When observing a patient post stroke, what is important to note?
- Bony prominences
- Muscle atrophy
- Head position
- Shoulder height
- Pelvic position – Usually affected side is more posterior in standing
- UE & LE position
what is cerebral shock?
flaccidity following stroke; moves to spasticity (similar to spinal shock
what is the flexion synergy of the UE?
- Scapular retraction/elevation
- Shoulder abduction/ER
- Elbow flexion**/supination
- Wrist and finger flexion
what is the extension synergy of the UE?
- Scapular protraction
- Shoulder adduction**/IR
- Elbow extension/pronation**
- Wrist and finger flexion
what is the flexion synergy of the LE?
- Hip flexion**, abduction, ER
- Knee flexion
- Ankle DF/Inv
- Toe DF
what is the extension synergy of the LE?
- Hip extension, adduction**, IR
- Knee extension**
- Ankle PF**/Inv
- Toe PF
what are the stages of motor recovery (synergy patterns) according to Brunnstrom?
I. Flaccidity II. Synergies; some spasticity III. Marked spasticity IV. Out of synergy; less spasticity V. Selective control of movement VI. Isolated/ coordinated movement
primitive reflex most often seen post stroke; pt may be unable to straighten arm wo/turning head toward that arm; to secure extension of the involved leg, pt can turn head to involved side
ATNR
primitive reflex; when pt is supine w/ head up on pillows, arms won’t fully extend & legs are in an extensor pattern; Coming to sitting while flexing head, LE’s go into EXT and are difficult to bend; Transfers – if head extends, legs may flex
STNR
primitive reflex most often seen post head injury; Extensor tone increases in supine if head is extended; Head pushes into supporting surface; Resistance to shoulder protraction; Rolling blocked by extensor tone; Sitting - when pt extends head, hips slide forward in chair (May slide out of chair)
TLR
primitive reflex most often seen post TBI; When ball of foot is in contact w/the floor, immediate extensor tone; Not a normal standing position - not conducive to regaining balance and equilibrium; Tx: get either entire foot on floor, or at least heel – do NOT want just balls of foot on floor or will cause this to occur
Positive Supporting Reaction
Unintentional movements of hemiparetic limb caused by voluntary movements of another limb or other stimuli; Can be cause by yawning, sneezing, or coughing
Associated Reactions
- Raimiste’s Phenomenon = Involved LE will ABD and/or ADD if resistance is applied to the uninvolved extremity; Ex: Supine/Sitting – put pillow between pt’s knees – have them ADD univolved side, & involved will kick in
what is the pattern of mm weakness after stroke?
usually distal, then proximal
can you use MMT for testing mm strength after stroke?
- Difficult to do due to compensations, spasticity, inability to isolate the muscle; If pt has spasticity – goal is to get functional idea of strength; document “Unable to MMT due to spasticity, but assessed….”
- MCA - 20% don’t regain use of their UE’s
- Stroke in General: must keep in mind that only 75-90% of corticospinal fibers cross, so MOST OFTEN you see Contralateral involvement, BUT may have some ipsilateral involvement as well; often we use ‘unaffected side’ as baseline – in these pt’s, ‘unaffected side’ might be weak too
What outcome measure do you use for with pts that are highly involved/ lower level?
- Five Time Sit to Stand Test
- Function in Sitting Test (FIST)
- Trunk Impairment Scale
What is pusher syndrome?
- Altered perception of body’s orientation
- Perceive body as vertical when it is actually tilted 20*
- Ipsilateral Pushing - active pushing w/stronger extremities toward weak side - Tendency to fall toward weak side
- visual and vestibular input intact
Where is the lesion when pusher syndrome is present?
posterolateral thalamus
How should a PT intervene for pusher syndrome?
- working in a corner, push towards wall
- Having something in front of them to make them more aware
- Mirror – for visual input so they know when they are doing this
(-) poor outcome – difficult to work on interventions if always push to weak side
(+) brain can compensate – generally will; disappear/ decrease around ~6 mo’s
What is the difference between an physiological, household, and community walker?
1) Physiological Walker- Walks for exercise only at home or during PT sessions ; Likely requires a good amt of help/assistance; in home, may stand to complete some ADL’s (toileting, etc)
2) Household Walker - Uses walking for home activities; Predictable environment; can getting around their house decently, though may use an AD; won’t walk into clinic for a PT session
3) Community Walker - Enter/leave home, ascend/descend curb, and manage stairs independently, Independent w/some community activities
Where is a lesion if there is speech and language impairments?
cortex of the dominant side
- majority of L sided stroke
trouble speaking fluently but their comprehension can be relatively preserved; difficulty producing grammatical sentences and their speech is limited mainly to short utterances; understand speech relatively well
Broca’s aphasia
- also known as non-fluent or expressive aphasia
form of aphasia the ability to grasp the meaning of spoken words and sentences is impaired, while the ease of producing connected speech is not very affected
Wernicke’s aphasia
- receptive aphasia
- increase tactile cues; simple sentences; don’t give options; give extra time to respond
Mixture of receptive and expressive aphasia
global aphasia
- poorer outcomes for rehab
difficulty swallowing
dysphagia
- mm problem (usually), nerve problem, or both
