NPTE Final Frontier Stroke & TBI PDF January 2025

NPTE Final Frontier Stroke Traumatic Brain Injury January 2025 Dr. Vrunda Kapadia, PT, DPT, MS, GCS, OCS, NCS Lead Instructor, NPTE Final Frontier  Objectives: By the end of the class, I will be able to :...

NPTE Final Frontier Stroke Traumatic Brain Injury January 2025 Dr. Vrunda Kapadia, PT, DPT, MS, GCS, OCS, NCS Lead Instructor, NPTE Final Frontier  Objectives: By the end of the class, I will be able to : - Differentiate between MCA vs PCA vs ACA - Differentiate between right vs left sided stroke - Differentiate between spasticity and synergy - Select best positioning strategies for my patient - Discuss the TBI levels of injury and treatment NPTE Final Frontier NPTE Final Frontier  Types of Stroke Ischemic Stroke Hemorrhagic Stroke Occurs when a clot blocks or Occurs when blood vessels rupture, impairs blood flow, depriving the causing leakage of blood in or brain of essential oxygen and around the brain nutrients A ruptured blood vessel leaks blood Blood flow into brain is obstructed NPTE Final Frontier  Anterior Cerebral Artery Syndrome Signs and Symptoms Contralateral hemiparesis (LE) Contralateral hemisensory loss (LE) Urinary incontinence Problems with imitation, bimanual tasks, apraxia Slowness, delay, motor inaction Contralateral grasp reflex, sucking reflex NPTE Final Frontier  Middle Cerebral Artery Signs and Symptoms Contralateral hemiparesis (UE and face) Contralateral hemisensory loss (UE and face) Language speech impairments – Broca, Wernicke, Global aphasia Perceptual disorders – e.g., Unilateral neglect Contralateral homonymous hemianopsia NPTE Final Frontier  SO…..What else do you know about APHASIA? – Left MCA NPTE Final Frontier Aphasia: Seen With a Left-Brain Lesion in Most Cases Broca’s aphasia/ Expressive/ Non-fluent aphasia: FRONTAL LOBE Patient has slow, hesitant speech Treatment: Yes/No questions Wernicke’s aphasia/Receptive/Fluent aphasia: TEMPORAL LOBE Patient cannot comprehend Word salad Treatment: Gestures and demonstration REMEMBER: Left hemisphere is usually called the DOMINANT HEMISPHERE NPTE Final Frontier  Perceptual Deficit: Unilateral Neglect – Right MCA Lack of awareness of the weak side Seen with Right CVA Encourage awareness and use of the environment on the hemiparetic side and use of the hemiparetic extremities Active visual scanning > turning of the head and axial trunk rotation to the more involved side NPTE Final Frontier  Homonymous Hemianopsia – Right or Left MCA NPTE Final Frontier  Practice Question 1 A patient with a diagnosis of left middle cerebral artery infarct is MOST LIKELY to have which of the following signs and symptoms? A. Excessive weakness of the right lower extremity B. Neglect of the left side of the body C. Left homonymous hemianopsia D. Inability to understand words spoken by the therapist NPTE Final Frontier  Posterior Cerebral Artery Syndrome Signs and Symptoms – Signs and Symptoms – Peripheral Territory Central Territory Contralateral homonymous hemianopsia Thalamus: Central Post Stroke THALAMIC PAIN syndrome Visual agnosia – PROSOPagnosia Dyslexia (difficulty reading) WITHOUT Agraphia (difficulty writing) Color discrimination Memory deficits Topographical disorientation NPTE Final Frontier  Right Hemisphere Left Hemisphere Tone/Sensation Left hemiparesis/hemisensory Right hemiparesis/hemisensory loss loss Impairments Visual- perceptual impairments: Language impairments: Right - Neglect - Difficulty with VISUAL cues - Aphasias - Difficulty with VERBAL cues vs Behavior Quick, impulsive, safety risk Slow, cautious Left Intellectual Emotional Rigidity of thought Difficulty with negative Highly distractible Difficulty with positive emotions Stroke emotions COMMON Homonymous Hemianopsia NPTE Final Frontier  Practice Question 2 A patient presents with sudden onset of weakness on one side of the body. When asked, they were unable to name their friend who accompanied them to the hospital. During assessment, they were able to write a sentence perfectly but was unable to read their sentence. A lesion in which of the following is the MOST LIKELY cause of this symptom? A. Superior division of Middle Cerebral Artery B. Central territory of Posterior Cerebral Artery C. Inferior division of Middle Cerebral Artery D. Peripheral territory of Posterior Cerebral Artery NPTE Final Frontier  Million $ Question: Spasticity vs Synergy NPTE Final Frontier  Spasticity vs Synergy NPTE Final Frontier  Brunnstrom Stages of Stroke Recovery Stage 1: Flaccidity No active limb movement Stage 2: Beginning of minimal voluntary movement In synergy, with associated reactions Increase tone Stage 3: Voluntary control of movement synergy (Spasticity at peak) Further increase tone to peak level Stage 4: Movement outside of synergy Decrease tone Stage 5: Increase complex movement, greater independence from limb synergies Stage 6: Individual joint movement, coordinated movement Stage 7: Normal function NPTE Final Frontier  Motor Function NPTE Final Frontier  Spasticity Pattern in Upper and Lower Extremity Upper Lower Action Action Limbs Limbs Scapula Retraction, downward rotation Pelvis Retraction (hip hiking) Shoulder Adduction, IR, depression Hip Adduction (scissoring) IR Elbow Flexion Extension Forearm Pronation Knee Extension Foot Plantarflexion Wrist Flexion, adduction and Inversion Hand Finger flexion, clenched fist Ankle Equinovarus thumb, adducted in palm Toes claw (tarsometatarsal extension, metatarsophalangeal flexion) Toes curl (tarso- and NPTE Final Frontier metatarsophalangeal flexion) NPTE Final Frontier  Spasticity: Positioning Strategies TRY IT ON YOURSELF NPTE Final Frontier  Obligatory Synergy Patterns in Stroke FLEXION SYNERGY EXTENSION SYNERGY Upper Scapula retraction/elevation Scapular protraction Extremity or hyperextension Shoulder adduction, IR Shoulder abduction, external Elbow extension rotation Forearm pronation Elbow flexion Wrist and finger flexion Wrist and finger flexion Lower Hip flexion, abduction, ER Hip extension, adduction, Extremity Knee flexion IR Ankle DF, inversion Knee extension Toe DF Ankle PF, inversion Toe PF Muscles not usually involved: (1) latissimus dorsi, (2) teres major, (3) serratus anterior, NPTE Final Frontier (4) finger extensors, and (5) ankle evertors  TIME TO BE A REAL PT/PTA! Let’s solve them case studies! NPTE Final Frontier  Scenario Based Question 3: Setting: Acute Inpatient Rehabilitation Age/Gender: 85 years old/Female Presenting Problem / Current Condition: Admitted for left MCA infarct Medical History : Previous TIA x 2 (unknown date) Other Information: Prior to admission, patient lived alone in a building and was independent with all ADLs, functional mobility, and transfer There are five steps to enter the home with a first-floor bedroom and bathroom possible Physical Therapy Examination(s) Hemiparesis of right arm with compensatory motions for overhead shoulder motions Partial ROM with elbow flexion and extension, but was uncoordinated and effortful Mild non-fluent aphasia Decreased standing tolerance and standing balance NPTE Final Frontier Minimal assist with transfers and moderate assist with walking  Practice Question 3.1: Setting: Acute Inpatient Rehabilitation Age/Gender: 85 years old/Female With respect to the upper extremity, which of the following MOST accurately describes Presenting Problem / Current Condition: Admitted for left MCA infarct the position at rest? Medical History : Previous TIA x 2 (unknown date) Other Information: A. Forearm pronation with wrist and finger Prior to admission, patient lived alone in a building and was flexion and thumb abduction independent with all ADLs, functional mobility, and transfer B. Forearm supination with wrist extension There are five steps to enter the home with a first-floor bedroom and finger flexion thumb adduction bathroom possible C. Shoulder in adduction and internal Physical Therapy Examination(s) rotation and thumb adduction Hemiparesis of right arm with compensatory motions for overhead shoulder motions D. Shoulder abducted, externally rotated, elbow flexed, forearm supinated Partial ROM with elbow flexion and extension, but was uncoordinated and effortful Mild non-fluent aphasia Decreased standing tolerance and standing balance Minimal assist with transfers and moderate assist with walking NPTE Final Frontier  Practice Question 3.2: Setting: Acute Inpatient Rehabilitation Age/Gender: 85 years old/Female The patient has extreme spasticity, and she demonstrates flexion synergy patterns of the Presenting Problem / Current Condition: Admitted for left MCA infarct upper extremity while attempting to move her Medical History : Previous TIA x 2 (unknown date) upper extremity. Which of the following is MOST Other Information: LIKELY to be seen when she lifts her arm and Prior to admission, patient lived alone in a building and was what is the appropriate classification per the independent with all ADLs, functional mobility, and transfer Brunnstrom staging? There are five steps to enter the home with a first-floor bedroom and bathroom possible A. Shoulder ER, abducted, elbow and wrist Physical Therapy Examination(s) flexed, and forearm supinated; Stage III Hemiparesis of right arm with compensatory motions for overhead B. Shoulder IR, adducted, elbow and wrist shoulder motions flexed, and forearm supinated; Stage III Partial ROM with elbow flexion and extension, but was uncoordinated and effortful C. Shoulder ER, abducted, elbow and wrist Mild non-fluent aphasia extended, and forearm pronated; Stage IV Decreased standing tolerance and standing balance D. Shoulder IR, abducted, elbow and wrist Minimal assist with transfers and moderate assist with walking flexed, and forearm pronated; Stage V NPTE Final Frontier  Practice Question 3.3: Setting: Acute Inpatient Rehabilitation Which of the following is the MOST APPROPRIATE position Age/Gender: 85 years old/Female while lying on the right side? Presenting Problem / Current Condition: Admitted for left MCA infarct Medical History : Previous TIA x 2 (unknown date) A. Head/neck: neutral, right scapular protracted; right arm in slight abduction and external rotation; elbow extended, Other Information: forearm supinated, wrist neutral, fingers extended, and Prior to admission, patient lived alone in a building and was thumb abducted independent with all ADLs, functional mobility, and transfer B. Head/neck: neutral, right scapular retracted; right arm in There are five steps to enter the home with a first-floor bedroom and slight abduction and internal rotation; elbow extended, bathroom possible forearm pronated, wrist neutral, fingers extended, and Physical Therapy Examination(s) thumb adducted Hemiparesis of right arm with compensatory motions for overhead C. Head/neck: neutral, right scapular retracted; left arm in shoulder motions slight abduction and internal rotation; elbow extended, forearm pronated, wrist neutral, fingers extended, and Partial ROM with elbow flexion and extension, but was uncoordinated thumb adducted and effortful D. Head/neck: neutral, left scapular protracted; left arm in Mild non-fluent aphasia slight adduction and external rotation; elbow flexed, Decreased standing tolerance and standing balance forearm supinated, wrist extended, fingers flexed, and Minimal assist with transfers and moderate assist with walking thumb abducted NPTE Final Frontier  Traumatic Brain Injury NPTE Final Frontier  Rancho Los Amigos (RLA) Levels I No Response Coma II Generalized Non-purposeful response whole body, vocal Inconsistent III Local response Purposeful Local and specific Inconsistent Follows simple commands – close eyes, squeeze hands NPTE Final Frontier  How to Manage Level I, II, III? Positioning: Head neutral, prevent ulcer, sit (if stable) Gentle PROM: Joint integrity, skin integrity Respiratory care: Postural drainage, percussion, vibration Educate family: What to expect, how to be more involved NPTE Final Frontier  RLA Level IV: Confused and Agitated Behavior: Heightened activity, just coming out of coma Aggressive: Doesn’t cooperate, verbalization is incoherent, confabulations Attention: No selective attention Memory: No long- and short-term memory NPTE Final Frontier  Treatment Continued… CONFUSED: Consistent: Same therapist, same staff, family introduce yourself daily. ESTABLISH A ROUTINE Orient the patient: Calendar, clock MEMORY: NO CARRYOVER: Chart and graph to measure progress AGITATED: Calm behavior. DO NOT confront! Environment – Closed – prevent harm to others NPTE Final Frontier  RLA Level V, VI Level V – Confused Inappropriate Level VI – Confused Appropriate Behavior: Behavior: Responds consistently to simple commands Follows simple instruction consistently Responds inconsistently to complex Goal oriented behavior with external input commands With structure, able to socialize for short Memory: Carryover of previous skills present period (self-care) Memory: Memory impaired. Inappropriate use of objects. Can’t learn new task. NPTE Final Frontier  Treatment Follow goals from level IV Complex commands cannot be followed - Avoid more complex open environments NPTE Final Frontier  Level VII, VIII Level VII - Automatic Appropriate Level VIII - Purposeful Appropriate Oriented in home and hospital Carryover of new skills present Daily routine - automatic but robot-like Impaired judgement in an emergency Judgement impaired situation, abstract reasoning and Able to initiate social or recreational reduced tolerance for stress activity with structure NPTE Final Frontier  How to Manage Levels VII, VIII? Focus on re-entry to work and community Emphasize skills related to problem solving, social interaction Trial period of independent living Adaptation at work or school to return to normal life NPTE Final Frontier  Scenario Based Question 4 Setting: IP-Rehab Sex: Male Age: 25 years Presenting Problem/Current Problem: Traumatic brain injury status post motorcycle accident with ejection Past Medical History: Motorcycle accident 25 days prior Other Information: Lives in apartment building on third floor with fiancé, elevator available in building Works as an accountant at small firm 5 days/week Uses rollator walker and requires moderate verbal and manual cues for proper use Weakness of the left lower extremity compared to right Physical Therapy Examination(s): Sit-to-stand transfer with no assistive device and moderate assistance required Gait: Patient ambulates 50 feet with a rollator walker and requires minimal – moderate assistance. Physical Therapy Plan of Care: Therapeutic Exercises Bed Mobility Training, Transfer Training Gait Training, Neuromuscular Re-education NPTE Final Frontier  Practice Question 4.1 Setting: IP-Rehab Sex: Male Upon further examination, the Age: 25 years patient seems to be in a heightened Presenting Problem/Current Problem: Traumatic brain injury status post motorcycle accident with ejection state of activity and is making up Past Medical History: stories. They are not coordinating Motorcycle accident 25 days prior Other Information: with the therapist at all. How would Lives in apartment building on third floor with fiancé, elevator the physical therapist MOST LIKELY available in building classify this patient’s level of Works as an accountant at small firm 5 days/week Uses rollator walker and requires moderate verbal and manual cues cognition? for proper use Weakness of the left lower extremity compared to right Physical Therapy Examination(s): A. Level VI Sit-to-stand transfer with no assistive device and moderate assistance required B. Level IV Gait: Patient ambulates 50 feet with a rollator walker and requires C. Level V minimal –moderate assistance. Physical Therapy Plan of Care: D. Level III Therapeutic Exercises Bed Mobility Training, Transfer Training Gait Training, Neuromuscular Re-education NPTE Final Frontier  Practice Question 4.2 Setting: IP-Rehab Sex: Male Which of the following strategies will Age: 25 years be MOST beneficial while working Presenting Problem/Current Problem: Traumatic brain injury status post motorcycle accident with ejection with the patient? Past Medical History: Motorcycle accident 25 days prior Other Information: A. Having a different PT work with Lives in apartment building on third floor with fiancé, elevator the patient every day so he gets available in building Works as an accountant at small firm 5 days/week used to meeting new people Uses rollator walker and requires moderate verbal and manual cues B. Involving patient in group therapy for proper use so he can make friends Weakness of the left lower extremity compared to right Physical Therapy Examination(s): C. Informing the patient two days in Sit-to-stand transfer with no assistive device and moderate assistance advance about what to expect in required Gait: Patient ambulates 50 feet with a rollator walker and requires the next few PT sessions minimal –moderate assistance. D. Giving the patient two options and Physical Therapy Plan of Care: having the patient select one Therapeutic Exercises Bed Mobility Training, Transfer Training Gait Training, Neuromuscular Re-education NPTE Final Frontier  Practice Question 4.3 Setting: IP-Rehab Sex: Male As the patient continues to improve, Age: 25 years the therapist decides to progress with Presenting Problem/Current Problem: Traumatic brain injury status post motorcycle accident with ejection patient’s gait training. Which of the Past Medical History: following is MOST APPROPRIATE about Motorcycle accident 25 days prior Other Information: guarding the patient? Lives in apartment building on third floor with fiancé, elevator available in building A. PT should always stand behind the Works as an accountant at small firm 5 days/week Uses rollator walker and requires moderate verbal and manual cues patient for proper use B. PT’s right hand should be placed Weakness of the left lower extremity compared to right Physical Therapy Examination(s): posteriorly on the guarding belt with Sit-to-stand transfer with no assistive device and moderate assistance forearm pronated required Gait: Patient ambulates 50 feet with a rollator walker and requires C. PT must be posterolateral to the patient minimal –moderate assistance. on the left Physical Therapy Plan of Care: Therapeutic Exercises D. PT must maintain a narrow base of Bed Mobility Training, Transfer Training support and be on the patient’s right Gait Training, Neuromuscular Re-education side NPTE Final Frontier  Upcoming: Day Date Timing Topic Saturday 12/7 8:30 am PST Pediatrics (11:30 am EST) Tuesday 12/10 5:00 pm PST Normal Gait (8:00 pm EST) * Free Class * FLC: Attend as normal * SB: Sign-up to attend LIVE *Invite your friends Saturday 12/28 1:00 pm PST APCFF Neuro Masterclass (4:00 pm EST) *Registration required – FREE for PT FLC and 50% off for PT Study Bundle (~$25 USD) * For PTs only (not needed for PTAs) * Directions on your course page to sign up to attend NPTE Final Frontier  Questions? Thank you! NPTE Final Frontier