Stroke

1. Stroke

2. Objectives Define Stroke Review Classifications, Statistics, and Risk Factors Identify Early Warning Signs of a Stroke Identify Primary Impairments Identify Secondary Impairments Recognize Hemispheric Differences Understand Prognosis Review Physical Therapy Interventions Review Effective Interventions Based on Research

3. Stroke is the sudden loss of neurological function caused by an interruption of the blood flow to the brain. Ischemic Stroke: A clot blocks or impairs blood flow. Hemorrhagic Stroke: Blood vessels rupture and leak in or around the brain.

4. Motor deficits are characterized by paralysis (hemiplegia) or weakness (hemiparesis) typically on the side of the body opposite the side of the lesion. i

5. Stroke Classification Etiological Thrombosis Embolus Hemorrhage Management Categories Transient Ischemic Attack Minor Stroke Major Stroke Deteriorating Stroke Young Stroke Vascular Territory Anterior Cerebral Artery Syndrome Middle Cerebral Artery Syndrome Internal Carotid Artery Syndrome Posterior Cerebral Artery Syndrome Lacunar Syndrome Vertebrobasilar Artery Syndrome

6. Statistics of Stoke in 2008 4th Leading cause of death in the United States 1st Cause of long-term severe disability 700,000 strokes a year 5,400,000 estimated stroke survivors= 2.6% of population 18.8 billion costs for care in the United States Incidence is 1.25 times greater for males than females Highest Risk for African-Americans, American Indians and Alaska Natives. Lowest Risk for Asians and Native Hawaiian/Other Pacific Islander Incidence increases with age, doubling in the decade after 65 years of age.

7. Risk Factors High Blood Pressure # 1 Risk Factor Atrial Fibrillation Diabetes Family History of Stroke High Cholesterol Increasing Age, especially after age 55 Race Birth control pills Unhealthy lifestyle: Excessive drinking, smoking, illegal drug use, eating too much salt or fat, and being overweight/obese.

8. Early Warning Signs of Stroke “Time is Brain” Sudden severe headache Sudden numbness or weakness on one side of the body Confusion, trouble speaking or understanding Vision problems in one or both eyes Trouble walking Difficultly w/ swallowing Lack of control over bladder or bowels Personality, mood or emotional changes Change in alertness (sleepiness, convulsions, coma)

9. Primary Impairments MOTOR Sensory Vision Language, Speech & swallowing Postural Control & Balance Cognition Affect Bladder/bowel function

10. Motor Impairments Weakness – UE usually more affected than LE Proximal muscles typically have more strength than distal muscles. Stages of Motor Recovery Tone – Flaccidity – usually lasting a few days or weeks, may persist in pts w/ lesions in primary motor cortex or cerebellum. Spasticity – Present in 90% of pts, also contributes to abnormal synergy patterns. Abnormal Reflexes – vary according to stage in recovery Altered Coordination – May cause ataxia, problems with timing and sequencing of muscles, slow movements, or involuntary movements. Altered Motor Programming- Ideational apraxia-inability to produce movement on command. Ideomotor apraxia-pt can perform habitual task when not commanded to.

11. Sensory Impairments Frequently Impaired, but rarely absent. Impaired Proprioception Impaired Superficial Touch Impaired Sensation of Pain Numbness, dyesthesia, or hyperesthesia. Hemisensory loss can contribute to unilateral neglect and injury. Severe headache, neck or face pain may develop. Thalamic pain – constant severe burning with intermittent sharp pains may develop after a few weeks or months following a stroke and may prevent the patient from participating in rehab.

12. Vision Impairments Homonymous Hemianopsia: A loss of vision in the nasal half of the visual field of one eye and the temporal half of the visual field of the other eye. (contributes to lack of awareness of hemiplegic side) Visual Neglect: Pt can see all of the visual field but ignores objects on one side. Depth perception and spatial relationship problems. Brain stem strokes may cause: diplopia, oscillopsia, or visual distortions.

13. Speech, Language and Swallowing Impairments Aphasia – Impairment of language ability Wernickes (Receptive) – Auditory comprehension is impaired, but speech production is preserved. Broca’s (Expressive) – Comprehension is good, but speech production is labored or lost completely. Global – Impairments in both production and comprehension of language. Dysarthria-Difficulty with controlling and coordinating muscles that are used for speech. Dysphagia – Difficulty in Swallowing.

14. Postural Control and Balance Impairments Asymmetry in Sitting or Standing Increased Postural Sway Reactive Postural Sway (Problems w/ reacting to external forces) Anticipatory Postural Control (Problems initiating movements) Abnormal timing and sequencing of muscle activity Ipsilateral Pushing

15. Perception and Cognition Body scheme/body image - relationship of body parts to each other and relationship of body to the environment. Spatial relationships – difficulty in perceiving the relationship between self and two or more objects in the environment. Agnosias – Inability to recognize incoming information despite intact sensory capacities. Attention Disorders – Impairments in sustaining attention Memory Disorders – Impairments in immediate recall, short-term memory, and long-term memory. Perservation – Continued repetition of words, thoughts, or acts. Executive Function Disorders - Unable to engage in purposeful behaviors. Multi-infarct Dementia – Progressive impairments in memory and cognition. Delirium- Acute confusional state.

16. Affect Pseudobulbar Affect: Emotional outbursts of uncontrolled or exaggerated laughing or crying that is inconsistent with mood. Apathy: Shallow affect and blunted emotional responses. Euphoria: Exaggerated feelings of well being. Irritability , Frustration, Social Inappropriateness Depression: Persistent feelings of sadness, hopelessness, helplessness. Contributes to fatigue, inability to concentrate, changes in wt, sleep, suicidal thoughts, etc.. Period between 6 mnths to 2 yrs most common time to occur. Prolonged depression can interfere with rehab and long-term functional outcomes.

17. Bowel and Bladder Problems Common during acute phase, occurring in 29% of cases. Can be caused by bladder hyperreflexia or hyporeflexia, disturbances in sphincter control and or sensory loss. Early treatment is desirable to prevent chronic UTI’s and skin breakdown. Persistent incontinence may lead to embarrassment, isolation, and depression, along with poor long-term prognosis and functional recovery.

18. Hemispheric Differences Right Brain Injury Left-side hemiplegia/paresis Left-side hemisensory loss Visual-Perceptual Impairments: Difficulty sustaining a movement Quick, impulsive behavior style Difficulty w/ problem solving Often unaware of impairments, poor judgment, inability to self-correct. Rigidity of thought, difficulty w/ abstract reasoning. Difficulty w/ perceptions of emotions and expression of negative emotions. Difficulty processing visual cues. Memory impairments, typically related to spatial-perceptual information. Left Brain Injury Right-side hemiplegia/paresis Right-side hemisensory loss Speech and Language Impairments Difficulty planning and sequencing movements. Apraxia more common Slow, cautious behavior style Disorganized problem-solving Often very aware of impairments and anxious about poor performance Difficulty with processing delays Difficulty with expression of positive emotions. Difficulty processing verbal cues and verbal commands. Memory impairments, typically related to language.

19. Secondary Impairments Musculoskeletal: Contractures, Disuse atrophy, Osteoporosis. Neurological: Seizures, Hydrocephalus Cardiovascular/Pulmonary: Thrombophlebitis/DVT Cardiac: Impaired cardiac output, cardiac deecompensation, serious rhythm disorders. Pulmonary : aspiration, decreased respiratory function Integumentry: decubitus ulcers

20. Prognosis Recovery is generally fastest in the first weeks after onset due to reduction of edema, absorption of damaged tissue and improved circulation that allows intact neurons to regain function. Pts can continue to make measurable gains generally at a reduced rate for months or years after insult. Late recovery (Greater than 1 year post-stroke) of function has been shown with extensive functional training. Rates of motor recovery very and depend upon stroke classifications. Recovery also depends on motivation, supportive family, financial resources and intensive training with practice.

21. INTERVENTIONS Sensory Function Motor Function Muscular Strength Motor Learning Postural Control and Functional Mobility Upper Extremity Function Lower Extremity Function Balance Gait

22. Sensation Interventions Encourage pt to use the more involved side to increase awareness and function. Stroking involved extremity using textured fabrics, pressing objects into hand, or drawing shapes and letters on the skin. Approximation through weight bearing in sitting/modified plantigrade/standing Stretching Superficial and Deep pressure stimulation Safety Awareness Training to ensure protection of anesthetic limbs, especially important during transfers and w/c activities.

23. Motor Function Interventions AROM and PROM daily in all jts and motions. (scapula is very important to prevent impingement in subacromial space during overhead movements) arm cradling, table top polishing, sitting leaning forward and reaching both hands down to the floor. Positioning strategies w/ proper jt alignment –splints may be necessary. In supine: head neutral on pillow, trunk aligned in midline, Affected UE: scapular protracted, shoulder forward; arm supported on a pillow; wrist neutral, fingers extended and thumb abducted. Affected LE: hip forward; knee on small towel roll to prevent hyperextension, nothing against the soles of feet. (If persistent plantar flexion a splint can be used to hold ankle in neutral position) Plantar flexion spasticity will limit active movement at the ankle – stretch the plantarflexors through weight shifting activities in modified plantigrade. Facilitate Dorsiflexion- combine w/ stretching of plantarflexors to provide reciprocal inhibition. Break up synergy pattern by lying pt supine on mat, involved LE abducted off to the side w/ knee flexed and foot flat on the mat.

24. Manage Spasticity Rhythmic rotation: Slowly move limb into the lengthened range while gently rotating it back and forth, then maintain limb in lengthened position w/ wb for 5-10 minutes. Prolonged pressure on long flexor tendons in arm Kneeling or quadruped to reduce spasticity in the quadriceps Hooklying w/ lower trunk rotation or PNF chops to reduce tone in the trunk Ice wraps or ice packs can be used temporarily to reduce spasticity. E-stim to antagonist muscles Relaxation techniques/Mental imagery Air splints to provide for early wb and break up synergy patterns

25. Strength Interventions Depends on pts muscle strength as to position and resistance. Gravity eliminated vs. gravity w/or w/o resistance. Careful Monitoring of vitals and perceived rate of exertion. Avoid High intensity exercises Avoid valsalva maneuver Sitting exercises produce less elevations in BP than supine positions Vary the exercise – work different muscle groups Ensure an adequate warm-up and cool down Free Weights Aquatic Therapy Elastic Tubing Step-ups while wearing ankle weights Functional Activities PNF Etc…

26. Motor Learning Interventions Demonstrate task, give clear simple commands, practice on less affected side first, practice both sides together. Mental Imagery Intrinsic feedback Extrinsic feedback Practice (Blocked Practice, Serial, Random) Motivate - Pt should be involved in goal-setting.

27. Postural and Functional Mobility Interventions Rollingto both sides- hooklying arms extended in prayer position. Supine <>Sit – from both sides- shift LE’s over edge of bed and use UE’s to push up. Sitting – with symmetrical posture and proper spine and pelvic alignment. Progress from stability>dynamic stabilty> reaching. Practice trunk flex/ext, lateral flex, and rotation. PNF chop patterns, butt walking. Bridging- Also lateral wt shifts – bridge and place to one side. Sit<>Stand- Feet should be placed back to allow dorsiflexion to assist with forward rotation, trunk should flex forward, hip and knee extensors engage to stand-up. Therapist may need to support involved LE and may need to higher surface to make it easier for pt to stand up. Standing, Modified Plantigrade- helps to break up synergy patterns and allows weight bearing. Progress from stabilty in the posture to weight shifts and reaching tasks. continued

28. Postural and Functional Mobility Interventions Standing: Stand with unilateral support on the affected side. Progress to no support> holding posture>weight shifts> reaching in all directions> stepping in all directions. Transfers: It is easiest to transfer towards the less affected side, but it is important to practice transferring using both sides. Practice transferring to different surfaces and heights. Pusher Syndrome: Emphasize vertical positions w/ shifts to the stronger side. Use a mirror, position stronger side towards the wall and instruct pt to lean into wall, practice weight shifts, provide consistent feedback to pt, engage pt in problem solving “what direction are you tilted?” “what direction do you need to move to be straight?”

29. UE Interventions Severe impairments: ROM, positioning, compensatory training. More functional: weight bearing w/ stabilized hand on support surface. Reaching to gain control of scapular upward rotation and protraction, elbow extension, wrist extension, and finger extension. (Excessive shoulder elevation should be discouraged) -table top polishing, reaching forward, down towards floor, PNF D1ext Manipulation & Dexterity- Use affected UE to assist in stabilizing paper while the other hand writes, help to hold a book, helping with ADLs> Progress to using UE in fine motor activities and ADLs. Constraint-induced movement therapy- Restrain unaffected UE and force pt to use affected UE. NMES - Improve sensory awareness, reduce spasticity, improve volitional limb movements. Management of shoulder pain – Proper positioning and handling, reduce subluxation, ROM.

30. LE Interventions PNF LE D1 Flex/Extension- break up synergy patterns Holding elastic band around upper thighs – supine or standing Lateral step-ups Sitting and crossing affected extremity over unaffected Bridging Lower trunk rotation exercises Pelvic rotation and control Partial wall squats Activate dorsiflexion in sitting by first having the pt hold in dorsiflexion and slowly lowering foot down, progress to pulling foot up.

31. Balance Interventions Achieve postural alignment and static stability, progress to weight shifting within limits of stability, maintain symmetrical weight bearing. Increase the difficulty by applying perturbations, standing on a less stable surface, narrow BOS, extend UE or LE out to side, add head movements, add dual tasks, move from a closed environment to an open environment.

32. Gait Training Interventions Overhead harness on treadmill Parallel bars and ambulation aids Maintain Natural rhythm of walking and speed. Encourage Pt to take even steps. Recognize gait abnormalities and correct. (critical areas are initial wt acceptance, midstance control, forward wt advancement on involved side. During swing phase control of knee and foot for toe clearance) Position UE in extension and abduction with the hand open to break up synergy pattern. Practice walking forward/backward/sideward/cross-stepping, step-ups, stair climbing, step-overs/travel training in environment. NMES for foot drop Orthotics- Required in persistent problems prevent safe ambulation.

33. Research on Interventions Meaningful Task-Specific Training showed statistically significant improvements in UE motor recover than did Brunnstrom and Bobath neurodevelopment technique. 95 participants divided into two groups (MTST and standard training group) The MTST group showed positive improvement in comparison to the control group in Fugal-Meyer Assessment, Acton Research Arm Test, Graded Wolf Motor Functional Test, and Motor Activity Log. PNF is an effective treatment for functional ambulatory gains in stroke rehab. PNF can improve ambulation by improving muscle tone, strength and flexibility. Various PNF procedures were used, depending on the target body part. Some of the procedures were UE patterns, LE patterns, pelvic patterns, etc.

34. Research on Interventions Three different therapy treatment approaches were compared by dividing 131 stroke pts into 3 groups for a 6 week study. These approaches included: Traditional exercises/functional activities, PNF, and Bobath techniques. No advantage could be attributed to any specific approach in areas of ADLS, muscle tone, muscle strength, ROM, and ambulation.

35. Conclusion There isn’t one panacea for rehabilitation of patients with CVA’s. Because a stroke can cause various impairments therapists must choose interventions according to specific limitations and based on patients’ responses to treatments. A variety of techniques and interventions may need to be implemented to identify which will bring the best outcome.

36. References: Akosile CO, Adegoke BOA, Johnson OE, Maruf FA. Effects of proprioceptive neuromuscular facilitation technique on the functional ambulation of stroke survivors. Journal of the Nigeria Society of Physiotherapy. 2011;18/19:22-27. Arya K, Verma R, Garg R, Sharma V, Agarwal M, Aggarwal G. Meaningful Task-Specific Training (MTST) for Stroke Rehabilitation: A Randomized Controlled Trial. Topics In Stroke Rehabilitation [serial online]. May 2012;19(3):193-211. Dickstein R, Hocherman S, Pillar T, Shaham R. Stroke rehabilitation. Three exercise therapy approaches. Physical Therapy [serial online]. August 1986;66(8):1233-1238. Available from: MEDLINE, Ipswich, MA. Goldstein LB, Bushnell CD, Adams RJ, Appel LJ, Braun LT, Chaturvedi S, et al. Guidelines for the primary prevention of stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2011;42:517-584 Lori Thein Brody, Carrie M. Hall. Therapeutic Exercise. 2011:340-356 Susan B. O’Sullivan, Thomas J. Schmitz. Improving Functional Outcomes in Physical Rehabilitation. 2010:43-96