual field in BOTH eyes
57
occipital lobe lesion visual impairments
- homonymous hemianopsia
58
Optic Nerve Testing
- usually test with glasses on
- screen both eyes at the same time
- if deficit noted, test each individual eye
- know the optic nerve pathway (optic nerve, chiasm, tract, radiation)
59
Test 1 for Optic Nerve
- determine peripheral vision "edges"
| - find the visual deficit in which quadrant
60
Test 2 optic nerve test
- which finger moving in each quadrant
61
Test 2/3?
- number of fingers held up in each quadrant
62
TBI cause
- caused by a bump, blow or jolt to the head or a penetrating head injury that disrupts the normal function of the brain
- altered consciousness (no matter how brief)
63
CHI of TBI
- closed head injury
- no skull fracture or laceration of the brain
- coup-countercoup
64
OHI of TBI
- Open head injury
| - meninges have been breached, brain is exposed
65
Coup-countercoup
- coup: primary injury at impact in one direction from blow
| - countercoup: secondary injury on the opposite side from bounce back/counteraction of forces
66
TBI prevelance
- 1.7 million TBIs occur either as an isolated injury or along with other injuries each year
- about 75% of TBIs that occur each year are concussions or mild TBI
- TBI is a contributing factor to about 1/3 (30.5%) of all injury-related deaths
67
TBIs by AGE
- 3 large peaks in lifetime of TBI
- children 0-4 years
- older adolescents 15-19
- adults afed >65 years
* *adults 75+ have highest rates of TBI-related hospitalization and death
68
TBI by GENDER
- in every age group, TBI rates are higher for males as compared to females
69
Costs of TBI
- direct medical costs and indirect costs such as lost productivity totaled an estimated $76.6 billion in the USA in 2000
70
TBI causes
- MVA >60% (auto 70%, pedestrian 5%, motocycle 25%)
| - other <40%
71
TBI Prevention
- risk of brain injury in hospitalized motorcyclists is 2X for un-helmed vs. helmeted motorcyclists
- acute care costs for unhelmeted drivers are 3X cost
- in Cali, first year's implementation of 1992 helmet law resulted in 37.5% DECREASE in statewide crash fatalities
- 140,000 head injuries per year are attributed to children and adolescents in bicycle accidents (estimated 74-85% mod-severe TBIS are prevented by bike helmets)
- 14% decrease in fatality for front passangers wearing seat belts
72
General Risk Factors of TBI
- young (avg TBI = 29 yo)
- male
- risk taking behaviors
- low income, urban
- substance abuse (50% hospitaliations for TBI associated with alc)
- availability of firearm
- previous TBI (sports-related concussions)
- older age (more susceptible to tearing of blood vessels, declines in cerebrovascular circulation)
73
Skull Fractures
- 24% of all patients admitted for CNS trauma sustained a skull fracture
- 38% of fractures were open
- 10% were depressed (<3 mm)
74
Location of Skull fractures in order most to least common
- frontal
- basilar
- parietal
- occipital
- temporal
75
Extracranial Injuries with TBI
- 82% at admission had one or more extra-cranial injury with TBI
- most common: head laceration (61%)
- facial fractures 13%
- hemo/pneumothorax 9%
- rib fx/long contusion 10%
- spleen 4%
- liver or bowel 11%
- genitourinary 3%
- UE fracture 14%
- LE fracture 19%
- pelvic fracture 4%
- hip fracture 2%
- other laceration 20%
76
Scapula Subluxation
- common occurrence after stroke
- humerus subluxes inferiorly out of glenoid fossa
- due to weakness or spasticity
- weight of humerus causes upward rotation of inferior angle of scapula
- abnormal position of scapula
- flaccid or low tone or weak muscles at shoulder and trunk lead to altered alignment of scapula and humerus
- dynamic stabilizers not present
- reliance on static stabilizers which overstretch due to weight of arm in dependent position
- inferior subluxation is most common
- assume due to low tone, but also hypertonicity pullin scap up that may not even be related to RCM
- best to position sidelying or with table/armrest under
77
Impairment if have an optic nerve lesion
- blind in one eye
78
Impairment if have an optic chiasm lesion
- Bilateral temporal field deficit
| - i.e. blind in the outside/lateral of both eyes
79
Impairment if have an optic tract, optic radiations, and/or occipital lobe lesion
- L homonymous hemianopsia
| - cannot see the L half of the visual field for BOTH eyes
80
Temporal lobe lesion eye impairment
- L upper quadrant homonymous hemianopsia
| - Cannot see the upper left 1/4 in BOTH eyes
81
Parietal lobe lesion visual impairments
- L lower quadrant homonymous hemianopsia
| - cannot see in the lower left 1/4 of visual field in BOTH eyes
82
occipital lobe lesion visual impairments
- homonymous hemianopsia
83
Optic Nerve Testing
- usually test with glasses on
- screen both eyes at the same time
- if deficit noted, test each individual eye
- know the optic nerve pathway (optic nerve, chiasm, tract, radiation)
84
Test 1 for Optic Nerve
- determine peripheral vision "edges"
| - find the visual deficit in which quadrant
85
Test 2 optic nerve test
- which finger moving in each quadrant
86
Test 2/3?
- number of fingers held up in each quadrant
87
TBI cause
- caused by a bump, blow or jolt to the head or a penetrating head injury that disrupts the normal function of the brain
- altered consciousness (no matter how brief)
88
CHI of TBI
- closed head injury
- no skull fracture or laceration of the brain
- coup-countercoup
89
OHI of TBI
- Open head injury
| - meninges have been breached, brain is exposed
90
Coup-countercoup
- coup: primary injury at impact in one direction from blow
| - countercoup: secondary injury on the opposite side from bounce back/counteraction of forces
91
TBI prevelance
- 1.7 million TBIs occur either as an isolated injury or along with other injuries each year
- about 75% of TBIs that occur each year are concussions or mild TBI
- TBI is a contributing factor to about 1/3 (30.5%) of all injury-related deaths
92
TBIs by AGE
- 3 large peaks in lifetime of TBI
- children 0-4 years
- older adolescents 15-19
- adults afed >65 years
* *adults 75+ have highest rates of TBI-related hospitalization and death
93
TBI by GENDER
- in every age group, TBI rates are higher for males as compared to females
94
Costs of TBI
- direct medical costs and indirect costs such as lost productivity totaled an estimated $76.6 billion in the USA in 2000
95
TBI causes
- MVA >60% (auto 70%, pedestrian 5%, motocycle 25%)
| - other <40%
96
TBI Prevention
- risk of brain injury in hospitalized motorcyclists is 2X for un-helmed vs. helmeted motorcyclists
- acute care costs for unhelmeted drivers are 3X cost
- in Cali, first year's implementation of 1992 helmet law resulted in 37.5% DECREASE in statewide crash fatalities
- 140,000 head injuries per year are attributed to children and adolescents in bicycle accidents (estimated 74-85% mod-severe TBIS are prevented by bike helmets)
- 14% decrease in fatality for front passangers wearing seat belts
97
General Risk Factors of TBI
- young (avg TBI = 29 yo)
- male
- risk taking behaviors
- low income, urban
- substance abuse (50% hospitaliations for TBI associated with alc)
- availability of firearm
- previous TBI (sports-related concussions)
- older age (more susceptible to tearing of blood vessels, declines in cerebrovascular circulation)
98
Skull Fractures
- 24% of all patients admitted for CNS trauma sustained a skull fracture
- 38% of fractures were open
- 10% were depressed (<3 mm)
99
Location of Skull fractures in order most to least common
- frontal
- basilar
- parietal
- occipital
- temporal
100
Extracranial Injuries with TBI
- 82% at admission had one or more extra-cranial injury with TBI
- most common: head laceration (61%)
- facial fractures 13%
- hemo/pneumothorax 9%
- rib fx/long contusion 10%
- spleen 4%
- liver or bowel 11%
- genitourinary 3%
- UE fracture 14%
- LE fracture 19%
- pelvic fracture 4%
- hip fracture 2%
- other laceration 20%
101
Primary vs. secondary TBI
- primary: direct injury to the brain (i.e. impact, missile, shearing)
- secondary: damage after the traumatic event caused by brain hypoxia (lack of oxygen), edema, herniation, hematoma, ischemia
102
Focal vs. Diffuse TBI
- focal: localized trauma (small blow or tumor)
| - diffuse: trauma over a large area (coup-countercoup)
103
Four Types of Hemorrhages
- epidural hematoma
- subdural hematoma
- subarachnoid hemorrhage
- intracerebral hematoma
104
Epidural Hematoma
- in epidural space, between dura mater and skull
- acute bleeding
- common in temporal bone fracture
105
Subdural Hematoma
- beneath the dura
- laceration of cortical veins during sudden head deceleration
- a feature of shaken baby syndrome
- seen in children because of firm adherence of dura to the inner skull
106
Subarachnoid Hemorrhage
- poor prognosis if bleeding into ventricular system
107
Intra-cerebral Hematoma
- in brain parenchyma (neurons & glial cells)
| - hematoma may enlarge during the first few days after injury
108
Concussion
- mild TBI
- alteration of consciousness and memory
- CT or MRI usually normal
- good prognosis
- cumulative effects of repeated concussion (can cause dimentia)
109
Post-concussion
- dizziness, disorientation, nausea, headache, fatigue
- decreased control of emotions and personality changes
- attention deficit
110
Altered Level of Consciousness
- reduction in response to stimuli
- arousal is associated with wakefulness and depends on an intact reticular formation and upper brainstem
- coma rarely lasts > 4 weeks
- DEPTH AND DURATION OF COMA IS USED TO DETERMINE CURRENT STATUS AND PROGNOSIS
111
Coma
- state of unresponsiveness
| - not opening eyes
112
Persistent Vegetative State
- no evidence of cerebral cortical function
| - eye opening with sleep-wake cycles
113
Lethargy
- severe drowsiness
| - aroused by moderate stimuli and then drift back to sleep
114
Confusion
- disorientation, bewilderment, and difficulty following commands
115
Glascow Coma Scale Overview
- out of 15 points
| - 3 sections: eye opening response, verbal response, motor response
116
Eye Opening Response Glascow Coma Scale
- spontaneous... open with blinking at baseline (4 pts)
- to verbal stimuli, command, speech (3 pts)
- to pain only (not applied to face) (2 pts)
- no response (1 pt)
117
Verbal Response Glascow Coma Scale
- oriented (5 pts)
- confused conversation, but able to answer questions (4 pts)
- inappropriate words (3 pts)
- incomprehensible speech (2 pts)
- no response (1 pt)
118
Motor Response Glascow Coma Scale
- obeys commands for movement (6 pts)
- purposeful movement to painful stimulus (5 pts)
- withdraws in response to pain (4 pts)
- flexion in response to pain (decorticate posturing) (3 pts)
- extension response in response to pain (decerebrate posturing) (2pts)
- no response (1 pt)
119
Outcomes of the Glascow Coma Scale
```
<8 ..... 70% mortality
9-11 .... 6% mortality
12-13 ..... 1% mortality
>14 .... <1% mortality
- DEPTH and DURATION of coma is the MOST ACCURATE INDICATOR OF SEVERITY OF CNS DAMAGE
```
120
Mild Concussion loss of consciousness, Glascow scale, memory loss, and prognosis
- <30 minutes of loss of consciousness
- 13-15 on Glascow scale
- <24 hr memory loss
- good prognosis, most recover completely
121
Moderate Concussion loss of consciousness, Glasgow coma, memory loss, and prognosis
- >30 minutes but < 24 hours loss of consciousness
- 8-12 glascow scale
- >24 hr <7 memory loss
- good prognosis, learn to manage problems resulting from TBI
122
Severe Concussion loss of consciousness, glasgow scale, memory loss, and prognosis
- >24 hours of loss of consciousness
- <8 glasgow scale
- >7 days of memory loss
- most impossible to recover completely and physical and/or cognitive disability
123
Severe TBI
- assess severity of brain injury
- acute surgical care: expanding mass lesion from increasing ICP
- address life-threatening injuries (ABC: airway, breathing, circulation)
- prevent complications
- preventative rehab interventions
124
Cognitive Impairments with TBI
- difficulties in:
- attention
- concentration
- learning
- memory
- abstract thinking, information processing
- problem solving
- initiation, executive functions
125
Rancho Los Amigos Cognitive Scale
- best to wait at least 3 days before you use this test
- I: no response
- II: generalized response
- III: localized response
- IV: confused, agitated
- V: confused, inapropriate
- VI: confused, appropriate
- VII: automatic, appropriate
- VIII: purposeful, appropriate
126
Rancho Los Amigos Cognitive Rating of I
- no response
| - patient appears to be in a deep sleep and is completely unresponsive to any stimulus
127
Rancho Los Amigos Rating II
- generalized response
- patient reacts inconsistently and non-purposefully to stimuli in a non-specific manner
- responses are limited and often the same regardeless of stimuli
- responses may be physiological, gross body movements, or vocalization
128
Rancho Los Amigos Rating III
- localized response
- patient reacts specifically but inconsistently to stimuli
- responses are directly related to the type of stimulus presented
- may follow simple commands such as closing the eyes or squeezing the hand in an inconsistent, delayed manner
129
Rancho Los Amigos Cognitive Rating of IV
- confused, agitated
- patient in heightened state of activity
- bizarre and non-purposeful behavior to environment
- decreased attention span, aggressive
130
Rancho Los Amigos Cognitive rating of V
- confused, inappropriate
- patient responds to simple commands fairly consistently
- responses become random or non-purposeful when commands become more complex
- gross attention intact but highly distractable
- verbalization is often inappropriate and confabulated
- memory and ability to learn new tasks severely impaired
131
Rancho Los Amigos Cognitive Rating of VI
- confused, appropriate
- shows goal-directed behavior but is dependent on external input or direction
- follows simple directions consistently and shows carryover for relearned tasks (i.e. self care)
- responses may be incorrect due to memory deficits but are appropriate for the situation
132
Rancho Los Amigos Cognitive Rating of VII
- automatic, appropriate
- patient appears appropriate and oriented within the hospital and home settings
- goes through daily routine automatically
- minimal to no confusion and has shallow recall of activities
- shows carryover for new learning but at a decreased rate
- able to initial social activities with structure
- judgement remains impaired
133
Rancho Los Amigos Cognitive Rating VIII
- purposeful, appropriate
- patient is able to recall and integrate past and recent events and is aware of and responsive to enviornment
- shows carryover for new learning and needs no supervision once activities are learned
- may continue to show a decreased ability relative to premorbid abilities, abstract reasoning, tolerance for stress, and judgement in emergencies or unusual circumstances
134
Retrograde Amnesia
- period of loss of recall of events prior to injury
135
Post-Traumatic Amnesia (PTA)
- period between the injury and time of continuous day to day memory
136
STM
- short term memory
| - immediate past
137
Short Term Working Memory
- inability to learn new information
138
LTM
- long term memory
- 1 min to 1 hour
- may of may not include over-learned material
139
Personality and Social impairments with TBI
- disinhibition: "basic personality" emerges
- inappropriate, excessive social behaviors
- exaggerated dependency or more independent
- irresponsible or lacks judgement
- egocentric or inconsiderate
- violent/aggessive
- childishness
- tactless
- miss goodie two shoes
140
Frontal Lobe TBI Signs
- decreased ability to take cues from enviornment
- silence: when say something embarrassing or inappropriate
- blush: when embarrassed or something of sexual nature
- angry look: patient bumps into someone with their wheelchair
141
Sexual Behavior Issues with TBI
- tactless attempts at intimacy
- conversation with a lot of sexual content
- inappropriate touching
- crude remarks
- indecent exposure
- masturabation
- frontal or temporal lobe
142
Mood Behavior Changes with TBI
- mood disturbances including depression and anxiety
- irritability, rage, refuse to cooperate
- euphoria: involuntary laughing or crying
- apathy: indifference
- motor, sensory, verbal perservation
143
Perservation
- uncontrollable repetition of a particular response, such as a word, phrase, or gesture despite the absence or cessation of a stimulus
144
Decortical Posturing
- seen with TBI
| - flex BUE, Extend BLE
145
Decerebrate Posturing
- happens with TBI
| - extend BUE and BLE
146
Visual Impairments with TBI
- neurological impairments: field cuts due to tract, radiation injuries, visual-perceptual deficits, diplopia, gaze palsies, nystagmus, tracking disorders, etc
- ophthalmologica injuries: direct injury to the eye (globe, retina, intraoccular hemorrhage, glaucoma, etc)
147
Neurological complications with TBI
- infection: brain abscess, meningitis, wound infection, osteomyelitis of skull
- recurrent hemorrhage, thrombus, aneurysm
- hydrocephalus (increased ICP)
- seizures
148
Increased Intracranial Pressure
- caused by swelling, fluid build-up in the brain and hematomas
- increased ICP compresses the brain within the rigid skull
- serious, life-threatening
- ICP monitoring: medications, fluid management, decompressive craniectomy, shunt
149
General Medical Complications with TBI
- infection
- drug toxicities
- upper respiratory trauma, infection, obstruction
- pulmonary embolism
- endocrine-metabolic disorders
- musculoskeletal disorders
- skin disorders
- autonomic disturbances
- urinary tract disorders
150
Movement Symptoms with CVA (TBI & CP)
- abnormal movement synergies
| - abnormal muscle tone: hypotonia with cerebral shock, followed by hypertonia, brunnstrom stage progression
151
Abnormal Tone Scales/Tests
- modified Ashworth Scale (MAS)
- clonus
- DTRs
- UMN lesion: Babinski and Hoffmans
152
Brunstrom Stages
- Stage 1: flaccid
- Stage 2: associated reactions/beginning spasticity (no voluntary movement)
- Stage 3: synergy stage (voluntary movement present)
- Stage 4: movements deviating from the basic synergies
- Stage 5: relative independence of the basic synergies
- Stage 6: near normal (impaired strength, coordination, speed)
- Stage 7: normal (Except when fatigued)
153
Brunnstrom UE Synergy Pattern for FLEXION
- scap: elevation and/or retraction
- shoulder: abduction, external rotation (hyperextension)
- elbow: flexion
- forearm: supination
- wrist/hand: wrist flexion and/or mass finger flexion
154
Brunnstrom UE Synergy Pattern for EXTENSION
- scap: depression and/or protraction
- shoulder: adduction, internal rotation
- elbow: extension
- forearm: pronation
- wrist&Hand: wrist extension and/or mass finger flexion
155
Brunnstrom LE Synergy Pattern for FLEXION
- hip: flexion, abduction, external rotation
- knee: flexion
- ankle: dorsiflexion
- foot: inversion and mass flexion of toes
156
Brunnstrom LE Synergy pattern for EXTENSION
- hip: extension, adduction, internal rotation
- knee: extension
- ankle: PF
- foot: inversion and extension of toes
157
What Brunnstrom stage do you usually start the testing at?
- STAGE 4!
158
Post Brain Injury Medication ANTIDEPRESSANTS
- Elavil
159
Post-Brain Injury Medications ANTICONVULSANTS
- Phenobarbital
- Dilantin
- Tegretol
160
Post-brain injury medications that control spasticity
- Dantrium
- Lioreseal (baclofen)
- Valium
161
Tranquilizer Medications for Post-Brain Imjury
- Thorazine
- Haldol
- Mellaril
162
When in Brunnstrom Stages is it appropriate to do MMT
- at stage 6 when you know the strength is not influenced by any muscle synergies/tone
163
SCI Incidence
- about 40 cases per million population in USA
| - 12,000 new cases each year
164
SCI Prevalence
- 270,000 individuals alive with SCI in USA
165
SCI avg age
- 41 years
166
SCI gender stats
- 80.6% male
| - 19.4% femlase
167
SCI race/ethnicity
- 66 white
- 26. 2 AA
- 0.9 native americans
- 2.1% Asian
- 8.3% Hispanic
168
Causes of SCI
- vehicular: 40%
- falls: 28%
- violence: 15%
- sports: 8%
- other: 9%
169
Amount of incomplete and complete SCI
- incomplete tertraplegia: 40%
- complete paraplegia: 21%
- incomplete paraplegia: 21%
- complete tetraplegia: 16%
170
SCI length of stay
- median days hospitalized in acute care medical/surgical unit is 11 days
- median days in rehab: 37 days
171
Cost of care of SCI
- C1-C4 highest cost
| - incomplete motor functional at any level has lowest cost
172
Cause of death with SCI
- currently pneumonia and specticemia
- specticemia is caused when certain bacteria get into bloodstream (skin/wound/respiratory management)
- renal failure, advances in urologic management
173
Hyper extension of C4 on C5 would compress what nerve root?
C5!
| - because nerve roots are above their spinal vertebrae
174
Contusion Injury with SCI
- bruising of SC following fractures and dislocations of the vertebrae
- initially severe symptoms from loss of SC function (compression from swelling)
- usually rapid return of function in weeks
- amount of return depends on severity of injury
- contusion has the best prognosis since the SC is still intact
175
Compression injury with SCI
- from fractures and dislocations of vertebrae, tumors, disc herniation
- amount of return depends on severity of injury
176
Laceration injury with SCI
- from knife, gunshot, or other projectile/foreign object
- partial to complete loss of function below level of lesion
- impairment depends on extent of lesion
177
Loss of vascular supply with SCI
- from thrombosis, embolus, arteriovenous malformation or direct disruption of blood vessels
- partial loss of SC function below level
178
Complete loss SCI
- loss of all sensation and motor function below the level of the lesion
- ASI A
179
Incomplete loss SCI
- partial loss of sensation and motor function below the level of the injury
- AIS B, C, or D
180
ASI A
- complete SCI
- no sensory or motor function preserved
- NOON sign
181
ASI B
- incomplete SCI
- sensory preserved but no motor function
- bowel/bladder function; violate NOON sign
182
ASI C
- incomplete SCI
| - motor preserved with majority of muscles graded less than 3
183
NOON sign
- turn them on their side
- expose anal sphincter
- act like you are stopping a bowel movement and watch for contraction
- if yes, violated noon sign! ASI B
- if get 1 or 2 (have sensation to light touch around anal area) then violated noon sign! ASI B
- if get 1 or 2 with pin prick around anal
- put finger into deep anal area and press around and ask for sensation
- if spell noon...then have ASI A
- if cannot spell noon....then have ASI B
184
ASI D
- incomplete SCI
| - motor preserved with majority of muscles graded greater or equal to 3
185
ASI E
- normal
186
C2-C3
- ventilatory dependent
| - total care
187
C3-C5
- phrenic nerve
- independent breathing
- off ventilator
188
start getting slips of abs at what level
usually T6
189
DCML
- dorsal column medial lemniscus
- proprioception
- vibration
- fine discrimination
- two-point touch
190
Antero-lateral System
- crude touch
- sharp/dull
- temperature
- pain
- tickle
- itch
- sexual sensations
191
Anterior Cord Syndrome
- damage to the anterior (ventral) spinal cord
- Partial or full loss of bilateral ALS & lateral CST below level of lesion
- Preserved posterior columns (DCML) bilaterally below level of lesion
- Most common injury of cervical spine
- Mechanism of Injury – Flexion (Flexion teardrop or burst fracture...Infarct or compression of anterior spinal arteries)
192
Posterior Cord Syndrome
- Damage to the posterior (dorsal) spinal cord
- Loss of DCML sensory modalities below the level of lesion
- Preservation of bilateral ALS sensory modalities
- Partial or full preservation of CST motor function bilaterally
- Mechanism of injury: Hyperextension
193
Central Cord Syndrome
- central SC hemorrhage and necrosis
- sparing of the peripheral areas of the spinal cord (central area more susceptible to damage due to poor arterial supply)
- most often in cervical region
- pronounced weakness in the UEs > LEs
- sparing of sacral motor and sensory functions
- hyperextension injuries in the elderly or any age
- more common in cervical spine
- Contusion of central region of SC
- Can be from MVAs, but reduced frequency since head rests in cars
194
Spinal Stenosis
- there is compression all around the outside of the SC
- pressure is uniform on all sides
- b/c center of SC is much less well vascularized, so similarly looks like central cord syndrome (?) i think
195
Incidence of SCI
- 40 cases per million population in US
| - 12,000 new cases each year
196
Prevelence of SCI
- 2012: 270,000 persons alive with SCI in US
197
SCI average age at injury
- 41 years old
198
SCI prevalence in gender
- 80.6% males
| - 19.4% females
199
SCI prevalence in race/ethnicity
- 66% caucasions
- 26.2% african americans
- 0.9% Native American
- 2.1% Asian
- 8.3% hispanic
200
Causes of SCI
- vehicle (40%)
- falls (30%)
- violence (15%)
- sports (8%)
- other (9%)
201
Percent Incomplete and Complete Tetraplegia of SCI
- 40.8% incomplete tetraplegia
| - 15.8% complete tetraplegia
202
Percent incomplete and complete paraplegia
- 21.6% complete paraplegia
| - 21.4% incomplete paraplegia
203
Length of Stay in Hospital for SCI
- median days hospitalized in the acute care medical/surgical unit (in model systems) is 11 days
- median days in rehab = 37 days
204
Cause of death for SCI
- in the past, renal failure (advances in urologic management)
- currently pneumonia and septicemia
- septicemia is caused when certain bacteria get into the bloodstream
205
Types of Spinal Cord Injuries
- contusions
- compression
- laceration
- loss of vascular supply
206
SCI Contusions
- bruising of SC following fractures and dislocations of the vertebrae
- initially severe symptoms from loss of SC function
- usually rapid return of function within weeks
- amount of return depends on severity of injury
- has the best prognosis since the SC is still intact
207
SCI Compression
- from fractures and dislocations of vertebrae, tumors, disc herniation
- amount of return depends on severity of injury
208
SCI Laceration
- from knofe, gunshot, or other projectile/foreign object
- partial to complete loss of function below level of lesion
- impairment depends on extent of lesion
209
SCI Loss of vascular supply
- from thrombosis, embolus, arteriovenous malformation or direct disruption of blood vessels
- partial loss of SC function below level of lesion in distribution blood supply
210
Complete Injury of SCI
- loss of all sensation and motor function below the level of the lesion
- AIS A
211
Incomplete injury of SCI
- partial loss of sensation and motor function below the level of the unjury
- AIS B, C, or D
212
AIS A
- complete SCI injury
| - no sensory or motor function preserved
213
AIS B
- incomplete SCI injury
- sensory preserved but no motor function
- bowel/bladder function
- violates NOON sign
214
AIS C
- incomplete SCI injury
- motor preserved with majority of muscles graded <3
- violates NOON sign
215
AIS D
- incomplete SCI injury
- motor preserved with majority of muscles graded >3
- violates NOON sign
216
AIS E
- normal
217
C2-3 care
- ventilator dependent, total care
218
C3-5 Care
- phrenic nerve
- independent breathing
- off ventilator
219
C5 care
- can raise shoulders and flex arm to use a joystick on a power WC, possibly manual WC with adaptations
220
C6 care
- have wrist extension so weak, functional, tenodesis grasp
| - wrist extends, passive finger flexion due to contracted finger flexors
221
C7 Care
- have triceps
| - can perform pressure relief and transfers and to help self prevent ulcers
222
Thoracic region care
- adds postural stability and respiration function
| - acessory breathing muscles
223
T6-T12 Care
- abdomminal function
224
L2 Care
- hip flexion
225
DCML
- proprioception
- vibration
- fine discrimination
- two-point touch
226
Antero-lateral system
- crude touch
- sharp/dull
- temperature
- pain
- tickle and itch
- sexual sensations
227
Anterior Cord Syndrome
- damage to the anterior (ventral) spinal cord
- partial or full loss of bilateral ALS and lateral CST below level of lesion
- preserved posterior columns (DCML) bilaterally below level of lesion
- most common injury of cervical spine
- mechanism of injury: flexion
- flexion teardrop burst fracture
- infarct or compression of anterior spinal arteries
228
Posterior Cord Syndrome
- damage to the posterior (dorsal) SC
- loss of DCML sensory modalities below the level of lesion
- preservation of bilateral ALS sensory modalities
- partial or full preservation of CST motor function bilaterally
- mechanism of injury: hyperextension
229
Central Cord Syndrome
- central SC hemorrhage and necrosis
- sparing of peripheral areas of the SC (central area more susceptible to damage due to poor arterial supply)
- most often in teh cervical region
- pronounced weakness in UEs > LEs
- sparing of sacral motor and sensory function
- hyperextension injuries in the elderly or at any age
- more common in cervical spine
- contusion of central region of SC
- can be from MVAs, but reduced frequency since head rests in cars
230
Brown - Sequard
- hemisection (damage to one side) of the SC
- ipsilateral DCML: loss of proprioception, vibration, fine discriminatory, 2-point touch
- ipsilateral CST: loss of voluntary motor control
- contralateral ALS: crude touch, sharp/dull, temperature, pain, tickle and itch, sexual sensations
- traumatic SCI, pretending injuries (gunshot, kife wound), burst fractures
- mechanism of injury: rotation
- pure rotation injury is more common in cervical spine, but occurs most often with flexion injuries
- not much rotation possible in thoracic and lumbar regions
231
Acute Management of SCI
- ABCs: airway, Breathing, Circulation
- if necessary to move, log roll, maintaining spine in neutral
- immobilie
- monitor BP & ECG
- x-ray, CT, and/or MRI
232
Indications for Surgery with SCI
- bone fragments and disc material in spinal canal
- unstable fracture
- progression of neurologic deficit (even if spinal column is stable)
- decompression due to edema, increased blood in area, etc
233
Harrington Rods
- stainless steel rods with hooks on either end placed on either side of injury area
- distracts spine until proper alignment is achieved
- just above and below the rods pts tend to be hypermobile
234
Stable fracture with no surgery immobilization
6-12 weeks
235
Cervical Fusion Immobilization
- 3-4 months using a halo or SOMI (sterno-occipital-mandibular immobilizer)
236
Thoracolumbar Fusions Immobilization
- 4-6 months using a rigid body jacket (TLSO)
237
Spinal Shock
- onset: immediately post-injury
- duration: 1 week to several months (mean = 6 wks)
- below level of lesion: flaccid paralysis, no reflex activity, absent bowel and bladder tone, decreased blood pressure.
- spasticity develops AFTER spinal shock ends
- true spinal shock = no tone at all originally
238
Respiratory System Changes with SCI
- phrenic nerve = C3/4/5
- those with C1-3 sCI are on respirator/ventilator b/c they have no or minimal diaphragm function
- C4-5 (even C6-T1): may need respirator permanently or at least temporarily (b/c chest accessory mm loss)
- C8-T12: when intercostal and abdominal muscles are lost, 20-70% decrease in vital capactiy
239
Physiological Changes in Circulatory System with SCI
- bradycardia
- dysrhythmias
- orthostatic hypotension
- low BP (esp when elevating head, coming to upright)
- cause: loss of sympathetic input below lesion level
- prolonged bed rest decreases vascular tone
- loss of muscle pumping action to return blood from LEs
- blood pools in feet, watch for S&S, take BP before during and after intervention
240
Complications in Circulatory System SCI
- increased risk for DCTs and pulmonary emboli
| - DVT: warm and red in area (very localized)
241
Intervention for Circulatory System With SCI
- heparin
- anti-embolism stockings (TED hose)
- abdominal binder (increases blood flow)
242
Gastrointestinal Changes with SCI
- loss of bowel control
- incontinence
- constipation
- bowel obstructions
- bowel accidents are often due to use of medications needed to treat constipation
- spasticity increases when bladder problems
243
Interventions for Gastrointestinal changes iwith SCI
- oral meds: colace as a stool softener and metamucil to produce well-formed soft stool
- suppositories: i.e. dulcolaz, for bowel program
- high fiber diets
244
Urologic Changes with SCI
- urinary incontinence
- flaccid neurogenic bladder
- reflexic neurogenic bladder
245
Flaccid Neurogenic bladder
- areflexic bladder
- neurological injury at S2-4 level
- only empties a little when it "overflows" so it must be artificially or manually emptied
- bladder fill to normal or larger capacity before being emptied articifialy
- some patients may be able to learn to do self-catheterization (increased risk of bladder infection)
246
Reflexic Neurogenic Bladder
- spastic bladder
- S2-4 reflexes must be intact (all SC level injuries above S2)
- MOST COMMON
- detrusor muscle becomes spastic and contracts
- empties at smaller than normal volumes some patients may be able to stimulate reflex emptying
247
Complications in Urologic System with SCI
- UTI
- kidney stones
- bladder stones
248
Loss of Sensation with SCI
- complete or partial loss of sensation below the level of the SCI
249
MOtor Function with SCI
- complete or partial loss of muscle function below the level of the SCI
- decreased strength remaining, innervated muscles
- potential for recovery below level of lesion
- nmost likely in zone of injury (1-3 neurological levels below the neurological level of injury)
- intense rehab programs
250
Neuropathic Pain
- experienced by 90% of all SCI patients at least intermittently below level of lesion
- burning sensation
- some are on medical maryJ for this
251
Spasticity/Hypertonicity with SCI
- can interfere with positioning, transfers, maintenance of joint ROM, and with active motion
252
Spasticity Definition
- a motor disorder characterized by a velocity dependent increase in tonic stretch reflexes with exaggerated deep tendon (phasic) reflexes resulting from the hyper-excitability of the monosynaptic stretch reflex as one component of the UMN syndrome
253
Gamma Spasticity
- most common and predominate theoryu
- normal inhibition to gamma MNs from higher CNS is not functioning; resulting in excess gamma MN firing
- supersensitive muscle spindle
- continual firing of monosynaptic reflex arc
254
Autonomic Dysreflexia (AD)
- occurs in persons with lesions above T6
- consequence of over-activity of ANS (elevated BP)
- precipitated by a noxious stimulus (triggers)
- full bladder or blocked catheter, UTI (most common)
- constipation, distention, hemorrhoids
- infection or irritation
- sunburn
- tight clothing
- pain
- prolongued pressure by object
- pressure sores
- ingrown toenails
- DO NOT LAY THESE pts DOWN!!!
255
How AD Happens:
- some stimulus triggers a sympathetic (ANS) response (elevated BP)
- sympatheticc system can only be adjusted above the level of the lesion; reflex cannot be turned off below the level of the lesion
256
Autonomic Dysreflexia S&S
- pounding headache (caused by the elevation in the blood pressure)
- goosebumps
- sweating above the level of injury
- nasal congestion
- blotching of the skin
- restlessness
- hypertension
- flushed (reddened face)
257
Temperature control problems with SCI
- loss of ability to control body temp due to inability to sweat or shiver below level of lesion
- less able to tolerate extremes in temperature
258
Intervention for temperature control with SCI
- avoid extreme hot.cold temperatures
- separate heating or air conditioning may be a necessity
- dress extra warm in winter
- spray bottle of water
259
Integumentary Changes with SCI
- decubitus ulcers
| - cuts, burns, etc occur before patient is aware of them
260
Intervention for Integumentary System with sCI
- prevention of pressure sores
- WC and bed cushions
- pressure relief techniques
- good transfer techniques to avoid sheer forces
- teach awareness and protection of insensate body parts to prevent injuries
261
Musculoskeletal Changes with SCI
- loss of calcium from bone occurs following injury
- hypercalcemia (high blood calcium levels)
- can cause cardiac arhythmias
- osteoporosis (if DEXA scans less than -3.5 then high risk for fracture)
- heterotopic ossification
262
FES cycling
- helps prevent and treat osteroporosis
| - adds muscle bulk which can help prevent decubiti
263
Heterotropic Ossification
- calcium deposits in soft tissues around joints that recieve stress
- marked limiation of ROM
- treatment: didronel and radiation therapy to inhibit osteoblast function (slows HOLD ON A SEC but doesnt stop it)
- maintain ROM if possible
- if surgically removed, likely to come back and be worse
264
Female Reproductive system with SCI
- menses typically returns in 3-6 months
- women CAN GET PREGNANT even if they cannot feel or move below the level of injury
- many have normal vaginal deliveryu
- autonomic dysreflexia may occur during labor = C-section to deliver baby quickly
265
Males reproductive system with SCI
- reflexogenic (controlled at S2-4, must be intact)
- spontaneous (secodary to internal stimulation)
- ejaculation usually does not occur unless sacral sensation is in tact
- fertility of sperm decreases significantly over time
266
Central Pattern Generators (CPGs)
- groups of neurons and interneurons that produce rhythmic or oscillatory motor activity
- hard-wired, less variable, less flexible than more complex, goal-directed motor control
- used in body weight support treadmill training (BWSTT)
267
Evarts of CPGs
- Evarts are spinal rhythm generators
- a group of neurons that inherently present a pre-arranged sequence of muscle activity arranged temporally and spatially
- need some type of trigger to start off the neural network and keep it going
268
Example of CPGs with dog
- spinal transection
- stimulation to flank produces rhythmic scratching
- range and frequency of rythmic flexion and extension (scratching) is dependent on strength of stimulus
269
Example of CPGs with cats
- spinal cats
- shik preparation (midbrain, cerebellum, and spinal cord)
- cerebral cortex cannot communicate with spinal cord
270
Halo
- screwed into skull
- stabilizes cervical spine
- balance is thrown off because so top-heavy
271
TLSO
- thoracic-lumbosacral stabilizer
272
SOMI
- cervical/thoracic stabilizer
273
need at least what % in what broadmanns area to initiate gait?
- 10-20% input to broadmanns area 4 to initiate gait
Neuro D&D
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