Stroke Stroke Classification Statistics of Stoke in 2008 Risk Factors Early Warning Signs of Stroke
Buser, Matt, Fantasy Expert has reference to this Academic Journal, PHwiki organized this Journal StrokeObjectives Define Stroke Review Classifications, Statistics, in addition to Risk FactorsIdentify Early Warning Signs of a StrokeIdentify Primary ImpairmentsIdentify Secondary ImpairmentsRecognize Hemispheric DifferencesUnderst in addition to PrognosisReview Physical Therapy InterventionsReview Effective Interventions Based on ResearchStroke 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 in addition to leak in or around the brain.
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iMotor deficits are characterized by paralysis (hemiplegia) or weakness (hemiparesis) typically on the side of the body opposite the side of the lesion.Stroke ClassificationEtiological ThrombosisEmbolusHemorrhageManagement CategoriesTransient Ischemic AttackMinor StrokeMajor StrokeDeteriorating StrokeYoung StrokeVascular TerritoryAnterior Cerebral Artery SyndromeMiddle Cerebral Artery SyndromeInternal Carotid Artery SyndromePosterior Cerebral Artery SyndromeLacunar SyndromeVertebrobasilar Artery SyndromeStatistics of Stoke in 20084th Leading cause of death in the United States1st Cause of long-term severe disability700,000 strokes a year5,400,000 estimated stroke survivors= 2.6% of population18.8 billion costs as long as care in the United StatesIncidence is 1.25 times greater as long as males than femalesHighest Risk as long as African-Americans, American Indians in addition to Alaska Natives.Lowest Risk as long as Asians in addition to Native Hawaiian/Other Pacific Isl in addition to erIncidence increases with age, doubling in the decade after 65 years of age.
Risk Factors High Blood Pressure 1 Risk FactorAtrial FibrillationDiabetesFamily History of StrokeHigh CholesterolIncreasing Age, especially after age 55RaceBirth control pills Unhealthy lifestyle: Excessive drinking, smoking, illegal drug use, eating too much salt or fat, in addition to being overweight/obese. Time is Brain Sudden severe headache Sudden numbness or weakness on one side of the bodyConfusion, trouble speaking or underst in addition to ingVision problems in one or both eyesTrouble walkingDifficultly w/ swallowingLack of control over bladder or bowelsPersonality, mood or emotional changesChange in alertness (sleepiness, convulsions, coma)Early Warning Signs of StrokeMOTORSensoryVisionLanguage, Speech & swallowing Postural Control & BalanceCognitionAffectBladder/bowel functionPrimary Impairments
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 recoveryAltered Coordination May cause ataxia, problems with timing in addition to sequencing of muscles, slow movements, or involuntary movements.Altered Motor Programming- Ideational apraxia-inability to produce movement on comm in addition to . Ideomotor apraxia-pt can per as long as m habitual task when not comm in addition to ed to.Sensory Impairments Frequently Impaired, but rarely absent. Impaired Proprioception Impaired Superficial TouchImpaired Sensation of PainNumbness, dyesthesia, or hyperesthesia.Hemisensory loss can contribute to unilateral neglect in addition to 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 in addition to may prevent the patient from participating in rehab.Vision ImpairmentsHomonymous Hemianopsia: A loss of vision in the nasal half of the visual field of one eye in addition to 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 in addition to spatial relationship problems.Brain stem strokes may cause: diplopia, oscillopsia, or visual distortions.
Speech, Language in addition to Swallowing ImpairmentsAphasia Impairment of language ability Wernickes (Receptive) Auditory comprehension is impaired, but speech production is preserved. Brocas (Expressive) Comprehension is good, but speech production is labored or lost completely. Global Impairments in both production in addition to comprehension of language.Dysarthria- Difficulty with controlling in addition to coordinating muscles that are used as long as speech.Dysphagia Difficulty in Swallowing.Postural Control in addition to Balance ImpairmentsAsymmetry in Sitting or St in addition to ingIncreased Postural SwayReactive Postural Sway (Problems w/ reacting to external as long as ces)Anticipatory Postural Control (Problems initiating movements)Abnormal timing in addition to sequencing of muscle activityIpsilateral Pushing Perception in addition to CognitionBody scheme/body image – relationship of body parts to each other in addition to relationship of body to the environment.Spatial relationships difficulty in perceiving the relationship between self in addition to two or more objects in the environment.Agnosias Inability to recognize incoming in as long as mation despite intact sensory capacities.Attention Disorders Impairments in sustaining attentionMemory Disorders Impairments in immediate recall, short-term memory, in addition to 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 in addition to cognition.Delirium- Acute confusional state.
AffectPseudobulbar Affect: Emotional outbursts of uncontrolled or exaggerated laughing or crying that is inconsistent with mood. Apathy: Shallow affect in addition to blunted emotional responses.Euphoria: Exaggerated feelings of well being.Irritability , Frustration, Social InappropriatenessDepression: 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 in addition to long-term functional outcomes.Bowel in addition to Bladder ProblemsCommon during acute phase, occurring in 29% of cases.Can be caused by bladder hyperreflexia or hyporeflexia, disturbances in sphincter control in addition to or sensory loss.Early treatment is desirable to prevent chronic UTIs in addition to skin breakdown.Persistent incontinence may lead to embarrassment, isolation, in addition to depression, along with poor long-term prognosis in addition to functional recovery.Hemispheric Differences Right Brain InjuryLeft-side hemiplegia/paresisLeft-side hemisensory lossVisual-Perceptual Impairments: Difficulty sustaining a movement Quick, impulsive behavior styleDifficulty w/ problem solvingOften unaware of impairments, poor judgment, inability to self-correct.Rigidity of thought, difficulty w/ abstract reasoning.Difficulty w/ perceptions of emotions in addition to expression of negative emotions.Difficulty processing visual cues.Memory impairments, typically related to spatial-perceptual in as long as mation. Left Brain InjuryRight-side hemiplegia/paresisRight-side hemisensory lossSpeech in addition to Language ImpairmentsDifficulty planning in addition to sequencing movements. Apraxia more commonSlow, cautious behavior styleDisorganized problem-solvingOften very aware of impairments in addition to anxious about poor per as long as manceDifficulty with processing delaysDifficulty with expression of positive emotions.Difficulty processing verbal cues in addition to verbal comm in addition to s.Memory impairments, typically related to language.
Musculoskeletal: Contractures, Disuse atrophy, Osteoporosis.Neurological: Seizures, HydrocephalusCardiovascular/Pulmonary: Thrombophlebitis/DVTCardiac: Impaired cardiac output, cardiac deecompensation, serious rhythm disorders.Pulmonary : aspiration, decreased respiratory functionIntegumentry: decubitus ulcersSecondary ImpairmentsPrognosis Recovery is generally fastest in the first weeks after onset due to reduction of edema, absorption of damaged tissue in addition to improved circulation that allows intact neurons to regain function.Pts can continue to make measurable gains generally at a reduced rate as long as 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 in addition to depend upon stroke classifications.Recovery also depends on motivation, supportive family, financial resources in addition to intensive training with practice.INTERVENTIONS Sensory Function Motor Function Muscular Strength Motor Learning Postural Control in addition to Functional Mobility Upper Extremity Function Lower Extremity Function Balance Gait
Sensation InterventionsEncourage pt to use the more involved side to increase awareness in addition to function.Stroking involved extremity using textured fabrics, pressing objects into h in addition to , or drawing shapes in addition to letters on the skin.Approximation through weight bearing in sitting/modified plantigrade/st in addition to ing StretchingSuperficial in addition to Deep pressure stimulationSafety Awareness Training to ensure protection of anesthetic limbs, especially important during transfers in addition to w/c activities.Motor Function InterventionsAROM in addition to PROM daily in all jts in addition to motions. (scapula is very important to prevent impingement in subacromial space during overhead movements) arm cradling, table top polishing, sitting leaning as long as ward in addition to reaching both h in addition to s 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 as long as ward; arm supported on a pillow; wrist neutral, fingers extended in addition to thumb abducted. Affected LE: hip as long as ward; 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 in addition to foot flat on the mat.Manage SpasticityRhythmic rotation: Slowly move limb into the lengthened range while gently rotating it back in addition to as long as th, then maintain limb in lengthened position w/ wb as long as 5-10 minutes.Prolonged pressure on long flexor tendons in armKneeling or quadruped to reduce spasticity in the quadricepsHooklying w/ lower trunk rotation or PNF chops to reduce tone in the trunkIce wraps or ice packs can be used temporarily to reduce spasticity.E-stim to antagonist musclesRelaxation techniques/Mental imageryAir splints to provide as long as early wb in addition to break up synergy patterns
Strength InterventionsDepends on pts muscle strength as to position in addition to resistance. Gravity eliminated vs. gravity w/or w/o resistance.Careful Monitoring of vitals in addition to 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 in addition to cool downFree WeightsAquatic TherapyElastic TubingStep-ups while wearing ankle weightsFunctional ActivitiesPNF Etc Motor Learning InterventionsDemonstrate task, give clear simple comm in addition to s, practice on less affected side first, practice both sides together.Mental ImageryIntrinsic feedbackExtrinsic feedbackPractice (Blocked Practice, Serial, R in addition to om)Motivate – Pt should be involved in goal-setting.Postural in addition to Functional Mobility InterventionsRolling to both sides- hooklying arms extended in prayer position.Supine <>Sit from both sides- shift LEs over edge of bed in addition to use UEs to push up.Sitting with symmetrical posture in addition to proper spine in addition to pelvic alignment. Progress from stability>dynamic stabilty> reaching. Practice trunk flex/ext, lateral flex, in addition to rotation. PNF chop patterns, butt walking.Bridging- Also lateral wt shifts bridge in addition to place to one side.Sit<>St in addition to – Feet should be placed back to allow dorsiflexion to assist with as long as ward rotation, trunk should flex as long as ward, hip in addition to knee extensors engage to st in addition to -up. Therapist may need to support involved LE in addition to may need to higher surface to make it easier as long as pt to st in addition to up.St in addition to ing, Modified Plantigrade- helps to break up synergy patterns in addition to allows weight bearing. Progress from stabilty in the posture to weight shifts in addition to reaching tasks. continued
Postural in addition to Functional Mobility InterventionsSt in addition to ing: St in addition to 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 in addition to heights.Pusher Syndrome: Emphasize vertical positions w/ shifts to the stronger side. Use a mirror, position stronger side towards the wall in addition to 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 straightUE InterventionsSevere impairments: ROM, positioning, compensatory training.More functional: weight bearing w/ stabilized h in addition to on support surface.Reaching to gain control of scapular upward rotation in addition to protraction, elbow extension, wrist extension, in addition to finger extension. (Excessive shoulder elevation should be discouraged) -table top polishing, reaching as long as ward, down towards floor, PNF D1extManipulation & Dexterity- Use affected UE to assist in stabilizing paper while the other h in addition to writes, help to hold a book, helping with ADLs> Progress to using UE in fine motor activities in addition to ADLs.Constraint-induced movement therapy- Restrain unaffected UE in addition to as long as ce pt to use affected UE.NMES – Improve sensory awareness, reduce spasticity, improve volitional limb movements.Management of shoulder pain Proper positioning in addition to h in addition to ling, reduce subluxation, ROM.LE InterventionsPNF LE D1 Flex/Extension- break up synergy patternsHolding elastic b in addition to around upper thighs supine or st in addition to ing Lateral step-upsSitting in addition to crossing affected extremity over unaffectedBridgingLower trunk rotation exercisesPelvic rotation in addition to controlPartial wall squatsActivate dorsiflexion in sitting by first having the pt hold in dorsiflexion in addition to slowly lowering foot down, progress to pulling foot up.
Research on InterventionsThree different therapy treatment approaches were compared by dividing 131 stroke pts into 3 groups as long as a 6 week study. These approaches included: Traditional exercises/functional activities, PNF, in addition to Bobath techniques. No advantage could be attributed to any specific approach in areas of ADLS, muscle tone, muscle strength, ROM, in addition to ambulation.ConclusionThere isnt one panacea as long as rehabilitation of patients with CVAs. Because a stroke can cause various impairments therapists must choose interventions according to specific limitations in addition to based on patients responses to treatments. A variety of techniques in addition to interventions may need to be implemented to identify which will bring the best outcome. 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) as long as Stroke Rehabilitation: A R in addition to omized 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 as long as the primary prevention of stroke: a guideline as long as healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2011;42:517-584Lori Thein Brody, Carrie M. Hall. Therapeutic Exercise. 2011:340-356 Susan B. OSullivan, Thomas J. Schmitz. Improving Functional Outcomes in Physical Rehabilitation. 2010:43-96
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