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Certified Stroke Rehabilitation
Specialist (CSRS 2025) Questions
and Verified Answers
Action Observation - ANSClient watches another perform, observe mvmt in non paretic arm, tasks viewed are practiced (use of mirror neurons: frontal lobe neurons activated by observation of another's activity) -Action observation has been shown to facilitate motor learning and the building of a motor memory trace in normal adults as well as in stroke patients -During each rehabilitation session, patients are required to observe a specific object-directed daily action presented through a video clip on a computer screen, and afterwards to execute what they have observed.
- Only one action is practiced during each rehabilitation session. The presented action is divided into three to four motor acts. Adaptive Plasticity - ANSThe brains ability to compensate for loss functionality due to brain damage as well as in response to interaction with the environment by reorganizing its structure -This occurs in response to compensation for the brain injury and in "adjustment to new experiences" -Neural changes are "sprouting & rerouting" -Occurs over the lifespan but is more efficient and effective during infancy/early childhood
Affected Artery and Corresponding Vison Impairments - ANSMiddle Cerebral Artery (MCA) -visual filed impairment (B) -visuospatial impairment (R) -contralateral homonymous hemianopsia (B) -visual perceptual and unilateral neglect (R) Posterior Cerebral Artery (PCA) -contralateral homonymous hemianopsia (B) -visual agnosia (B) -cortical blindness (R) -visuospatial impairments (R) Amplitude: E-STIM - ANSSometime referred to as intensity) refers to the strength of the stimulation delivered, measured in milliamps (mA) -This parameter is always adjustable in EMS devices and often appears like a volume switch. -Adjustment of this parameter is always available as amplitude may not always be set to the same level at each treatment session. (adjust to produce the desired physiological response) -How "BIG" "INTENSE" the stimulation is compared to baseline -Measured in amperes (milliamps) or volts (millivolts) -Inc in amplitude more deeper, and smaller fibers are reached -> stronger contraction, inc the depth of penetration PHYSIOLOGICAL RESPONSE is the "KEY", do not focus on the number of milliamps -Amplitude: How Much?
Apraxia (Lesson 6) 2 types of Apraxia -Ideational Apraxia -Ideomotor Apraxia Damage to the praxis system: The network of structures underlying praxis is thought to include the frontal and parietal cortex, basal ganglia, and white matter tracts containing projections between these areas - ANSA neurological disorder characterized by the inability to perform learned (familiar) movements on command, even though the command is understood and there is a willingness to perform the movement. Both the desire and the capacity to move are present but the person simply cannot execute the act. -the inability to carry out learned, skilled motor acts despite preserved motor and sensory systems, coordination, comprehension, and cooperation
- difficulty in executing learned movements sequences beyond limitations that could be explained be weakness, lack of coordination, sensory deficits/loss, comprehension of deficits, memory and/or motivation Assessment of NEGLECT THINGS TO CONSIDER - ANS-Make sure that your assessment is catching multiple domains ( use good assessments) -Make sure you are insightful if patient has other deficits (e.g global aphasia "DOES THE PATIENT UNDERSTAND THE TASK) -Look for poor eye contact, failure to care for one-side of the body and not the other, does patient drop things on one side
BEST SCALE/ WIDELY USED
-Catherine Bergago SCALE: all the task are imbedded in functional activities 10-item checklist (assess performance of different daily activities rather than using test situation) (can understand level of neglect mild, moderate severe) -Personal Neglect Test (e.g bathing, shaving, combing hair) -Paper-Pencil Test: Line bisection test, Reading on a text on the (L), Line crossing subtest, Star cancellation test -Extrapersonal Test of Neglect: Point to objects Attention (MIA) Knowledge of Results External Cues - ANSFOCUS MORE ON: external feedback & knowledge of results Extrinsic feedback -KP: (knowledge of performance) external feedback that focuses on the "quality of movement" -KR: (knowledge of results) external feedback that focuses on the "outcome or goal of a skills" -Motivational feedback: "your going to do great with this, can't wait to see how you do", ADD: autonomy/self-control: How fast do you think you can do it? Intrinsic feedback: A person's own sensory-perceptual information that is a result of movement being performed (ie proprioception, vision, auditory, vestibular that can mediate this information)
-initiation of thought -initiation of emotion -plays an important role in motor control -directs actions of all motor tracts -Parkinson's disease is characterized by a loss of dopaminergic innervation in the basal ganglia leading to complex motor and non-motor symptoms. Behavior Contract (CIMT) (mCIT) UE - ANS-Therapy schedule, location and what to accomplish during treatment -Patient expectations for attendance, advance noticed of missing session -Patient bring sling/mitt UE -Achieve safety while at home Home exercises/homework: schedule. examples activities/exercise Establish: activities to be done Indep by patient, with SUP/help by the caregiver, and activities not to be done d/t safety reasons Blood supply to the brain - ANSinternal carotids and vertebral arteries Brainstem - ANSThe oldest part and central core of the brain, responsible for automatic survival functions. -Controls: heart rate, breathing, blood pressure, eye movement, hearing, speech, swallowing -responsible for autonomic survival and function Brief Visual Screen - ANS-Left Visual Screen: Patient is unaware of items located to the left (e.g clothing, grooming items) but is able to locate them when cued
-Focusing; Patient is unable to bring objects into focus at near as demonstrated by holding them out or moving back to view them -Near acuity: Patient complains that print is blurred when viewing menu or daily schedule -Low contrast acuity: Patient is unable to distinguish between items that are the same or similar color as the background during dressing, grooming etc. or difficulty completing ask in dem-lighting Broca's Area - ANSControls language expression - an area of the frontal lobe, usually in the left hemisphere, that directs the muscle movements involved in speech. -Speech motor area (expressive) -located only in the left side of the brain in 90% of people -can be flipped with left -handed people Cerebellum - ANSthe "little brain" at the rear of the brainstem; functions include processing sensory input and coordinating movement output and balance -Vestibulocerebellum: coordinates balance -Spinocerebellum: coordinates posture and gait, proximal limb muscles -Cerebrocerebellum: coordinates distal limb movements of small muscles used for speech, regulates force, timing, and direction of movement, involved in detecting and correcting movement errors, plays a role in motor learning and nonverbal communication and the ability to shift focus of attention Cerebrum - ANS-frontal, parietal, temporal, and occipital lobes
-Middle Cerebral Artery (MCA) -Posterior Cerebral Artery (PCA) Clinical Assessment & Goals : Pusher Syndrome - ANSUse 3 variables (diagnosis, severity, improvement)
- Symmetry of spontaneous body posture
- Abduction & extension of non-paretic extremities
- Resistance to passive correction of tilted posture Other outcome measures: -Modified SCale for Contraversive Pushing -Burke Lateropulsion SCale -Four point Pusher Scale (4PPS) GOAL: -Patient should be able to sit without falling with moderate vc in 2 days -Patient should be able to maintain midline for 2 min while brushing hair with vc in 5 days -Patient should be able to perform sit/pivot on even surface with no extension of intact UE with vc in 2 wks Clinical Importance of Adaptive Plasticity in Stroke - ANSThe goal of rehab is to restore (change compensation to restoration) What we measure: (functional measures & brain based measures (MRI) -personalize & adjust therapy based on the patient. integrate the patient into recovery
Cognition : BALANCE - ANSPsychological trauma & fear of falling cause self-imposed activity reduction consider: strength, flexibility, mobility, and Further Risk of FUTURE FALLS Controlling Cognitive Risk Factors: -lightening problems, floor clutter, rugs, bathroom safety, tubs, unstable furniture, shelves (high/low), regular bathroom schedules, check-off list for your family to take home and review/bring back. -Have the family take pictures of the home environment and bring them to show you Complex Regional Pain Syndrome (CRPS)(PNS) -RSD (Reflex Sympathetic Dystrophy) -Sudek Atrophy -Shoulder-hand syndrome - ANS-A form of chronic pain that usually affects an arm or a leg. CRPS typically develops after an injury, a surgery, a stroke or a heart attack. The pain is out of proportion to the severity of the initial injury Type I. (NO definable nerve lesion) most common for stroke patients, this type occurs after an illness or injury that didn't directly damage the nerves in your affected limb. About 90% of people with CRPS have type 1. Type II: (definable nerve root/trauma) also referred to as causalgia, this type has symptoms similar to those of type 1. But type 2 CRPS occurs after a distinct nerve injury. -characterized by: pain, vasomotor changes, and patchy bone demineralization of the more affected extremity, -between 2 and 49% of stroke survivor's have CRPS
Constraint-Induced Movement Therapy (CIMT) LE - ANSEncourages use/integration of both LE's -3hrs/day of clinical time for 10 consecutive days -30 second trials KR (knowledge of reflection/performance) after each performance (how many, how high) -NO RESTRAINT DEVICE (some therapist have used knee immobilizers on less affected side) -Complexity level of the shaping task should be set as just beyond what the participant can easily accomplish Inclusion Criteria: (mCIT) LE must be able to walk independently 10ft on flat surface without the use of AE or be able to walk 25ft using AE or not, at least 3x a day Contraindications : Kinesiology Taping - ANSDO NOT APPLY TO: -overactive malignancy site -overactive colitis or skin infections -open wounds -deep vein thrombosis Precautions: -Diabetes, Kidney Disease, CHF, CAD or Bruits in Carotid Artery, fragile or healing skin, pregnancy, 99% of patient over 60 yo, Taping may require MD approval Controversies Pushing- Pusher syndrome
(Lesson 17) - ANS"Pusher syndrome" is a clinical disorder following left or right brain damage in which patients actively push away from the non- hemiparetic side, leading to a loss of postural balance.Investigation of patients with severe pushing behavior has shown that perception of body posture in relation to gravity is altered. The patients experience their body as oriented "upright" when the body actually is tilted to the side of the brain lesion (to the ipsilesional side) -Characterized by leaning an active pusher towards hemiplegic side with:
- Resistance to passive correction towards midline
- No compensation for the instability (ie. the patient CANNOT passively correct the pushing it is mostly done actively. If actively corrected by the therapist the patient will push back even harder) -Perception to body posture in relation to gravity is altered resulting in actively pushing towards the involved side with the uninvolved side
- Processing is not distributed by the visual & vestibular system
- Commonly associated with aphasia (when seen with L-side lesion) Neglect (when seen with R-side lesion) Denervation Hypersensitivity - ANSstroke: if a presynaptic neuron dies the post-synaptic neuron will re-route using denervation hypersensitivity by developing additional channels from adjacent presynaptic neurons that can innervate it becoming hypersensitive so the action potential can continue -Hypersensitivity: A sharp increase of sensitivity of post-synaptic membranes to a chemical transmitter after denervation (loss of nerve supply) (e.g a nerve that has been compromised or chnaged
-occurs over the lifespan, but diminishes with age Diagnosis and Treatment of Pain: STROKE - ANSDiagnosis: -verbal description: aching, burning, freezing, sqeezing -Spontaneous dysesthesia damage to lesion in PNS and/or CNS (burning, wet, itching, shock, pins & needles -Raised threshold for perception of touch and two-point discrimination (variable pain quality) Treatment -Anticonvulsants (e.g gabapentin) -Antidepressants (e.g SSRI) -Deep brain stimulation (thalamus) -rTMS -Acupuncture/Acupressure ( massage pain points no expert needed Therapist: provide modalities (e.g hot/cold packs, limb movement) Differential Diagnosis : Neglect vs Homonymous Hemianopsia - ANSClient with Neglect: CANNOT GO PAST MIDLINE -Turning head contralesionally causes inability to see stimulus -client may not demonstrate insight into visual loss -will not scan during clinical test (everything is fine) Client with HOMO-Hemianopsia -Turning head contralesionally they can see stimulus on the wall of in front of them
-client demonstrates insight into visual loss -can scan and perform clinical test (will attempt to actively compensate Dynamic Balance - ANS-The ability to maintain a position while moving, such as while walking, running, or standing up and throwing a ball. -Requires the persons center of mass to be balanced over his or her base of support. Question:
- Can the patient move within a posture
- Can the patient maintain posture when walking
- Can the patient move within varying environments
- Can the patient move with varying sensory inputs REMEBER: Muscle used for dynamic balance are being activated distal to proximal E-STIM Devices & Evidence to support use - ANSChattanooga Continuum Empi Trigger Switches SaeboStim One Evidence: Level 1a evidence that neuromuscular electrical stimulation in combination with gait/balance training improves gait/balance when compared to stimulation or training alone Evidence: There is level 1a and level 2 evidence that functional electrical stimulation during conventional rehabilitation improves gait, balance, and independence when compared to rehabilitation alone
-Vascular Changes alteration of filtration and reabsorption of fluid (18.5% in acute stroke) Other causes of Edema: -NSAIDS -High salt intake -Corticosteroids (predisone) -Some DM2 medications Treatment -Lycra pressure garments (glove/splint) bilateral PROM UE exercises, laser therapy, acupressure (train caregiver) Electrical Stimulation : STROKE (Lesson 13) - ANSElectrical stimulation (e-stim) is the use of a device to send gentle electrical pulses through the skin -Electrical muscle stimulation (EMS) to help repair muscles -Transcutaneous electrical nerve stimulation (TENS) to help with pain 4 Types: TENS, NMES, EMG-Triggered NMES, FES 4Types Parameters: Amplitude, Pulse Duration, Frequency, Ramp-Time Embolic Stroke (Ischemic) - ANS26% of all strokes -typically occurs while awake -sudden, immediate deficits (sometimes seizures) -11% are associated with prior TIA EMG-Triggered NMES - ANSEMG-triggered stimulation is a technology to detect the extremely small electrical ElectroMyoGraphic (EMG) signals still measurable in paralyzed muscles after stroke and use these signals to
initiate electrical stimulation impulses to the same muscles resulting in actual muscle movement -good for patients who get trace muscle movement but lack full control -therapist sets stim intensity and EMG threshold, and electrodes sense trace contraction/muscular attempt, so the device rewards the patient with stimulation ONLY when patient hits threshold. GOAL: Increase AROM in people with trace/minimal movement. Just-Right- Challenge as the patient becomes more successful. Visual-bio feedback based stimulation: patient must actively participate with trying to reach a threshold and are rewarded w/ stimulation when the goal is reached. Evaluation of Apraxia Functional Test Evaluation - ANSStandardized Test -Florida Apraxia Screening Test (revised) -Cambridge Apraxia Battery -Kaufman Hand Movement Test -Limb Apraxia Test -Movement Imitation Test -Diagnostic Test for Apraxia -TULIA Functional Task Evaluation -Structured observation of the errors that people make during functional activities is a valid method of assessing apraxia: Apraxia results in an observable problem related to functional. allowing person to make safe errors during task, analyzing the errors to classify them based on type of apraxia and error type Tasked Based Training
