Stroke: Background

Etiology/Patho  Caused by irreversible infarction

 Results in circumscribed infarction primary damage where ischemic tissues are damaged
 Perimeter of increased pressure due to inflammation (secondary damage that surrounds
initial trauma
 Most damaging results of vascular occlusion are produced by secondary damage -
adequate medical tx sooner helps this
Clinical  Characterized by sudden onset focal neuro deficits
Presentation  Mc in arms and face
 Sudden weakness numbness or paralysis of the face or extremities
 Sudden dimness or loss of vision (1 eye mc)
 Loss of speech difficult understanding speech
 Sudden sever HA with no cause
 Unexplained dizziness or unsteadiness of falls particularly if the y occur with any of the
above symptoms
 Hemiplegia (hemiparesis + hemi sensory impairment) is the hallmark finding of stroke
 The great vulnerability of the brain to ischemic damage is due to its dependence on
aerobic metabolism
o Glucose is only fuel source utilized
o Cannot make sufficient ATPT via anaerobic mechanisms
o Severely damaged by oxygen deprivation even for a short period of time
Epidemiology  800,000/year new or recurrent - 600,000 a re first attacks; 200,000 are recurrent
 Incidence increases with age (doubles every decade after age 65)
 CVA costs $36..5 billion/yr
 Leading cause of long-term disability
 4th leading cause of death in the US
 16% are fatal
 Af Amer are 2x more likely than Caucasians to have a stroke
 Af Amer are more likely to have more severe strokes/die from them
Recurrence  7-10% per year highest in first year after the first stroke
 Risk of stroke increases 10 times after first stroke
 Recurring strokes produce larger lesions (cumulative effects), greater cortical
involvement, greater impairment, higher mortality
 Outcome and pattern of recovery is similar to first time stroke
 Should receive similar rehab treatment as first-time stroke
CVA Morbidity The following disabilities were observed at 6mo post-stroke
 50% one sided paresis
 35% depressive symptoms
 30% unable to walk without assistance
 26% dependent in ADLs
 26% institutionalize din nursing home
 19% aphasia (trouble speaking or understanding)
Domains Motor Language Affect
affected by
Sensory Cognition Vision
stroke
Natural  Stage of recovery for most people of have a stroke
history of  First 3-4 mo - most capabilities return rapidly
recovery  3mo to 1yr - recovery may continue at a much slower rate
(graph)  After 1yr post stroke it is less likely that the deficits will resolve
Pattern of  Rate is typically the same for both sides but determined by how much damage is
recovery caused
 Window of repair is typically the same

 Initially - Hypotonia/flaccidity (LMN signs)

 due to interruption of UMN input to LMN
 No motor arm to contract the mm if you loose the LMN
 Days to weeks - hypertonia/spasticity (UMN signs)
 Due in part to
o Decreased excitation threshold in alpha LMN
o Changes in membrane receptors
o Denervation super sensitivity
o Changes in mm fibers (don’t worry about this)
o Altered MSR (mm spindle reflex - stretch stimulus with contraction response - UMN sign
is hyperreflexia - loss of UMN inhibition)
o Uninhibited UMN pools from ventromedial system input
 Ventromedial input - automate balance and posture - dorsolateral system checks this
Stroke in the  Characterized by (for most of the population assuming that they are LEFT hemisphere
Dominant dominant - opposite for someone who is RiGHT hemi domia
Hemisphere  Right hemiparesis
 Right sensory loss - Hemiplegia= hemiparesis + hemi sensory impairment
 Disturbances of language and temporal ordering
o Expressive/Broca's aphasia
o Receptive/Wernicke's aphasia
 Motor and ideational apraxia
o Cant sequence actions properly to reach a goal
o Ideational - visual or spatial constructs
o Not directly related to mm
 Difficulty initiating and sequencing tasks
 Delays in information processing
 Compulsive behavior with easy frustration
 Extreme distractibility
 Likely to have depressive sx
 Dominant hemisphere is determined where the Wernicke's and Broca's speech areas are
(80% have it in the L frontal gyrus and are L hemisphere dominant)
Non dominant  Left hemiplegia
Hemisphere  Disturbance of spatial orientation
 Left unilateral neglect syndrome - neglect everything to that side of their body
 Ability to perceive be aware of sensory input is lost even though sensory systems are in
tact
 Impairment of hand eye coordination, figure ground discrimination form constancy
 Dressing and constructional apraxia
 Poor judgement, impulsive - must be
  Unrealistic expectations
 Denial of disability - contributes to poor outcome

Right brain damage Left brain damage

 Left hemiplegia  R hemiplegia
 Left neglect  Impaired speech
 Spatial perceptual language and
deficits aphasia
 Tends to deny or
minimize problems
 Rapid performance
short attn span
 Impulsive safety
problems
 Impaired time
concepts and
judgment

Stroke: Rehab
Three domains  Mobility (PTs)
of Stroke  bed mobility, transfers, ambulation, stairs, wheelchair mobility, balance (
Rehab sitting, standing, walking)
 More LE
 ADLs (OTs)
 Grooming, dressing, toileting, fine motor control, cognition
 More UE
 Speaking/swallowing (SLPs)
 Speech production and comprehension, swallowing cognition
 Aphasia and dysphagia
Settings  Acute in patient hospital
 Assessment of overall function/mobility
 Initial rehabilitation and discharge planning
 Acute rehabilitation (in patient)
 Intense rehabilitation (3hr/day must be tolerated ) PT/OT/SLP - must need at
least TWO of these services to be accepted
 Pt with highest recovery potential, appropriate insurance
 Skilled nursing facility
 Less intense rehab (maybe only one service and shorter duration <3hr)
 Pt with lower recovery potential, insurance issues
 Willingness to work
 Outpatient Rehabilitation
 For pt D/C'd home, this therapy continues their rehab progression
 Severe debilitation - cant leave the home easily
Rehab team  PA/MD
 In charge of overall medical care
 Medically stable pt dC with input of the team
  Nursing
 Works most losely with pt knows PMHx
 PT/OT/SLP
 Direct physical and mental rehab
 Seess for accomodations of home
 Make discharge
 Case manager
 Coordination of care
PT  Bed mobility
interventions  Getting In/out
 Rolling over
 Adjusting positions in bed
 Transfers
 Moving from surface to surface
o Sitting to standing
o W/C to toilet
o In out of car
 Likely decrease balance, training using AD (Rw hemi walker quad cane
 Likely intact in pts with R side probs LE and trunk control most important
 Ambulation
 Normalizing gait pattern
o Training with least supportive aAD thaa allows pt to maintain balance
RW first hemi quad then single cane
o Higher level ambulation (stairs, curbs, uneven surfaces)
 Use of assistive devices
 Therapeutic exercises
 Strengthening and ROM for LE, Trunk and UE
 Endurance
 Nustep - like elliptical in reclined position
 Ambulation for distance stair training
 Functional activities
 Ambulation
 Balance training (sitting, standing ,dynamic)
 Stairs, curbs, outside ambulation
 Facilitation activities
 Special techniques to facilitate regaining mm performance, coordination
 "break down" part of a task to allow practice for individual actions to help
reprogram motor plan
 Ambulatory assistive devices -based on distance between and number of points
of contact with the ground
 Single point canes
 Quad canes
 Hemi walkers - can only use on one side of the body - good if one sided
paralysis/hemiplegia
 Walkers
o Standard vs front wheeled
 Wheeled - PT can hold and push following behind the patient
 Best for helping to reestablish the normal gait pattern
  Rollators - not very stable has four wheels - best if high level
functioning but pt lacks endurance

Cerebral AA Supply and Deficits

MCA  Frontal  UE
(MC infarct for stroke -  Temporal  Face
more widespread deficits  Parietal  Speech
larger supply area to the  Occipital  Trunk
brain)  Full
Red area in slide picture hemiplegia

ACA Medial aspect of the LE
two cerebral
hemispheres
PCA Occipital Visual (not motor)
Secondary Sensory
areas