Stroke and TBI from internship 1

Flaccidity (hypotonicity)

is present immediately after stroke and is due primarily to the effects of cerebral shock. It is generally short-lived, lasting a few days or weeks. Flaccidity may persist in a small number of patients with lesions restricted to the primary motor cortex or cerebellum.

Attention

is the ability to select and attend to a specific stimulus while simultaneously suppressing extraneous stimuli. Attention disorders include impairments in sustained attention, selective attention, divided attention, or alternating attention. Altered attention results from lesions in the prefrontal cortex and reticular formation.

Perseveration

is the continued repetition of words, thoughts, or acts not related to current context. Thus, the patient gets "stuck" and repeats words or acts without much success at stopping. Preservation results from lesions in the premotor and/or prefrontal cortex.

Anterior Cerebral Artery Syndrome

is the first and smaller of two terminal branches of the internal carotid artery. It supplies the medial aspect of the cerebral hemisphere (frontal and parietal lobes) and subcortical structures, including the basal ganglia (anterior internal capsule, inferior caudate nucleus), anterior fornix, and anterior four-fifths of the corpus callosum (Fig. 15.3). Because 650 651the anterior communicating artery allows perfusion of the proximal ACA from either side, occlusion proximal to this point results in minimal deficit. More distal lesions produce more significant deficits. Table 15.1 presents the clinical manifestations of anterior cerebral artery (ACA) syndrome. The most common characteristics of ACA syndrome include contralateral hemiparesis and sensory loss with greater involvement of the lower extremity (LE) than the upper extremity (UE) because the somatotopic organization of the medial aspect of the cortex includes the functional area for the LE.

Agnosia

is the inability to recognize incoming information despite intact sensory capacities. Agnosias can include visual object agnosia, auditory agnosia, or tactile agnosia (astereognosis).

Encephalomalacia

is the softening or loss of brain tissue after cerebral infarction, cerebral ischemia, infection, craniocerebral trauma, or other injury. The term is usually used during gross pathologic inspection to describe blurred cortical margins and decreased consistency of brain tissue after infarction.

TONIC RELFEXES

may appear in a readily identifiable form similar to that seen in other types of neurological insult (e.g., traumatic brain injury [TBI], cerebral palsy [CP]). Thus, movement of the head or position of the body may elicit an obligatory change in resting tone or movement of the extremities. The most commonly seen is the asymmetrical tonic neck reflex (ATNR) in which head rotation causes elbow extension of the UE on the jaw side with elbow flexion of the opposite skull limb

NSR

normal sinus rhythm, normal rhythm and rate 60-100

Depression

occurring in approximately 35% of stroke cases.18 It is characterized by persistent feelings of sadness accompanied by feelings of hopelessness, worthlessness, and/or helplessness. Depressed patients may also experience a loss of energy or persistent fatigue, an inability to concentrate, and decreased interest in daily life along with changes in weight and sleep patterns, generalized anxiety, and recurrent thoughts of death or suicide. Depression is seen with lesions in the left frontal lobe (acute stage) and with lesions in the right parietal lobes (subacute stage).20 Most patients remain significantly depressed for many months, with an average time of 7 to 8 months. The period from 6 months to 2 years after a CVA is the most likely time for depression to occur

Subarachnoid hemorrhage (SH)

occurs from bleeding into the subarachnoid space typically from a saccular or berry aneurysm affecting primarily large blood vessels.

Apathy

occurs in about 22% of cases and is characterized by a shallow affect and blunted emotional responses. In such patients, apathy is frequently misconstrued as depression or poor motivation. Patients can also demonstrate euphoria (exaggerated feelings of well-being), increased levels of irritability or frustration, and social inappropriateness.

Glasgow Coma Scale (GCS)

a scale used to assess the consciousness of a patient upon physical examination, typically in patients with neurological concerns or complaints.

Decerebrate rigidity

(abnormal extensor response) refers to sustained contraction and posturing of the trunk and limbs in a position of full extension. The elbows are extended with shoulders adducted, forearms pronated, and wrist and fingers flexed. The legs are held in stiff extension with plantarflexion. Decorticate rigidity is indicative of a corticospinal tract lesion at the level of diencephalon (above the superior colliculus)

Unilateral Neglect

(lack of awareness of part of the body or the external environment) will limit movement and use of the more involved extremities (usually the nondominant left side). The patient typically does not react to sensory stimuli (visual, auditory, or somatosensory) presented on the more involved side. Careful observation of spontaneous use of affected limbs, as well as specific responses to inquiries for movement on or toward the hemiplegic side, will provide important information about neglect. Persistent neglect may result in bruising or trauma to the hemiplegic limbs during activity and negatively affect rehabilitation outcomes.

Primary cerebral hemorrhage

(nontraumatic spontaneous hemorrhage) typically occurs in small blood vessels weakened by atherosclerosis producing an aneurysm.

Multi-infarct dementia

(vascular dementia) results from multiple small infarcts of the brain and is seen in 6% to 32% of patients. It is more common in individuals over age 60 and is associated with episodes of cerebral ischemia (microvascular or small vessel disease) and hypertension. Other contributing factors include arrhythmias, myocardial infarct, TIAs, diabetes, obesity, and smoking. Scattered areas of the brain are involved, evidenced by focal neurological deficits. Onset is frequently abrupt. The patient exhibits impairments in memory and cognition and may fluctuate between periods of impaired function and periods of improved function. This stepwise and paroxysmal deterioration of intellectual function is in contrast to the gradual onset and steadier, widespread decline seen in Alzheimer's dementia.

Primary progressive aphasia (PPA)

A slowly progressive isolated aphasia not due to stroke, trauma, tumor, or infection, which does not fit neatly into existing aphasia classification schemes. It can exist in the absence or relative absence of generalized intellectual and behavioral disturbances or cognitive impairment generally associated with dementia.

Broca's aphasia (expressive or motor aphasia)

A type of nonfluent aphasia; characterized by awkward articulation, restricted vocabulary, and restriction of simple grammatical forms with relative preservation of auditory comprehension. Associated with lesions involving the third frontal convolution of the left hemisphere (Broca's areaa).

Voluntary Movements

Abnormal and highly stereotyped obligatory synergies emerge with spasticity following stroke. Thus, the patient is unable to perform an isolated movement of a single limb segment without producing movements in the remainder of the limb. Obligatory synergies can appear reflexively during very early recovery, or as voluntary movements. As recovery progresses they become stronger and are linked to the presence and severity of spasticity. Two distinct abnormal synergy patterns have been described for each extremity: a flexion synergy and an extension synergy (Table 15.6). An inspection of the synergy components reveals that certain muscles are not usually involved in either the flexion or extension synergy. These muscles include the (1) latissimus dorsi, (2) teres major, (3) serratus anterior, (4) finger extensors, and (5) ankle evertors. These muscles, therefore, are generally difficult to activate while the patient is exhibiting these patterns. Obligatory synergies are often incompatible with normal ADL and functional mobility skills. For example, the patient with a strong LE extensor synergy will have difficulty walking owing to foot plantarflexion and inversion with hip and knee extension and adduction (scissoring gait pattern). As recovery progresses, spasticity and obligatory synergies begin to disappear and more normal synergies with isolated joint control become possible.

Flexibility and Joint Integrity

An examination of joint flexibility should include passive ROM using a goniometer, joint hypermobility/hypomobility, and soft-tissue changes (swelling, inflammation, or restriction). The shoulder and wrist should be examined closely because joint malalignment problems are common. Edema of the wrist often produces malaligned carpal bones with resulting impingement during wrist extension. Problems with spasticity may result in inconsistent ROM findings, because fluctuations in tone may occur from one testing session to the next. Thus, tonal abnormalities should be noted at the time of examination. Active ROM (AROM) may be limited or impossible for the patient in early or middle recovery in the presence of paresis, spasticity, or obligatory synergies that can preclude isolated voluntary movements. ROM limitations and developing contractures should be carefully documented. In the UE, limitations in the shoulder motions of flexion, abduction, and external rotation are common. Contractures are likely in the elbow flexors, wrist and finger flexors, and forearm pronators. In the LE, plantarflexion contractures are common.

Intraparenchymal hemorrhage (IPH)

An intraparenchymal hemorrhage is a blood clot that develops in the brain. Intraparenchymal hemorrhage is one form of intracerebral bleeding in which there is bleeding within brain parenchyma. The other form is intraventricular hemorrhage. Intraparenchymal hemorrhage accounts for approx. 8-13% of all strokes and results from a wide spectrum of disorders. It is more likely to result in death or major disability than ischemic stroke or subarachnoid hemorrhage, and therefore constitutes an immediate medical emergency. Intracerebral hemorrhages and accompanying edema may disrupt or compress adjacent brain tissue, leading to neurological dysfunction. Substantial displacement of brain parenchyma may cause elevation of intracranial pressure and potentially fatal herniation syndromes. Intraparenchymal hemorrhage may occur suddenly without any apparent cause, according to the Mayo Clinic. In such cases, the affected individuals normally have weakened blood vessels as a result of long term hypertension. Other causes of intraparenchymal hemorrhage include tumors, anticoagulant medication and brain lesions, according to the Mayo Clinic. The Mayo Clinic notes that, as with most brain lesions, intraparenchymal hemorrhage may present with various symptoms, such as severe headache, seizures, memory loss and coma in cases that are severe.

Apraxia

Apraxia is more evident with left hemisphere damage than right and is commonly seen with aphasia. The patient demonstrates difficulty planning and executing purposeful movements that cannot be accounted for by any other reason (i.e., impaired strength, coordination, sensation, tone, cognitive function, communication, or uncooperativeness). There are two main types of apraxia.

Strategies when treating those with left hemiplegia

Because the patient with left hemiplegia may behave in ways that tend to minimize his or her disabilities, it is easy for staff to overestimate the patient's perceptual abilities. For the patient with visuospatial deficits, the use of gestures or visual cues may decrease this patient's ability to perform tasks, whereas verbal cues may increase chances for success. Equally important strategies include carefully structuring the environment to minimize clutter and activity, provide adequate lighting, and provide clear boundaries and reference points.

Practice

Blocked practice (constant repetition of a single task) is used to improve initial performance and motivation, especially for patients with disorganized movements. distributed practice schedule with adequate rest periods owing to limited endurance as both physical and cognitive fatigue can result in decreased performance. The patient should be encouraged to self-monitor practice sessions and recognize when fatigue may be setting in and rest is required. variable practice (practice of more than one task within a session) using a serial or random order as soon as possible. Variable practice improves performance and results in better retention of learned skills and improved ability to adapt to changing task demands. Patient, staff, and family efforts should be coordinated to ensure continued and consistent practice during off-therapy times.

Fluent aphasia

Characterized by impaired auditory comprehension and fluent speech that is of normal rate and melody. In fluent aphasia (Wernicke's/sensory/receptive aphasia), speech flows smoothly with a variety of grammatical constructions and preserved melody of speech. Auditory comprehension is impaired. Thus, the patient demonstrates difficulty in comprehending spoken language and in following commands. The lesion is located in the auditory association cortex in the left lateral temporal lobe.

Nonfluent aphasia

Characterized by limited vocabulary, slow, hesitant speech, some awkward articulation, and restricted use of grammar in the presence of relatively preserved auditory comprehension. nonfluent aphasia (Broca's/expressive aphasia), the flow of speech is slow and hesitant, vocabulary is limited, and syntax is impaired. Speech production is labored or lost completely whereas comprehension is good. The lesion is located in the premotor area of the left frontal lobe.

Aphasia

Communication disorder caused by brain damage and characterized by an impairment of language comprehension, formulation, and use; excludes disorders associated with primary sensory deficits, general mental deterioration, or psychiatric disorders. Partial impairment often is referred to as dysphasia. Broca's aphasia (expressive or motor aphasia) A type of nonfluent aphasia; characterized by awkward articulation, restricted vocabulary, and restriction of simple grammatical forms with relative preservation of auditory comprehension. Associated with lesions involving the third frontal convolution of the left hemisphere (Broca's areaa). Fluent aphasia Characterized by impaired auditory comprehension and fluent speech that is of normal rate and melody. Global aphasia Severe aphasia with marked dysfunction across all language modalities; severely limited residual use of all communication modes for oral-aural interactions; global is not a type of aphasia but a designation of severity. Nonfluent aphasia Characterized by limited vocabulary, slow, hesitant speech, some awkward articulation, and restricted use of grammar in the presence of relatively preserved auditory comprehension. Primary progressive aphasia (PPA) A slowly progressive isolated aphasia not due to stroke, trauma, tumor, or infection, which does not fit neatly into existing aphasia classification schemes. It can exist in the absence or relative absence of generalized intellectual and behavioral disturbances or cognitive impairment generally associated with dementia. Wernicke's aphasia (sensory aphasia or receptive aphasia) The most common type of fluent aphasia; characterized by impaired ability to understand spoken or written words. Associated with lesions to the Wernicke's area of temporal lobe of dominant hemisphere.

SENSATION

Deficits in somatic sensations (touch, temperature, pain, and proprioception) are common after stroke. The type and extent of impairment are related to the location and size of the vascular lesion. Specific localized areas of dysfunction are common with cortical lesions, whereas diffuse involvement throughout one side of the body suggests deeper lesions involving the thalamus and adjacent structures. Impairment in touch sensation (64% to 94%), proprioception (17% to 52%), vibration (44%), and loss of pinprick sensation (35% to 71%) have been reported.57-59 667 669. Sensory loss has also been reported in the ipsilateral, less affected limbs though to a lesser extent (12% to 25%). Symptoms of crossed anesthesia (ipsilateral facial impairments with contralateral trunk and limb involvement) typify brainstem lesions. Disturbances in cortical sensory modalities (two-point discrimination, stereognosis, kinesthesia, graphesthesia) are also found.60,61 Profound sensory impairments will negatively affect motor performance, motor learning, and rehabilitation outcomes and contribute to unilateral neglect and learned nonuse of limbs. Sensory impairment is also associated with pressure sores, abrasions, and shoulder pain and subluxation. A sensory examination should include testing of superficial sensations (e.g., touch, pressure, sharp or dull discrimination, temperature) and deep sensations (proprioception, kinesthesia, vibration). Combined (cortical) sensations such as stereognosis, tactile localization, two-point discrimination, and texture recognition should also be examined once the integrity of the superficial sensations of touch and pressure is established. Sensory testing procedures are described in detail in Chapter 3, Examination of Sensory Function. The quality of sensory impairments experienced can range from mild altered perception to marked changes in sensory thresholds, delayed perceptions, uncertainty of responses, altered time for sensory adaptation, and sensory persistence.57 Impairments may be evident in one sensory modality and not in others. Differences can also be expected between upper and lower hemiplegic extremities, depending on lesion location. Comparisons with the intact side should be viewed with caution because impairments may exist in the supposedly "normal" extremities due to aging and co-morbidities. Sensory testing may be difficult or need to be deferred owing to cognitive or communication deficits.

Diaphoresis

Diaphoresis is the medical term used to describe excessive, abnormal sweating in relation to your environment and activity level. It tends to affect your entire body rather than a part of your body. This condition is also sometimes called secondary hyperhidrosis. https://www.sweathelp.org/pdf/Diaphoretic_Diseases.pdf

Postural Control and Balance with stroke

Disruptions of central sensorimotor processing contribute to an inability to recruit effective postural strategies and adapt postural movements to changing task and environmental demands. Patients with stroke typically demonstrate uneven weight distribution and increased postural sway in standing. Delays in the onset of motor activity, abnormal timing and sequencing of muscle activity, and abnormal co-contraction result in disorganization of normal postural synergies. For example, proximal muscles are typically activated in advance of distal muscles or, in some patients, very late (a finding also found in many elderly). Compensatory responses typically include excessive hip and knee movements. Corrective responses to perturbations or destabilizing forces are inadequate and result in loss of balance and frequent falls. Patients with hemiplegia typically fall in the direction of weakness.

GIB - gastrointestinal bleed

Gastrointestinal bleeding (GI bleed), also known as gastrointestinal hemorrhage, is all forms of bleeding in the gastrointestinal tract, from the mouth to the rectum. When there is significant blood loss over a short time, symptoms may include vomiting red blood, vomiting black blood, bloody stool, or black stool.

Intraventricular hemorrhage

Intraventricular hemorrhage, also known as intraventricular bleeding, is a bleeding into the brain's ventricular system, where the cerebrospinal fluid is produced and circulates through towards the subarachnoid space. It can result from physical trauma or from hemorrhaging in stroke.

pseudobulbar affect (PBA) also known as emotional lability or emotional dysregulation syndrome.

Lesions of the brain affecting the frontal lobe, hypothalamus, and limbic system can produce a number of emotional changes. PBA occurs in about 18% of cases and is characterized by emotional outbursts of uncontrolled or exaggerated laughing or crying that are inconsistent with mood. The patient quickly changes from laughing to crying with only slight provocation. The patient is typically unable to control these episodes or to inhibit the expression of spontaneous emotions. Frequent crying may also accompany depression.

Feedback

Mirror therapy (MT) is a therapeutic intervention that focuses on moving the less impaired limb while watching its mirror reflection. A mirror is placed in the patient's midsagittal plane, presenting the patient with the mirror image of his or her less affected limb as if it were the hemiparetic limb. It was first introduced by Ramachandran et al126 for individuals with arm amputation. For patients with stroke, MT has been shown to improve LE recovery and ankle dorsiflexion.127 MT has also been shown to improve UE recovery and distal motor function and recovery from hemineglect.128,129 In these studies, both the mirror groups and the control groups also participated in a conventional stroke rehabilitation program. It is important to note that use of mirrors is contraindicated in patients with marked visuospatial perceptual impairments.

Motor Praxis

Motor praxis is the ability to plan and execute coordinated movement. Lesions of the premotor frontal cortex of either hemisphere, left inferior parietal lobe, and corpus callosum can produce apraxia.

Internal Carotid Artery Syndromes

Occlusion of the internal carotid artery (ICA) typically produces massive infarction in the region of the brain supplied by the middle cerebral artery. The ICA supplies both the MCA and the ACA. If collateral circulation to the ACA from the circle of Willis is absent, extensive cerebral infarction in the areas of both the ACA and MCA can occur. Significant edema is common with possible uncal herniation, coma, and death (mass effect).

MEDICAL DIAGNOSIS OF STROKE

Of particular importance are the exact time and pattern of symptom onset. An abrupt onset with worsening symptoms and decreasing level of consciousness is suggestive of cerebral hemorrhage. Severe headache described as "the worst headache of my life" is suggestive of subarachnoid hemorrhage. An embolus also occurs rapidly, with no warning, and is frequently associated with heart disease and/or heart complications. A more variable and uneven onset is typical with thrombosis. The patient's past history, including episodes of TIAs or head trauma, presence of major or minor risk factors, and medications, pertinent family history, and any recent alterations in patient function (either transient or permanent) are thoroughly investigated.31 Stroke can mimic a number of other conditions that must be ruled out, including seizures, space-occupying lesions (e.g., subdural hematoma, cerebral abscess/infection, tumor), syncope, somatization, and delirium secondary to sepsis. The physical examination of the patient includes an investigation of vital signs (heart rate, respiratory rate, blood pressure), signs of cardiac decompensation, and function of the cerebral hemispheres, cerebellum, cranial nerves, eyes, and sensorimotor system. The presenting symptoms will help to determine the location of the lesion, and comparison of both sides of the body will reveal the side of the lesion. Bilateral signs are suggestive of brainstem lesions or massive cerebral involvement.

MUSCLE STRENGTH

Owing to the high incidence of MCA strokes, the UE is frequently more affected than the LE. About 20% of individuals with MCA strokes fail to regain any functional use of the affected UE. Typically, distal muscles exhibit greater strength deficits than proximal. This can be explained by the greater facilitation of distal muscles than proximal by the corticospinal system. Mild weakness also occurs on the ipsilateral, "supposedly normal" side.70,71 This can be explained by the fact that only 75% to 90% of the corticospinal fibers cross in the medulla to the contralateral side. The remainder are transmitted to the spinal cord ipsilaterally in the anterior or ventral corticospinal tract. Once in the spinal cord some of these fibers cross while the rest remain uncrossed, thereby explaining bilateral weakness Post-stroke weakness is associated with a number of changes in both the muscle and the motor unit. Changes occur in muscle composition, including atrophy of muscle fibers. There is a selective loss of type II fast-twitch fibers with subsequent increase in the percentage of type I fibers (a finding also reported in the elderly). This selective loss of type II fibers results in slowed force production, difficulty with initiation and production of rapid, high-force movements, and rapid onset of fatigue.60,73-75 The number of functioning motor units and discharge firing rates also decrease. This is explained by the presence of transsynaptic degeneration of alpha motor neurons that occurs with loss of corticospinal innervation. Abnormal recruitment of motor units with altered timing occurs.

Parenchyma

Parenchyma refers to the functional tissue in the brain that is made up of the two types of brain cell, neurons nad glial cells. Damage or trauma to the brain parenchyma often results in a loss of cognitive ability or even death.

Interventions to Improve Hemianopsia and Unilateral Neglect

Patients with hemianopsia or unilateral neglect demonstrate a lack of awareness of the contralesional side. The impairments are more pervasive in patients with neglect and in its most severe form (anosognosia) may extend to a total unawareness of the disability or the extent of the problems. These patients benefit from training strategies that encourage awareness and use of the environment on the hemiparetic side and use of the hemiparetic extremities. It is important to teach active visual scanning movements through turning of the head and axial trunk rotation to the more involved side. Cueing (e.g., visual, verbal, or motor cues) is used to direct the patient's attention. For example, a red anchor line can be taped on the floor and the patient directed to visually follow the line from one side to the other. Or a red ribbon can be attached to the patient's hemiparetic wrist and the patient directed to keep the red ribbon in sight. Scanning movements can also be stimulated using visual tracking tasks using a computer. Patients are given feedback about the success of their efforts and reinforcement for each successful performance (shaping). Imagery has also been shown to help (e.g., "Imagine you are a lighthouse beam; use your beam to sweep and scan the floor from one side to the other"). During therapy, the therapist stimulates and encourages active voluntary movements of the neglected limbs while encouraging the patient to look at his or her limbs while moving. UE exercises that involve crossing the midline toward the hemiparetic side (e.g., reaching activities or PNF chop or lift patterns) are important. Functional activities that encourage bilateral interaction are also valuable (e.g., pouring a drink and drinking from a cup; picking up an object with the more involved hand and placing it in the other; "dusting a tabletop" with a cloth held by both hands). The therapist needs to maximize the patient's attention by optimizing visual, tactile, or proprioceptive stimuli on the more affected side. These can include stroking, brushing, tapping, or vibrating the hemiparetic limbs. The therapist also needs to consistently reorient the patient as inattention develops. Patients with very low levels of arousal are likely to be less responsive to therapy efforts.

Functional Walking Categories

Physiological Walker •Walks for exercise only either at home or in parallel bars during physical therapy. Household Walker Limited household walker: •Relies on walking to some extent for home activities.•Requires assistance for some walking activities, uses a wheelchair, or is unable to perform others. Unlimited household walker: •Able to use walking for all household activities without any reliance on a wheelchair.•Encounters difficulty with stairs and uneven terrain.•May not be able to enter or leave the house independently. Community Walker Most-limited community walker: •Can enter and leave the home independently.•Can ascend and descend a curb independently.•Can manage stairs to some degree.•Independent in at least one moderate community activity (e.g., appointments, restaurants) and needs assistance or is unable in no more than one other low-challenge activity (e.g., church, neighborhood, visiting friend). Least-limited community walker: •Demonstrates independent stair management.•Independent in all moderate community activities without assistance or use of wheelchair.•Independent in either local stores or uncrowded shopping centers.•Independent in at least two other moderate community activities. Community walker: •Independent in all home and community activities.•Can accept crowds and uneven terrain.•Demonstrates complete independence in shopping centers.

Coordination

Proprioceptive losses can result in sensory ataxia. Strokes affecting the cerebellum typically produce cerebellar ataxia (e.g., lateral medullary syndrome, basilar artery syndrome, pontine syndromes) and motor weakness. The resulting problems with timing and sequencing of muscles can significantly impair function and limit adaptability to changing task and environmental demands. Basal ganglia involvement (posterior cerebral artery syndrome) may lead to slowed movements (bradykinesia) or involuntary movements (choreoathetosis, hemiballismus). The therapist focuses on elements of speed/rate control, steadiness, response orientation, and reaction and movement times. Fine motor control and dexterity should be examined using writing, dressing, and feeding tasks (see Chapter 6, Examination of Coordination and Balance). Although more significant impairments can be expected on the hemiparetic side, it is important to remember that subtle deficits can occur on the less involved side.

REFLEXES

Reflexes are altered and also vary according to the stage of recovery. Initially, stroke results in hyporeflexia with flaccidity. When spasticity and synergies emerge, hyperreflexia is seen. Deep tendon reflexes are hyperactive and patients may demonstrate clonus, clasp-knife response, and a positive Babinski, all consistent findings of upper motor neuron syndrome.

Rigidity

Rigidity is a hypertonic state characterized by constant resistance throughout ROM that is independent of the velocity of movement (lead-pipe rigidity). It is associated with lesions of the basal ganglia system (extrapyramidal syndromes) and is seen in Parkinson's disease. Rigidity is the result of excessive supraspinal drive (upper motor neuron facilitation) acting on alpha motor neurons; spinal reflex mechanisms are typically normal. Patients demonstrate stiffness, inflexibility, and significant functional limitation. Cogwheel rigidity refers to a hypertonic state with superimposed ratchet-like jerkiness and is commonly seen in upper extremity movements (e.g., wrist or elbow flexion and extension) in patients with Parkinson's disease. It may represent the presence of tremor superimposed on rigidity. Tremor, bradykinesia, and loss of postural stability are also associated motor deficits in patients with Parkinson's disease. In the patient with rigidity, resistance is constant and not responsive to increasing the velocity of passive motion.

Stages of Motor Recovery

STAGE 1: Initially, flaccid paralysis is present (stage 1). This is replaced by the development of spasticity, hyperreflexia, and mass patterns of movement, termed obligatory synergies, all characteristics of upper motor neuron syndrome. Muscles involved in obligatory synergy patterns are strongly linked in a highly stereotyped, abnormal pattern; isolated joint movements outside the obligatory pattern are not possible. STAGE 2: During stage 2 (early synergy), facilitatory stimuli will elicit synergies with minimal voluntary movement. STAGE 3: As recovery progresses, spasticity is marked with full strong obligatory synergies (stage 3). STAGE 4: Synergy influence begins to decline in stage 4 as some isolated out-of-synergy joint movements emerge. STAGE 5: relative independence of synergy, spasticity continues to wane and isolated joint movements become more apparent. STAGE 6: patterns of movement are near normal. Several important points merit consideration. An overall pattern of motor recovery exists though individual recovery is highly variable. Some patients experience mild involvement with early full recovery whereas other patients demonstrate severe involvement with incomplete recovery. The degree of recovery depends on a number of factors, including lesion location and severity and capacity for adaptation through training. Finally, recovery differs within patients. For example, the UE may be more involved and demonstrate less complete recovery than the LE as is seen in MCA syndrome.

Global aphasia

Severe aphasia with marked dysfunction across all language modalities; severely limited residual use of all communication modes for oral-aural interactions; global is not a type of aphasia but a designation of severity. Global aphasia is a severe aphasia characterized by marked impairments of both production and comprehension of language. It is often an indication of extensive brain damage. Severe problems in communication may limit the patient's ability to learn and often impede successful outcomes in rehabilitation.

Interventions to Improve Flexibility and Joint Integrity

Soft tissue/joint mobilization and ROM exercises are initiated early to maintain joint integrity and mobility and prevent contractures. Passive ROM (PROM), and AROM when possible, with terminal stretch should be performed daily in all motions. If a contracture is developing, more frequent ROM (twice daily or more) is necessary. Positioning strategies are also important in maintaining soft tissue length (Box 15.8). Effective positioning of the hemiparetic extremities encourages proper joint alignment while positioning the limbs out of the abnormal postures typically assumed. The use of protective devices such as resting splints may be necessary. Coordination with staff, family, and caregivers is essential for long-term management.

Spatial relations syndrome.

Spatial relations syndrome refers to a constellation of impairments that have in common a difficulty in perceiving the relationship between the self and two or more objects in the environment. It includes specific impairments in figure-ground discrimination, form discrimination, spatial relations, position in space, and topographical disorientation.

right parietal cortex lesions can lead to...

Stroke can produce visual-perceptual deficits, with a reported incidence ranging from 32% to 41%. seen more with left hemiplegia than right. These may include disorders of body scheme/body image, spatial relations, and agnosias.

asomatognosia

a form of neglect in which patients deny ownership of their limbs.

BRAINSTEM LESIONS

Symptoms of crossed anesthesia (ipsilateral facial impairments with contralateral trunk and limb involvement) typify brainstem lesions

Chedoke-McMaster Stroke Assessment

The Chedoke-McMaster Stroke Assessment examines physical impairment and disability after stroke. It includes two components: the Impairment Inventory and the Activity Inventory. There are 14 items scored using a 7-point scale with a 2-point score used for walking distance. The Impairment Inventory examines the presence and severity of impairments in six areas (shoulder pain, postural control, and control of the arm, hand, foot, and leg). The Activity Inventory is subdivided into the Gross Motor Function Index (with items including moving in bed and transferring to a chair) and the Walking Index (with items including walking on rough terrain and climbing stairs).

clinical stroke rehabilitation specialist (CSRS)

The National Stroke Association has instituted a process to certify stroke rehabilitation specialists. The designation of clinical stroke rehabilitation specialist (CSRS) ensures that therapists are expert stroke clinicians through a rigorous set of four-tiered courses culminating in a written examination and nationally recognized credential, the CSRS certification. Additional information can be found at www.stroke.org.

Stroke Impact Scale (SIS)

The SIS is a self-report measure developed to assess function and quality of life after stroke. It includes 59 items organized into 8 subgroups: strength, memory and thinking, emotions, communication, ADL, mobility, hand function, and participation. The final item asks the person to rate perceived recovery on a scale of 0 to 100 with 100 representing full recovery and 0 representing no recovery. It takes about 30 minutes to complete. The SIS is a valid, reliable, and sensitive measure of change in this population.111,112 Responses can also be accurately provided by proxy.113 The form and user agreement is available at the following website: www2.kumc.edu/coa/SIS/Stroke-Impact-Scale.htm.

Stroke Rehabilitation Assessment of Movement (STREAM)

The STREAM is a clinical measure of voluntary movements and basic mobility following stoke. It consists of 30 items (test movements) distributed equally among three subscales: upper-limb movements, lower-limb movements, and basic mobility items. Voluntary movement items explore out-of-synergy control and are scored using a 3-point ordinal scale (unable to perform, partial performance, complete performance). The basic mobility section includes a variety of items (rolling, bridging, sit-to-stand, standing, stepping, walking, and stairs) and is scored using a 4-point ordinal scale (unable, partial, complete/with aid, complete/no aid). The maximum STREAM score is 70 with each limb subscore worth 20 points and the functional mobility subscore worth 30 points.107 The instrument has good construct validity and high reliability.108 It has been used to document motor recovery over time and predict discharge destination following stroke.

Middle Cerebral Artery Syndrome

The middle cerebral artery (MCA) is the second of the two main branches of the internal carotid artery and supplies the entire lateral aspect of the cerebral hemisphere (frontal, temporal, and parietal lobes) and subcortical structures, including the internal capsule (posterior portion), corona radiata, globus pallidus (outer part), most of the caudate nucleus, and the putamen (Fig. 15.4). Occlusion of the proximal MCA produces extensive neurological damage with significant cerebral edema. Increased intracranial pressures typically lead to loss of consciousness, brain herniation, and possibly death. Table 15.2 presents the clinical manifestations of middle cerebral artery (MCA) syndrome. The most common characteristics of MCA syndrome are contralateral spastic hemiparesis and sensory loss of the face, UE, and LE, with the face and UE more involved than the LE. Lesions of the parieto-occipital cortex of the dominant hemisphere (usually the left hemisphere) typically produce aphasia. Lesions of the right parietal lobe of the nondominant hemisphere (usually the right hemisphere) typically produce perceptual deficits (e.g., unilateral neglect, anosognosia, apraxia, and spatial disorganization). Homonymous hemianopsia (a visual field defect) is also a common finding. The MCA is the most common site of occlusion in stroke.

Interventions to Improve Sensory Function

The more the patient can be encouraged to use the affected side, the greater the chance of increased awareness and function. Conversely, the patient who refuses to use the hemiplegic side contributes to the problems imposed by lack of sensorimotor experience. Without attention during treatment, this learned nonuse phenomenon can contribute to further deterioration. Sensory retraining programs include use of mirror therapy (previously discussed), repetitive sensory discrimination activities, bilateral simultaneous movements, and repetitive task practice (e.g., sensorimotor integrative treatment with its focus on normalizing tone, practice of functional activity, and use of augmented sensory cues). Sensory stimulation intervention includes compression techniques (weight-bearing, manual compression, inflatable pressure splints, intermittent pneumatic compression), mobilizations, electrical stimulation, thermal stimulation, or magnetic stimulation. In a review of 13 studies, Cochrane reviewers48 found significant clinical and methodological diversity, limited RCT trials, generally small sample sizes with inadequate data, variability in outcome measures, and limited used of functional performance and participation outcome measures. They concluded there was insufficient evidence to support or refute the effectiveness of many of these interventions in improving sensory function. Limited evidence was found in support of the following: •Mirror therapy for improving detection of light touch, pressure, and temperature pain•Thermal stimulation intervention for improving rate of recovery of sensation•Intermittent pneumatic compression for improving tactile and kinesthetic sensation The results of a systematic review of sensory retraining by Schabrun and Hillier131 were similar with additional support found for electrical stimulation interventions. During functional training, the therapist needs to maximize weight-bearing and compression of the sensory deficient limbs. Approximation can be applied with the sensory-deficient UE weight-bearing in sitting or standing/modified plantigrade position and to the pelvis during standing activities. While sitting on a ball, the patient can practice bouncing. The compression and approximation that occur through the spine enhances activity in the postural extensors. During the application of sensory stimulation to the more involved limbs, the therapist directs the patient's attention and assists in shaping the patient's responses.

Wernicke's aphasia (sensory aphasia or receptive aphasia)

The most common type of fluent aphasia; characterized by impaired ability to understand spoken or written words. Associated with lesions to the Wernicke's area of temporal lobe of dominant hemisphere.

The Patient with Ipsilateral Pushing (Pusher Syndrome) Treatment ideas

The patient sits or stands asymmetrically, but with most of the weight shifted toward the weaker side. The patient uses the stronger UE or LE to push over to the weaker side, often resulting in instability and falls. Efforts by the therapist to passively correct the patient's tilted posture often result in the patient pushing stronger. Training needs to emphasize upright positions with active movement shifts toward the stronger side. Use of visual stimuli is effective as patients retain the ability to correct posture with such stimuli but may not be able to do so spontaneously. Patients should be asked to look at their posture and see if they are upright. Environmental prompts can be used to assist orientation. These can include use of a mirror if visuospatial deficits are not present or vertical structures in the environment. For example, the therapist can sit on the patient's less involved side and instruct the patient to "lean over to me." Or the patient can be positioned with the stronger side next to a wall and instructed to "lean toward the wall."95 Therapists can provide verbal and tactile cues for postural orientation. To improve sitting posture, training activities can include sitting on a therapy ball to promote symmetry and sitting. In early standing the weaker LE is often flexed and has difficulty supporting the body on that side. Extension can be assisted by the use of an air splint or a posterior leg splint or by direct tapping over the quadriceps muscle. The modified plantigrade position is effective for early supported standing; however, the therapist should focus on unilateral support using the weaker UE. Again, an air splint can be used to assist extension of the weaker arm. If a cane is used, it can be shortened to encourage weight shift to the stronger side. An environmental boundary can be used to achieve symmetrical standing (e.g., standing in a doorway or corner standing). It is important to limit pushing with the sound extremities. For example, in sitting or standing, the therapist should block the stronger limb from drifting laterally into abduction and extension and pushing.205,206 During wheelchair sitting, the patient should be assisted to maintain upright posture and midline orientation. Motor learning strategies are very effective in reducing the effects of this disorder and enhancing recovery. In particular, the therapist should demonstrate correct orientation to vertical, provide consistent feedback about body orientation, and practice correct orientation and weight shifts. The patient should be fully involved in problem solving. For example, the therapist should ask questions such as "what direction are you tilted?" and "what direction do you have to move in order to achieve vertical?"

EXAMINATION

The purposes of the examination are to •Determine the diagnosis and classification within a specific practice pattern.•Monitor recovery from stroke.•Identify patients who are most likely to benefit from rehabilitation services and the most appropriate choice of a care setting.•Develop a specific POC, including anticipated goals, expected outcomes, prognosis, and interventions.•Monitor progress toward projected goals and outcomes through periodic reevaluation.•Determine if referral to another practitioner is indicated.•Plan for discharge.

Cranial Nerve Integrity

The therapist should examine for facial sensation (CN V), facial movements (CNs V and VII), and labyrinthine/auditory function (CN VIII). The presence of swallowing difficulties and drooling necessitates an examination of the motor nuclei of the lower brainstem cranial nerves (CNs IX, X, and XII) affecting the muscles of the face, tongue, larynx, and pharynx. This includes determination of motor function of the lips, mouth, tongue, palate, pharynx, and larynx. The gag reflex should be examined because hypoactivity may lead to aspiration into the airway. Adequacy of cough mechanisms should also be carefully examined. The therapist needs to be able to recognize the presence of swallowing difficulties and initiate prompt referral. The visual system should be carefully investigated, including tests for visual field defects (CN II, optic radiation, visual cortex), acuity (CN II), pupillary reflexes (CNs II and III), and extraocular movements (CNs III, IV, and VI). Ocular motility disturbances may be present with brainstem strokes, such as diplopia, oscillopsia, visual distortions, or paralysis of conjugate gaze. Visual field defects (homonymous hemianopsia) need to be differentiated from visual neglect, a perceptual deficit characterized by an inattention to or neglect of visual stimuli presented on the involved side. The patient with pure hemianopsia is typically aware of the deficit and may spontaneously compensate by moving the eyes or head toward the side of deficit; the patient with visual neglect will be unaware (inattentive) of the deficit (see Chapter 29). The use of prescriptive eyeglasses should be determined before any testing; the therapist should ensure that eyeglasses are worn and clean.

Posterior Cerebral Artery Syndrome

The two posterior cerebral arteries (PCAs) arise as terminal branches of the basilar artery and each supplies the corresponding occipital lobe and medial and inferior temporal lobe (see Fig. 15.3). It also supplies the upper brainstem, midbrain, and posterior diencephalon, including most of the thalamus. Table 15.3 presents the clinical manifestations of posterior cerebral artery (PCA) syndrome. Occlusion proximal to the posterior communicating artery typically results in minimal deficits owing to the collateral blood supply from the posterior communicating artery (similar to ACA syndrome). Occlusion of thalamic branches may produce hemianesthesia (contralateral sensory loss) or central post-stroke (thalamic) pain. Occipital infarction produces homonymous hemianopsia, visual agnosia, prosopagnosia, or, if bilateral, cortical blindness. Temporal lobe ischemia results in amnesia (memory loss). Involvement of subthalamic branches may involve the subthalamic nucleus or its pallidal connections, producing a wide variety of deficits. Contralateral hemiplegia occurs with involvement of the cerebral peduncle.

dysarthria

a category of motor speech disorders caused by lesions in parts of the central or peripheral nervous system that mediate speech production. Respiration, articulation, phonation, resonance, and/or sensory feedback may be affected. The lesion can be located in the primary motor cortex in the frontal lobe, the primary sensory cortex in the parietal lobe, or the cerebellum. Volitional and automatic actions such as chewing and swallowing and movement of the jaw and tongue are impaired resulting in slurred speech. In patients with stroke, dysarthria can accompany aphasia, complicating the course of rehabilitation

apraxia

Total or partial loss of the ability to perform coordinated movements or manipulate objects in the absence of motor or sensory impairment.

M1 Occlusion

Unilateral occlusion of Middle Cerebral Arteries at the stem (proximal M1 segment) results in: Contralateral hemiplegia affecting face, arm, and leg (lesser).

Vertebrobasilar Artery Syndrome

Vertebrobasilar Artery Syndrome The vertebral arteries arise from the subclavian arteries and travel into the brain along the medulla where they merge at the inferior border of the pons to form the basilar artery. The vertebral arteries supply the cerebellum (via posterior inferior cerebellar arteries) and the medulla (via the medullary arteries). The basilar artery supplies the pons (via pontine arteries), the internal ear (via labyrinthine arteries), and the cerebellum (via the anterior inferior and superior cerebellar arteries). The basilar artery then terminates at the upper border of the pons giving rise to the two posterior arteries (see Fig. 15.2). Occlusions of the vertebrobasilar system can produce a wide variety of symptoms with both ipsilateral and contralateral signs, because some of the tracts in the brainstem will have crossed and others will not. Numerous cerebellar and cranial nerve abnormalities also are present. Table 15.4 presents the clinical manifestations of vertebrobasilar artery syndromes.

Associated Reactions

also typically present in patients with stroke who exhibit strong spasticity and 670 671obligatory synergies. These consist of unintentional movements of the hemiparetic limb caused by voluntary action of another limb or by other stimuli such as yawning, sneezing, or coughing. For example, the patient vigorously contracts the elbow flexors of the stronger UE; the hemiparetic elbow also flexes. Or the patient flexes the hip to lift the hemiparetic LE in sitting; the hemiparetic UE also flexes. Associated reactions can limit functional performance, especially in the UE. An examination of stretch reflexes and pathological reflexes (e.g., Babinski, tonic reflex activity, associated reactions) should be performed.

Ideation apraxia

an inability of the patient to produce movement either on command or automatically and represents a complete breakdown in the conceptualization of the task. The patient has no idea how to do the movement and thus cannot formulate the required motor programs.

Dysphagia

an inability to swallow or difficulty in swallowing, occurs in about 51% of patients with stroke. It can be seen in hemispheric stroke, brainstem stroke, or pseudobulbar and suprabulbar palsy. In brainstem stroke, the reported incidence is as high as 81%. Cranial nerve involvement results in swallowing dysfunction of the oral stage (CN V [trigeminal], CN VII [facial]), the pharyngeal stage (CN IX [glossopharyngeal], CN X [vagus], and CN XI [accessory]), or oral and pharyngeal (CN XII [hypoglossal]). Dysphagia is also common in patients with multiple strokes. The most common problems seen in patients with dysphagia include delayed triggering of the swallowing reflex, reduced pharyngeal peristalsis, and reduced lingual control. Altered mental status, altered sensation, poor jaw and lip closure, impaired head control, and poor sitting posture also contribute to the patient's swallowing difficulties. Most patients demonstrate multiple problems that can include drooling, difficulty ingesting food, compromised nutritional status, and dehydration.

pusher syndrome or contraversive pushing / ispilateral pushing

an unusual motor behavior characterized by active pushing with the stronger extremities toward the hemiparetic side with a lateral postural imbalance. The end result is a tendency to fall toward the hemiparetic side. Ipsilateral pushing occurs in about 10% of patients with acute stroke and results from stroke affecting the posterolateral thalamus. The result is an altered perception of the body's orientation in relation to gravity. The result is an altered perception of the body's orientation in relation to gravity. Karnath et al90 found that patients experienced a misperception of subjective postural vertical position, perceiving their body as vertical when it was actually tilted about 20° toward the hemiparetic side. They also found that the visual and vestibular input for orientation perception to vertical remained intact as patients were able to align their bodies with the help of visual cues and conscious strategies. No significant association between ipsilateral pushing and hemineglect, anosognosia, aphasia, or apraxia has been found. Functional skills are significantly impaired for patients with ipsilateral pushing. During sitting, the push results in a strong lateral lean toward the weaker side; when sitting in a wheelchair, this often thrusts the patient over onto the wheelchair arm. In standing, a strong push creates an unstable situation with a high risk of falls because the hemiparetic LE typically cannot support the body weight. The patient shows no fear even when active pushing leads to instability and strongly resists any attempts to passively correct posture to midline, symmetrical weight-bearing. This pattern is totally opposite the expected postural deficiency seen in most patients after stroke, that is, increased weight-bearing to the stronger side to compensate for deficits on the hemiparetic side. Patients also typically demonstrate severe problems in transfers and gait. During transfers to the less involved side, the patient demonstrates increased pushback away from that side. During walking, the patient typically exhibits inadequate extension of the hemiparetic LE with inability to transfer weight toward the less involved LE. During swing, strong scissoring (adduction) of the more involved LE is typically evident. The use of a cane during ambulation is problematic because patients use the cane to increase push to the hemiplegic side. Pedersen et al91 demonstrated that patients with ipsilateral pushing behavior have poorer rehabilitation outcomes with longer hospital stays and prolonged recovery times. They also had significantly lower functional scores on admission and discharge with increased levels of dependence at discharge. However, with training, the brain can compensate well. The syndrome is rarely still evident at 6 months

Lacunar strokes

are caused by small vessel disease deep in the cerebral white matter (penetrating artery disease). They are strongly associated with hypertensive hemorrhage and diabetic microvascular disease. Lacunar syndromes are consistent with specific anatomical sites. Pure motor lacunar 651 653stroke is associated with involvement of the posterior limb of the internal capsule, pons, and pyramids. Pure sensory lacunar stroke is associated with involvement of the ventrolateral thalamus or thalamocortical projections. Other lacunar syndromes include dysarthria/clumsy hand syndrome (involving the base of the pons, genu of anterior limb, or the internal capsule), ataxic hemiparesis (involving the pons, genu of internal capsule, corona radiata, or cerebellum), sensory/motor stroke (involving the junction of the internal capsule and thalamus), or dystonia/involuntary movements (choreoathetosis with lacunar infarction of the putamen or globus pallidus; hemiballismus with involvement of the subthalamic nucleus). Deficits in consciousness, language, or visual fields are not seen in lacunar strokes because the higher cortical areas are preserved. A hypertensive hemorrhage affecting the thalamus can also produce central post-stroke pain.

JP Drain - Jackson-Pratt Drain

is a closed-suction medical device that is commonly used as a post-operative drain for collecting bodily fluids from surgical sites. The device consists of an internal drain connected to a grenade-shaped bulb via plastic tubing.

Central post-stroke pain (CPSP)

defined as pain arising as a direct consequence of a lesion or disease affecting the central somatosensory system and occurs in about 10% of strokes.62 It can result from lesions at any level of the somatosensory pathways including the medulla, thalamus, and cortex. The thalamus is thought to play an important part in the underlying pathophysiology of central pain. CPSP can be severe and persistent (described as "burning," "aching"), spontaneous and intermittent (described as "lacerating" or "shooting" pain), or evoked by mechanical (stroking the skin, pressure) or thermal (heat or cold) stimuli. Symptoms may be focal, affecting the hand/arm or foot/leg, or in severe cases affect half the body. Development of pain is typically within the first few months after stroke though onset may be delayed for many months. Spontaneous recovery is rare and chronic suffering common. The debilitating nature of CPSP frequently limits participation in rehabilitation programs and outcomes. Does this happen on the effected side of the body?

Executive functions

defined as those abilities that enable a person to engage in purposeful behaviors, include volition, planning, purposeful action, and effective performance. Patients with lesions of the prefrontal cortex typically demonstrate impairments in executive function including some or all of the following: impulsiveness, inflexible thinking, lack of abstract thinking, impaired organization and sequencing, decreased insight, impaired planning ability, and impaired judgment. Patients are unable to realistically appraise their environment and the people and events in it. They also demonstrate difficulty in self-monitoring and self-correcting behaviors, thereby posing safety risks.

left hemisphere lesions (right hemiplegia)

demonstrate difficulties in communication and in processing information in a sequential, linear manner. They are frequently described as cautious, anxious, and disorganized. This makes them more hesitant when trying new tasks and increases the need for feedback and support. They tend, however, to be realistic in their appraisal of their existing problems.

right hemisphere lesions (left hemiplegia)

demonstrate difficulty in spatial-perceptual tasks and in grasping the whole idea of a task or activity. They are frequently described as quick and impulsive. They tend to overestimate their abilities while acting unaware of their deficits. This lack of insight and concreteness impairs the patient's ability to participate in rehabilitation. Safety is a far greater issue for patients with left hemiplegia, where poor judgment is common. These patients also require a great deal of feedback when learning a new task. The feedback should be focused on slowing down the activity, checking sequential steps, and relating them to the whole task. Patients also need help recognizing the consequences and risks of their actions. The patient with left hemiplegia frequently cannot attend to visuospatial cues effectively, especially in a cluttered or crowded environment

anosognosia

is a deficit of self-awareness, a condition in which a person who suffers some disability seems unaware of the existence of their disability. results from physiological damage to brain structures, typically to the parietal lobe or a diffuse lesion on the fronto-temporal-parietal area in the right hemisphere.

Spasticity (hypertonicity)

emerges in about 90% of cases and occurs on the side of the body opposite the lesion. Spasticity in upper motor neuron syndrome occurs predominantly in antigravity muscles (see Chapter 5, Table 5.3). In the patient with stroke, UE spasticity is frequently strong in scapular retractors; shoulder adductors, depressors, and internal rotators; elbow flexors and forearm pronators; and wrist and finger flexors. In the neck and trunk, spasticity may cause increased lateral flexion to the hemiplegic side. In the LE, spasticity is often strong in the pelvic retractors, hip adductors and internal rotators, hip and knee extensors, plantarflexors and supinators, and toe flexors. Spasticity results in tight (stiff) muscles that restrict volitional movement. Posturing of the limbs (e.g., a tightly fisted hand with the elbow flexed and held tightly against the chest or a stiff extended knee with a plantarflexed foot) is common with moderate to severe spasticity. Spastic posturing can lead to development of painful spasms (similar to muscle cramping), degenerative changes, and fixed contractures. The automatic adjustment of postural muscles that occurs normally in preparation for and during a movement task is also impaired. Thus, patients with stroke may lack the ability to adjust and stabilize proximal limbs and trunk appropriately during movement, with resulting postural abnormalities, balance impairments, and increased risk for falls.

Clinical signs of elevating intracranial pressure (ICP)

include decreasing level of consciousness (stupor and coma), widened pulse pressure, increased heart rate, irregular respirations (Cheyne-Stokes respirations), vomiting, unreacting pupils (cranial nerve [CN] III signs), and papilledema. Cerebral edema is the most frequent cause of death in acute stroke and is characteristic of large infarcts involving the middle cerebral artery and the internal carotid artery.

patent foramen ovale (PFO)

is a hole in the heart that didn't close the way it should after birth. During fetal development, a small flap-like opening — the foramen ovale (foh-RAY-mun oh-VAY-lee) — is normally present in the wall between the right and left upper chambers of the heart (atria)

Beck Depression Inventory

is a useful instrument for depression screening. It consists of 21 statements that are scored on a scale from 0 to 3 (the short version has 13 questions and takes 5 minutes to complete).

National Institutes of Health Stroke Scale (NIHSS)

is a valuable screening tool that focuses on initial and serial examination of impairments following acute 661 662stroke. The scale includes 11 items and uses a variable ordinal scale. Some items are scored 0−2 or 0−3 (level of consciousness, best gaze, visual fields, facial palsy, limb ataxia, sensory, best language, dysarthria, extinction, and inattention); other items are scored 0−4 (motor arm and motor leg). Specific descriptors are attached to each score. It was designed to be completed in 5 to 8 minutes. (The NIHSS is available at www.ninds.nih.gov/doctors/NIH_Stroke_Scale.pdf.)

(PEG tube) - Percutaneous endoscopic gastrostomy (PEG)

is an endoscopic medical procedure in which a tube (PEG tube) is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate (for example, because of dysphagia or sedation).

Arteriovenous malformation (AVM)

is another congenital defect that can result in stroke. AVM is characterized by a tortuous tangle of arteries and veins with agenesis of an interposing capillary system. The abnormal vessels undergo progressive dilation with age and eventually bleed in about 50% of cases.

Intracerebral hemorrhage (IH)

is caused by rupture of a cerebral vessel with subsequent bleeding into the brain.

Cerebral embolus (CE)

is composed of bits of matter (blood clot, plaque) formed elsewhere and released into the bloodstream, traveling to the cerebral arteries where they lodge in a vessel, producing occlusion and infarction. The most common source of CE is disease of the cardiovascular system.

Memory

is defined as the ability to store experiences and perceptions for later recall. Immediate and short-term memory impairments are common, occurring in about 36% of patients with stroke, whereas long-term memory typically remains intact.2 Thus, the patient cannot remember the instructions for a new task given only minutes or hours ago but can easily remember events 30 years ago. Short-term memory loss is associated with lesions of the limbic system, limbic association cortex (orbitofrontal areas), or temporal lobes. Long-term memory loss is associated with lesions of the hippocampus of the limbic system.

Locked-in syndrome (LIS)

occurs with basilar artery thrombosis and bilateral infarction of the ventral pons. LIS is a catastrophic event with sudden onset. Patients develop acute hemiparesis rapidly progressing to tetraplegia and lower bulbar paralysis (CNs V through XII are involved). Initially the patient is dysarthric and dysphonic but rapidly progresses to mutism (anarthria). There is preserved consciousness and sensation. Thus the patient cannot move or speak but remains alert and oriented. Horizontal eye movements are impaired but 653 655vertical eye movements and blinking remain intact. Communication can be established via these eye movements. Mortality rates are high (59%), and those patients who do survive are left with severe impairments associated with brainstem injury.

Body scheme

refers to a postural model of the body including the relationship of the body parts to each other and the relationship of the body to the environment. Body image is the visual and mental image of one's body that includes feelings about one's body. Both may be distorted following stroke. Specific impairments of body scheme/body image include unilateral neglect, anosognosia, somatoagnosia, right-left discrimination, finger agnosia, and anosognosia.

Decorticate rigidity

refers to sustained contraction and posturing of the upper limbs in flexion and the lower limbs in extension. The elbows, wrists, and fingers are held in flexion with shoulders adducted tightly to the sides while the legs are held in extension, internal rotation, and plantarflexion. Decerebrate rigidity indicates a corticospinal lesion in the brainstem between the superior colliculus and vestibular nucleus.

confabulation

results from lesions in the prefrontal cortex. The patient may be confused, demonstrating disorientation and an inability to understand the specific context of a conversation. Memory gaps may be filled with inappropriate words or fabricated stories.

Delirium also known as acute confusional state

seen more commonly in the acute care setting and results from a number of factors following acute stroke. Deprivation of oxygen to the brain, metabolic imbalance, or adverse drug reactions can all induce confusion. Additional contributory factors can include sensory and perceptual losses coupled with an unfamiliar hospital environment and inactivity. Delirium is characterized by a clouding of consciousness or dulling of cognitive processes and impaired alertness. Thus, the patient is inattentive, incoherent, and disorganized with fluctuating levels of consciousness. Hallucinations and agitation are also common. Nighttime may be particularly problematic. Patients with significant sensory loss following stroke may experience sensory deprivation problems evidenced by irritability, confusion, psychosis, delusions, and even hallucinations. These problems are more frequently seen in the acute phase, especially with patients who have been confined to a bed or whose bed is positioned to limit social interaction (e.g., with the more involved side toward the door). Some patients are equally unable to deal with a sensory overload, produced by too much stimulation. Altered arousal levels are implicated.

ideomotor apraxia

the patient is unable to produce a movement on command but is able to move automatically. Thus, the patient can perform habitual tasks when not commanded to do so and often perseverates, repeating the activity over and over.

Transient ischemic attack (TIA)

the temporary interruption of blood supply to the brain. Symptoms of focal neurological deficit may last for only a few minutes or for several hours, but by definition do not last longer than 24 hours. After the attack is over there is no evidence of residual brain damage or permanent neurological dysfunction. TIAs may result from a number of different etiological factors, including occlusive episodes, emboli, reduced cerebral perfusion (arrhythmias, decreased cardiac output, hypotension, overmedication with antihypertensive medications, subclavian steal syndrome), or cerebrovascular spasm. The major clinical significance of TIA is as a precursor to susceptibility for both cerebral infarction and myocardial infarction. Approximately 15% of all strokes are preceded by a TIA, with the greatest risk of occurrence within 90 days.1

Trunk Impairment Scale

was developed to evaluate motor impairment of the trunk after stroke. It includes 3 items of static control, 10 items of dynamic balance control, and 4 items of coordination. The items are tested in the sitting position (edge of bed or treatment table) without back or arm support. Each item is performed three times with the highest score accepted. Scores range from a minimum of 0 (unable) to a maximum of 23.

Postural Assessment Scale for Stroke Patients (PASS)

was developed to examine the postural abilities of patients with acute stroke. It includes 12 items that examine sitting and standing without support, standing on the paretic LE, and changing posture 673 674(supine-to-affected side, supine-to-unaffected side, supine-to-sitting, sitting-to-standing, and standing picking a pencil off the floor). It is scored using an ordinal scale with descriptors ranging from cannot perform to perform with little help, to perform without help. It demonstrates good construct validity and high interrater and intrarater reliability (0.88 and 0.72, respectively).