Spinal Cord Injury.pdf

SPINAL CORD INJURY (SCI) Background Info SCI: damage to the spinal cord due to traumatic or nontraumatic etiology Paraplegia: lower limbs have deficits Tetraplegia: all 4 limbs have some sort of sensory or motor deficit Hemiplegia: only half of spinal cord damaged TRACT REVIEW Spinothalamic: pain, t...

SPINAL CORD INJURY (SCI) Background Info SCI: damage to the spinal cord due to traumatic or nontraumatic etiology Paraplegia: lower limbs have deficits Tetraplegia: all 4 limbs have some sort of sensory or motor deficit Hemiplegia: only half of spinal cord damaged TRACT REVIEW Spinothalamic: pain, temperature, and crude touch. SCI may present with varied levels due to decussation 2-3 levels above entry Lateral Reticulospinal: posture, balance, trunk, and proximal muscle control Spinocerebellar: proprioception for trunk and LE Lateral Corticospinal: KING of voluntary movement (IL) Fasciculus Cuneatus: sensory info from UE (DCML) Fasciculus Gracilis: sensory info from LE (DCML) UPPER VS LOWER MOTOR NEURON Above conus medullaris = UMN At L1 vertebral body = UMN or LMN Cauda Equina = LMN SCI SYNDROMES Anterior Cord: variable loss of motor function and pain.temperature sensation below the level of lesion. Discriminative touch (DCML) is preserved (anterolateral, corticospinal, vestibulospinal, lateral column, spinocerebellar) Central Cord: motor impairments UE>LE, minimal impact on sensory system with a large impact on flexor muscles (Reticulospinal tract) Brown-Sequard: loss of IL motor control and proprioception below the lesion, loss of CL pain and temperature a few levels below injury (hemisection of SC so anterolateral and DCML) Conus Medullaris: Variable LE and sacral weakness, variable reflexia, sensory impairments (sacral crd and lumbar nerve roots) Cauda Equina: LMN presentation, areflexia, flaccid paralysis, and sensory loss beyond timeframe for spinal shock. Impaired bowel, bladder, and sexual function. (sacral n. root) ASIA Classification ASIA A = Complete injury (NOOON sign) ASIA B = Sensory Incomplete Sensory function is preserved below neurological level ASIA C = Motor Incomplete Less than half of key muscle groups have a grade of 3 ASIA D = Motor Incomplete More than half of key muscle groups have a grade of 3 or higher ASIA E = Normal Both motor and sensory present as normal but have history of SCI deficits Motor Key Muscle Groups C5 - Elbow Flexors C6 - Wrist Extensors C7 - Elbow Extensors C8 - Finger Flexors T1 - Finger Abductors L2 - Hip Flexors L3 - Knee Extensors L4 - Ankle Dorsiflexors L5 - Great Toe Extensors S1 - Ankle Plantarflexors MOTOR LEVEL IS UPPERMOST INTACT LEVEL (GRADE 5) UNLESS LEVEL BELOW IS AT LEAST A GRADE 3 Sensory Testing: Includes light touch and pinprick. Assessed at the dermatomes BL SENSORY LEVEL IS MOST CAUDAL INTACT SENSORY LEVEL (GRADE 2) Zone of Partial Preservation: most caudal spinal level with some degree of function Medical Management Rehabilitation of SCI Outcome Measures SCI INJURY TIMELINE 0-1 days: flaccid paralysis 1-3 days: reflexes return 1-4 weeks: early hyperreflexia (spasticity) 1-12 months: late hyperreflexia INITIAL MANAGEMENT OF SCI INCLUDES IMPROVING ENDURANCE AND PREVENTING SECONDARY COMPLICATIONS MEDICAL CONCERNS Respiratory Status: NUMBER 1 CAUSE OF MORTALITY Difficulty with clearance, atelectasis, and hypoventilation Note muscles involved with respiration Incentive spirometry or forced vital capacity Spinal Shock: temporary loss or depression of all spinal reflex activity below level of lesion Persists for days but resolves 1-4 weeks after injury Educate patients on hypertonicity that occurs and not to prematurely attribute these movements as return of voluntary muscle control Neurogenic Shock: altered autonomic function Initially leads to medical instability and is due to loss of sympathetic activation Autonomic Dysfunction - chronic imbalance between SNS & PNS leading to multiple concerns such as: Lower resting HR and loss of tone in peripheral vasculature Could lead to orthostatic hypotension Exercise intolerance, exercise-induced hypotension, reduced stroke volume, and cardiac output Impaired bronchi dilation and excessive mucus production predisposes them to pneumonia Impaired thermoregulation Reflexive (UMN) or atonic (LMN) bladder Impaired sexual function Autonomic Dysreflexia: INJURY AT T6 OR ABOVE MEDICAL EMERGENCY S/S: severe headache, sudden increase in BP, diaphoresis above injury, flushing of skin below injury level, blurred vision, nasal congestion CAUSED BY NOXIOUS STIMULI Primarily distended bowel or bladder in SCI Sit individual upright and lower legs, IDENTIFY NOXIOUS STIMULI and remove it, monitor BP until stable or in the ER If noxious stimuli can’t be found, can use antihypertensives to lower BP Blood Clots: increased risk of developing due to lack of muscle pump, reduced venous return, and dilation of peripheral vasculature Heparin within 72 hours of SCI and continue for 12 weeks Pressure Ulcers: development due to prolonged position they are in while gaining medical stability Change positions every 2-4 hours Sitting Tolerance: to progress mobility, we need to increase sitting tolerance and endurance to activities out of bed Monitor for BP changes, autonomic dysfunction, respiratory status, fatigue, and amount of time position is tolerated Pressure garments and abdominal binder can aid in managing BP Body Structures ASIA Impairment Scale MMT and Dynamometry Modified Ashworth Scale Penn Spasm Frequency Scale: self-reported measure that asks the individual to characterize frequency or triggers of spasm 0 = no spasm 1 = presence of spasm only with vigorous stimulation 2 = occasional spasms that are easily induced 3 = spasms that occur 1-10 times/hour 4 = spasms >10 times/hour Second part classifies intensity EMERGENT MANAGEMENT Stabilization and Resuscitation May be intubated or ventilated Spinal cord and blood perfusion Mantain BP systolic at 90-100 mmHg, HR between 60-100 bpm May present with neurogenic shock (bradyarrhythmia, vasodilation, and low BP) GOAL IS MINIMIZE NEURONAL DEATH AND DAMAGE METHYLPREDNISONE (synthetic glucocorticoid) Thought to reduce inflammation, enhance blood flow, and prevent decline in white matter Best if initiated within 8 hours of injury with 24-hour infusion No benefit to short or long-term motor or neurological status Increased risk of hyperglycemia and pneumonia MODEST SYSTEMIC HYPOTHERMIA Sparing of motor neurons surrounding level of injury NEED TO CONTROL FOR BRADYCARDIA Endovascular cooling catheters, cooling blankets, and ice baths FRACTURE MANAGEMENT Conservative: traction or stabilization via immobilization Surgical: for unstable fractures or fractures that can’t be realigned or reduced Orthotics: external stabilizers (HALO, Philly collar, TLSOs) Education is the MOST IMPORTANT FACTOR in working with SCI patients throughout rehabilitation process Sitting Balance: some individuals need to relearn how to maintain balance and should be challenged appropriately Supported vs unsupported stability of sitting surface Equilibrium reactions Incorporating functional movement Respiratory Management Assisted coughing, abdominal binders, positioning techniques to alter challenge of breathing, and use of incentive spirometers Diaphragmatic pacing: diaphragm stimulated intramuscularly ROM: maintain range of motion in all joints and educate individual on self-range of motion activities Tenodesis: attain hand grasp without active use of wrist or finger flexors USE OF PASSIVE TENSION Full extension at the wrist and fingers at the same time is CONTRAINDICATED COMPENSATORY STRATEGIES Functional Mobility Training: ASIA A and B: decreased potential for neuroplasticity but compensatory techniques can still improve function ASIA C and D: aim to restore as much function as possible Improve neuroplasticity, motor control, strength and sensation Muscle Substitution Using Gravity Use gravity to assist with motions that require little to no resistance or force generation Passive Tension Can assist or create motion and provides more force than gravity alone (tenodesis) Distal Fixation Individual is able to stabilize themselves in sitting using elbow extension for functional mobility and support Relies on fixating the hand or foot and using proximal musculature to create movement Angular Momentum: highly effective in increasing independence Uses mass, velocity, and moment arm to facilitate rotation once a motion has begun Head-hip Relationship: use of head position to facilitate movement of the trunk or lower limbs in the opposite direction FUNCTIONAL TRAINING STRATEGIES Training in Reverse: provides knowledge of what movement should feel like and the desired end position Part-Practice: breaking a task into parts Use of Adaptive Equipment STRENGTH TRAINING SPECIAL CONSIDERATIONS Bedrest will result in decreased strength combined with effect of atrophy due t limited innervation Some muscles may only be partially innervated Use of slings or slider boards may aid with gravityeliminated strength training Bands and weights assist with movement against gravity during functional strength training tasks Function and Activity Modified Functional Reach Test Spinal Cord Injury Independence: 19 items specific to SC pathology including mode of respiration, preventing pressure wounds, etc. Berg Balance TUG 6MWT 10MWT Dynamic Gait Index Functional Gait Assessment Walking Index for SCI (WISCII): ability to ambulate 10 meters on a scale of 0-20 For ASIA A injuries below T10, or any level of ASIA B, C, and D Takes into account orthotics, ADs and assistance level Wheelchair Skills Test: 32 skills on a 0-2 point scale Accounts for patient vs. caregiver ability and the use of a manual or power chair >80% = advanced manual wheelchair scores Participation World Health Organization Quality of Life BREF: self-report measure applicable across different cultures for assessment of QoL Sickness Impact Profile: self-report measure assessing biopsychosocial dimensions of QoL Traumatic Brain Injury (TBI) Background Info Rancho Levels of Cognition TBI RESULTS FROM EXTERNAL FORCE Mechanism of Injury Due to unintentional falls, MVA’s and strikes to the head Primary Injury: direct result of external force Contusion at the area of contact Coup-Contrecoup: occur with rapid acceleration or deceleration. Coup: brain bounces of one aspect of the cranium impacted Countrecoup: brain reverts back to hit the other aspect of the cranium (more sever injury occurs) Can cause additional forces within brain, createing diffuse axonal injury (DAI) which is associated with moderate to severe TBI Blast Injury: strong blasts result in transient shockwave causing damage No initial hit to the head Specific to military incidents Causes increase in CSF and subsequent cerebral edema Secondary Injury: result from normal injury cascade process Result in cerebral edma, increased ICP, hypoxemia, and hypotension Excessive release of excitatory neurotransmitters (glutame) causes further edema REQUIRES IMMEDIATE MEDICAL ATTENTION If the brain shifts, it can lead to herniations and midline shifts Normal ICP is 5-20 mmHg Level I: No Response No response to any stimuli (sounds, smells, touch, or movement) Patient appears to be in deep sleep, even when presented with noxious stimuli Level II: General Response Indivual begins to respond to various stimuli Delayed, slow, non-purposeful, and/or inconsistent Response tends to be nonspecific (the same regardless the type of stimuli) Reponses: chewing, sweating, moaning, moving, changes in vitals Level III: Localized Response Patient responds INCONSISTENTLY but specifically to simulus Individual may squeeze hand or close eyes when commanded May turn head toward familiar sounds or nod head but INCONSISTENT Response has purpose but continues to be delayed or slow More bodily movements occur along with improved wake periods Level IV: Confused-Agitated MOST CHALLANGING PHASE Individual is confused, agitated, and unable to understand their surroundings and what is being asked of them Patient will overreact when frustrated and begin hitting, screaming, or being verbally inappropriate due to agitation Need maximal assistance for functional tasks although they may be physical capable of doing them Poor short-term and long-term memory Individuals may make up stories or focus on a single thing EVERYTHING IS CONFUSING so any factor that increase confusion contributes to agitation Level V: Confused-Inappropriate Individual remain unable to respond to simple, purposeful commands DECREASED AGITATION WHEN CHALLENGED Increased ability to attend to the environment or task (only a few minutes at best) Highly distractable and unable to complete tasks without structure, cueing, or assistance Inability to learn new things and poor memory Continuation of perserverations, inappropriate verbal behavior, and making up stories May have increased agitation or inappropriate behavior when overloaded or stressed Level VI: Confused-Appropriate Improving memory and executive function to facilitate GOAL-DIRECTED BEHAVIOR Longer attention to environment and tasks Increasing active participation during PT sessions Complex tasks and busy environments remain a challenge Level VII: Automatic-Appropriate Responses are appropriate but may seem automatic or programmed Typically oriented to familiar settings and can function through routine daily activities Memory improves, with improved carryover of tasks and learning Lacking higher executive function and judgement especially in unpredictable or challenging circumstances. Level XIII-X: Purposeful-Appropriate Increased executive function and emotional/social intelligence Memory and learning continue to improve, along with tolerance for stressful situations, awareness and limitations. Level XIII: Standby assistance for task (safety) but still not fully aware of limitations Level IX: Requires standby assistance per request, aware of impairments and can use compensatory strategies Level X: Modified independent cognitively, but may require extra time or compensatory strategies. Consequences Long standing disability Financial burdens Changing family dynamics Premature death Cognitive Deficits Coma: unresponsive state with no arousal Unresponsive Wakefulness Syndrome: unaware of surroundings due to higher brain centers not integrated fully with brainstem Minimally Conscious State: mild awareness of self or environment Stupor: patient able to be aroused with noxious/vigorous stimuli Obtunded: patient able to be aroused and respond to environment when awake but delayed reactions. Fall back asleep easily. Neurobehavioral Impairments Dysautonomia: dysfunction of sympathetic nervous system elevated HR, respiratory rate, BP, and diaphoresis Decorticate posturing: abnormal flexor posturing of UE while LE is extended and IR. Lesion above red nucleus Decerebrate posturing: extended posturing Lesion below red nucleus Secondary Impairments Deficits to GI system, CV system, contractures, fractures, DVT, pulmonary embolus, heterotopic ossification Management of TBI/Outcome Measures Intracranial Pressure: management of ICP is vital Evacuation of mass Diuretics to lower ICP Position head with 30 degrees of elevation Ventilation via intubation CSF drainage (lumbar puncture) Hyperventilation causes vasoconstriction which decreases ICP Hypothermia to reduce metabolism Medically induced coma Decomprssion surgery via hemicraniectomy or craniotomy Mild TBI Rehabilitation Approach: Begins with a CHART REVIEW RESTORATIVE APPROACHES Gait Incorporate body weight supported locomotor training Constraint Induced Movement Therapy (CIMT) General Exercise and Conditioning Functional Electrical Stim (based on deficit) Dual-Tasking integrates motor, behavioral and cognitive programs Community Re-integration Programs Return to Sport Gradual Stepwise Progression Often, miild TBI will present with overstimulation effects which can make motor learning harder in high stimulation environments Moderate TBI Rehabilitation Approach: Begins with a CHART REVIEW EARLY ASSISTED MOBILIZATION FOR THOSE WHO ARE MEDICALLY STABLE Either compensatory or restorative approaches Can test ROM but note if spasticity is present Monitor vitals like BP and ICP PROM Bed mobility and reaching tasks Education on proper positioning and turning Pressure Relieving AFO’s or Multi-podus Boots Serial Casting for patients who have been immobile too long Caregiver and family education Outcome Measures: Glasgow Coma Scale >8 - severe TBI 9-12 - moderate TBI 13-15 - mild TBI Galveston Orientation and Amnesia Test (GOAT) 14 questions pertaining to person, place, time, situation Coma Recovery Sacle (CRS-R) Rancho Levels of Cognitive Functioning FIM or CARE (done with caution in mild-severe TBI) FIST (mild) Romberg (mild-mod) Gait/Balance/Endurance Specific BERG 10MWT 6MWT TBI SPECIFIC Community Balance and Mobility Scale Hi-MAT Includes bounding, running and skipping (great for return to sport) Community Integration Questionnaire How injury affects participation (ICF) Dizziness Handicap Inventory How much dizziness may impact QoL RLA Rehab management Level I: No Response Use simple, familiar stimuli to help increase arousal and orientation (playing their fav music, hearing a loved one, comforting scents) Tell the individual what you are going to do with them, they may be unconscious but they may still be aware of their environment Be mindful of tone and volume of voice Level II: General Response Continue previous strategies but incorporate simple, specific commands (“look at me” or “squeeze my hand”) Begin orienting the person to the environment, people, and time of day AVOID OVERSTIMULATION 1-2 stimuli max at any point in time Small # of visitors Level III: Localized Response Make simple commands more challinging (“look at your doctor” or “touch your other hand”) Ask simple yes or no questions to help orient patient Begin orienting to a specific time of day Repetivite orientation to their circumstances and who providers are WILL TIRE QUICKLY give time to rest and extra time to respond Allow incorrect responses Level IV: Confused-Agitated Continue to provide reorientation information ENSURE CALM ENVIRONMENT to limit the patient feeling threatened and overstimulated Take a step back and let the patient lead the session (within reason and safety) Find activities that are meaningful and purposeful to the patient Model calm behavior and choose controlled environments Level V: Confused-Inappropriate Patients have increased capacity for learning requires significant repitition, orientation, and cueing for basic tasks STEPS SHOULD BE GIVEN SEPERATELY FOR TASK Patients will often be impuslive and move before you can provide assistance or guard Patients may make up stories because their memory is impaired Patient may need redirection if they perservate/get stuck on an idea or activity Cue and assistant during simple tasks as needed (basic hygeine, wheelchair mobility, ADL’s) Avoid overstimulation and fatigue This can result in aggressive or inappropriate behaviors Level VI: Confused-Appropriate Individual has increased awareness of limitation Increased learning capacity and attention increases to about 30 min max UTILIZE CHECKLISTS Be aware of the environmental stimuli and complexity of provided commands Patient may move too quickly or impulsively Provide guidance to their movements and be ready to manage unpredictable movements Level VII: Automatic-Appropriate CHALLANGE INDIVIDUAL’S EXECUTIVE FUNCTION decrease use of simple words and commanfs Individual may be robotic so avoid using slanf or humor during interaction Patient may have difficulty with impulse control potentially making inappropriate comments Use problem-solving if patient is stuck to challenge ability to navigate less familiar circumstances and environments Level XIII-X: Purposeful-Appropriate Increased executive function but still may benefit from semistructured sessions ADDRESS PATIENT-IDENTIFIED GOALS AND OPINIONS FOR COMMUNITY REINTEGRATION How can we increase effectiveness of combined cognitive and physical rehabilitation Stroke Background Info Brunnstrom Stages Two Categories of Stroke Ischemic Stroke: blood supply to the brain is interrupted or reduced due to a thrombus or emboli. Hemorrhagic Stroke: leak of blood into brain tissue. (brain bleed) Stage 1: Flaccidity Flaccid or significantly hypotonic No active voluntary movement (requires protective measures to prevent shoulder subluxation) Stage 2: Synergy, Spasticity Appears Increased signs of spasticity Evidence of voluntary movement in weak synergistic patterns (limbs move in one direction) Occurs first proximally then progresses distally Stage 3: Synergy, Marked Spasticity PEAK SPASTICITY Movement in rigid, highly spastic patterns in basic synergy No isolated or fractionated movements possivle Stage 4: Out of Synergy, Decreased Spasticity Beginning of early, isolated motor control Rudimentary (inflatable man tube), minimal active movement outside of basic synergy Stage 5: Out of Synergy, More Complex Movements Spasticity significantly decreased Increased isolated motor control and success with complex movements Stage 6: Isolated Movements, No Spasticity Full or near full selective motor control Increased tone and spasticity may present under stress (using limb forcefully or quickly) Stage 7: Normal Function Able to function normally regardless of speed or force during a movement Synergy Patterns UE Flexion: scapular retraction/elevation, shoulder ABD/ER, elbow FLEX, forearm supination, wrist FLEX, and finger/thumb FLEX and ADD UE Extension: scapular protraction/depression, Shoulder ADD/IR, elbow EXT, forearm pronation, wrist either FLX or EXT LE Flexion: pelvis elevation/retraction, hip FLEX/ABD/IR, knee FLEX, ankle DF and INV, toe DF LE Extension: hip EXT/ADD/IR, knee EXT, ankle PF/INV, toe PF FLEXOR SYNERGY DOMINATES UE AND EXTENSOR SYNERGY DOMINATES LE Transient Ischemic Attack (TIA): brief interruption of blood flow due to ischemia in someone with stroke-like symptoms (no evidence on imaging) Intracerebral Stroke: occurs within brain tissue Subdural Hemorrhage: between dura mater and arachnoid layer Subarachnoid Hemorrhage: between pia mater and arachnoid layer Ischemic Core: brain tissue injured during initial stroke (primary injury) Penumbra: are around the care that has reversible damage/salvageable Risk Factors: cardiovascular disease, hypertension, type II diabetes, diet, and smoking Warning Signs (FAST): facial droop, arm weakness, slurred speech, time Comorbid Factors Post Stroke Seizures Bladder and Bowel Dysfunction Osteoporosis Increased fall risk and fracture risk Cardiopulmonary Dysfunction DVT and PE due to lack of mobility Vascular Supply: ACA: 1st branch off internal carotid. Medial aspect of the frontal and parietal lobes, basal ganglia, fornix, and corpus collosum LE > UE. MCA: Most common lesion site. Lateral aspect of frontal, temporal and parietal lobes. Significant edema and increased ICP Broca’s and Wernicke’s area UE > LE PCA: Posterior aspect of brainstem, midbrain, diencephalon and thalamus, occipital lobe. CL sensory loss or thalamic pain syndrome Vertebrobasilar System: supplies cerebellum, medulla, pons, and inner ear Lacunar Strokes: infarcts within the smaller vessels of the brain Outcome Measures Stroke Specific National Institutes of Health Stroke Scale (NIHSS): measures severity of symptoms post-stroke and is highly recommended for acute stroke Measured at baseline, after medical intervention, 24 hours, 7-10 days, 3 months >25 = extreme severity 1-5 = mild severity Stroke Impact Scale: Self-percieved changes in QoL after stroke Patient has to be able to interact with environment Activities and Participation on ICF Postural Assessment Scale for Stroke (PASS): Sitting and standing both with and without support, and on paretic and non-paretic limb Acute care, impatient rehab, home health, outpatient Clinical Assessment Scale for Contraversive Pushing Diagnosis of pushing made if all criteria present and score of at least 1 in each section Fugyl-Meyer Assessment of Motor Recovery: motor and sensory function, balance, joint pain, ROM Body Structures and Functions ICF Use in acute, subacute or chronic stroke Brunnstrom Stages of Motor Recovery: categorizes patient into stereotypical stages Gait Observational Gait Analysis (OGA) 10MWT 6MWT Functional Mobility Functional Independece Measure (FIM) CARE Barthel Index: performance of basic ADL’s) Upper Extremity Action Research Arm Test (ARAT): floor and ceiling effects. Looks at fine and gross movements of UE (grasping, gripping, pinching) Motor Activity log: self percieved quality and amount of movement in UE Body Functions and Structures: MMT/Dynamometry/ROM Modified Ashworth Scale: muscle tone and spasticity McGill Pain Questionnaire, NPRS, VAS, Wong-Baker FACES Mini-Mental Status Examination or Montreal Cognitive Assessment (MoCA) Clinical Presentation Increased Intracranial Pressure (ICP): Decreased consciousness Increased HR Cheyne-Stokes Respirations (fast, shallow breathing followed by heavier breathing) Vascular Dysfunctions: ACA: Contralateral LE>UE sensory and motor impairments, changes in executive function, personality, or behavior. MCA: CL UE>LE and face sensory and motor impairments, CL homonymous hemianopia, CL spasticity L: higher chance of language impairments (aphasia) R: higher chance of spatial awareness and nonverbal communication impairments PCA: IL ocular movement, visual deficits, pain, CL sensory loss with potential hemiparesis and impaired memory ICA: proximal arm and leg weakness, dysfunction with visual processing and altered speech Lacunar Stroke: purely motor or purely sensory deficits with good prognosis, ataxia, dystonia Vertebrobasilar System: presentation depends on where infarct is and determines whether it is IL or CL. gait and limb ataxia, limb weakness, headache, oculomotor dysfunction, dysphasia, visual dysfunction, dizziness, nausea, vomiting Cerebellar ataxia - symptoms IL to the lesion Locked-In Syndrome: lesion to the basilary artery and pons. Patients have preserved consciousness and sensation, but cannot move or speak. Other Associated Conditions: Aphasia: disorder of language comprehension and formulation Fluent Aphasia (Wernicke’s): unable to comprehend information, but can produce fluent random speech. Non-Fluent Aphasia (Broca’s): patient can comprehend information, but can’t get their words out Global Aphasia: both Broca’s and Wernicke’s affected. Comprehension aspect returns quicker, tend to struggle with expressive the most. Dysarthria: slurred speech Dysphagia: Swallowing disorder. Aspiration pneumonia is a risk factor Cognitive Deficits: disorientation, varied levels of attention and memeory, perseveration, and confabulation Executive Function Hemineglect: disregard of the environment or part of the body due to lack of awareness Pusher’s Syndrome: patients feel as if they are falling toward less involved/stronger extremity, so they push towards the more involved side Agnosia: inability to recognize information despite having intact sensation Visual Agnosia: inability to recognize visual cues being seen even though visual system is intact Left vs. Right Hemisphere L Hemisphere deficits in speech, language, and swallowing “Left Language” R Hemisphere CL weakness and sensory loss difficulty with abstract reasoning and safety awareness Impulsive Hemineglect Stroke Management General Approach - CONTROL, MAINTAIN, RESTORE Improve cerebral perfusion Maintain BP Permissive hypertension- physician holds off or decreases antihypertensive meds unless BP systolic >220 mmHg, diastolic >120 mmHg Restore homeostasis Fluids and blood glucose levels Stabilize edema and ICP VP shunts Maintain integumentary system Maintain bowel and bladder function Decrease further complications Pharmacological Management Thrombolytics (TPA) Clot buster (3-4 hours after stroke) ONLY FOR ISCHEMIC STROKE BP systolic