STROKE REHABILITATION EXAM QUESTIONS WITH
CORRET ANSWERS
L CVA
• L hemisphere injury
• presentation:
- R hemiparesis
- aphasia (language centers affected)
- apraxia
• behavior: frustration (due to insight into deficits)
• rehab should focus on addressing these specific deficits & their impact on function
R CVA
• R hemisphere injury
• presentation:
- L hemiparesis
- visual impairments
- neglect (unawareness of affected side/body parts)
• behavior: less awareness of impairments
• rehab should focus on addressing these specific deficits & their impact on function
Stroke Recurrence
• lifetime recurrence: ~30%
• varies by sex: 24% women & 42% men within 5 years of onset
• MI & sudden cardiac death account for a third of events
- more likely to be fatal
• knowledge of CAD is associated w/ improved compliance w/ prevention in
asymptomatic individuals
• prevalence of comorbidities is significant in individuals who sustain a 2nd stroke:
- HTN (75%)
- ischemic heart disease (37%)
- hyperlipidemia (56%)
- atrial fibrillation (29%)
- diabetes mellitus (24%)
activity level
______________ after stroke is an independent predictor of life satisfaction
Phases of Stroke
• surveillance
- cardiac disease
• acute
- developing
- acute care
• chronic
,- rehabilitation
- lifetime f/u
Early Mobility s/p Stroke
• Very Early Mobility (VEM) = within 24 hours of stroke
- AVERT study
- subsequent studies (24 hrs & after)
• Time to First Mobilization (TTFM)
- ongoing debate regarding optimal window for neuroplasticity
- many facilities (including Level 1 trauma centers) still wait > 24 hours for stability
• External Ventricular Device (EVD)
- drains CSF to manage ICP
- safe to mobilize w/ ICP < 20 mmHg
- decreases: LOS, costs
- improves DC destination to other than IRF
Acute Management - Stroke
• ED via 911 call & state "I think someone is having a stroke"
• glucose check
• history & physical exam
• CT (MRI(a) for tPA/TNK eligibility or endovascular need
• stabilized & admitted w/ 24 hrs of bed rest
• PT, OT
- SLP but 100% swallowing
• DC to IRF unless proven otherwise
Tenecteplase (TNK) in Stroke
• bioengineered tPA variant
• FDA approved for single dose in ischemic stroke
• thrombolytic
• considered non-inferior to alteplase (t-PA)
• administered up to 24 hrs after symptoms
Benefits of Tenecteplase (TNK)
• cost benefit
• easier to administer
• longer half life
• less ICH risk
• higher affinity for fibrin
• longer window to administer (up to 24 hours)
• less monitoring
• better predictability
Chronic Stroke Management
• Rehabilitation Phase(s)
- IRF
- subacute/SNF
- long term care
• Lifetime Management
- manage the cardiac disease
- provide optimal participation in community activities
, - f/u w/ specialists
Prognosis s/p Stroke
• age: 75 & older have higher risk of early death after stroke
• extent of damage
• infarct size
• UI
• LOC
• ischemic > hemorrhagic for survival
• genetic profile (BDNF)
• NIHSS: higher score indicates greater severity
Rehabilitations Considerations - Stroke
• often in acute care, clients w/ the most debility receive the least amount of therapy
• end of “formal” rehab should not be an end
• apathy in > 50% of survivors at 1 year after stroke
• fatigue is common & debilitating
• daily physical activity is low
• depressive symptoms are high
• many challenges related to:
- community activity
- self efficacy
- maintenance of activity levels
Medicare
rehabilitations guidelines for stroke are largely designated by _____________:
• only 70% of clients covered under Medicare use post-acute services
• ⅔ of all stroke survivors receive rehab after hospitalization
Stroke Acuity
• Developing: onset to ~24 hours
• Acute: onset to 7 days
• Sub-Acute: 7 days to 4 months from onset
• Chronic: > 4 months from onset
**lifetime f/u is essential for continued activity & management**
Stroke Severity
• can be based on the:
- grading of impairment of body structures & function
- gait velocity
• utilizes the NIHSS
Permissive Hypertension
• allowed for ischemic stroke patients to improve perfusion
- BP up to 185/110 mmHg
• for a limited time
• PTs should note this in discharge.
National Institutes of Health Stroke Scale (NIHSS)
• clinical assessment tool for:
- classifying stroke
- determining appropriate treatment
- predicting client outcomes
CORRET ANSWERS
L CVA
• L hemisphere injury
• presentation:
- R hemiparesis
- aphasia (language centers affected)
- apraxia
• behavior: frustration (due to insight into deficits)
• rehab should focus on addressing these specific deficits & their impact on function
R CVA
• R hemisphere injury
• presentation:
- L hemiparesis
- visual impairments
- neglect (unawareness of affected side/body parts)
• behavior: less awareness of impairments
• rehab should focus on addressing these specific deficits & their impact on function
Stroke Recurrence
• lifetime recurrence: ~30%
• varies by sex: 24% women & 42% men within 5 years of onset
• MI & sudden cardiac death account for a third of events
- more likely to be fatal
• knowledge of CAD is associated w/ improved compliance w/ prevention in
asymptomatic individuals
• prevalence of comorbidities is significant in individuals who sustain a 2nd stroke:
- HTN (75%)
- ischemic heart disease (37%)
- hyperlipidemia (56%)
- atrial fibrillation (29%)
- diabetes mellitus (24%)
activity level
______________ after stroke is an independent predictor of life satisfaction
Phases of Stroke
• surveillance
- cardiac disease
• acute
- developing
- acute care
• chronic
,- rehabilitation
- lifetime f/u
Early Mobility s/p Stroke
• Very Early Mobility (VEM) = within 24 hours of stroke
- AVERT study
- subsequent studies (24 hrs & after)
• Time to First Mobilization (TTFM)
- ongoing debate regarding optimal window for neuroplasticity
- many facilities (including Level 1 trauma centers) still wait > 24 hours for stability
• External Ventricular Device (EVD)
- drains CSF to manage ICP
- safe to mobilize w/ ICP < 20 mmHg
- decreases: LOS, costs
- improves DC destination to other than IRF
Acute Management - Stroke
• ED via 911 call & state "I think someone is having a stroke"
• glucose check
• history & physical exam
• CT (MRI(a) for tPA/TNK eligibility or endovascular need
• stabilized & admitted w/ 24 hrs of bed rest
• PT, OT
- SLP but 100% swallowing
• DC to IRF unless proven otherwise
Tenecteplase (TNK) in Stroke
• bioengineered tPA variant
• FDA approved for single dose in ischemic stroke
• thrombolytic
• considered non-inferior to alteplase (t-PA)
• administered up to 24 hrs after symptoms
Benefits of Tenecteplase (TNK)
• cost benefit
• easier to administer
• longer half life
• less ICH risk
• higher affinity for fibrin
• longer window to administer (up to 24 hours)
• less monitoring
• better predictability
Chronic Stroke Management
• Rehabilitation Phase(s)
- IRF
- subacute/SNF
- long term care
• Lifetime Management
- manage the cardiac disease
- provide optimal participation in community activities
, - f/u w/ specialists
Prognosis s/p Stroke
• age: 75 & older have higher risk of early death after stroke
• extent of damage
• infarct size
• UI
• LOC
• ischemic > hemorrhagic for survival
• genetic profile (BDNF)
• NIHSS: higher score indicates greater severity
Rehabilitations Considerations - Stroke
• often in acute care, clients w/ the most debility receive the least amount of therapy
• end of “formal” rehab should not be an end
• apathy in > 50% of survivors at 1 year after stroke
• fatigue is common & debilitating
• daily physical activity is low
• depressive symptoms are high
• many challenges related to:
- community activity
- self efficacy
- maintenance of activity levels
Medicare
rehabilitations guidelines for stroke are largely designated by _____________:
• only 70% of clients covered under Medicare use post-acute services
• ⅔ of all stroke survivors receive rehab after hospitalization
Stroke Acuity
• Developing: onset to ~24 hours
• Acute: onset to 7 days
• Sub-Acute: 7 days to 4 months from onset
• Chronic: > 4 months from onset
**lifetime f/u is essential for continued activity & management**
Stroke Severity
• can be based on the:
- grading of impairment of body structures & function
- gait velocity
• utilizes the NIHSS
Permissive Hypertension
• allowed for ischemic stroke patients to improve perfusion
- BP up to 185/110 mmHg
• for a limited time
• PTs should note this in discharge.
National Institutes of Health Stroke Scale (NIHSS)
• clinical assessment tool for:
- classifying stroke
- determining appropriate treatment
- predicting client outcomes
