1

Stroke Rehabilitation: Contemporary Physical Therapy Management

Session 3

Yamaguchi University – Dept of Physical Therapy31 August – 3 September, 2009Dr. Julie Ekstrum, PT, DPT, CCS

2

Cerebrovascular Accident (CVA): Pathology and

PresentationSession 3

Dr. Julie Ekstrum, PT, DPT, CCSCardiovascular & Pulmonary Clinical

SpecialistAssistant Professor of Physical Therapy

Creighton University Omaha Nebraska USAjekstrum@creighton.edu

Copyright 2009 Julie Ekstrum PT, DPT, CCS and Jennifer Furze PT, DPT

3

Upon completion of the lecture the student will be able to:◦Discuss the risk factors, warning signs,

and pathology of a CVA.◦Determine the clinical presentation of

ACA, MCA, PCA, and VBA syndrome stroke.

◦Distinguish between right and left CVA symptoms and clinical presentation.

Objectives

4

Identify and apply Brunnstrom stages of recovery to a case scenario.

Determine the appropriate tests and measures including standardized assessments when working with a patient diagnosed with a CVA.

Objectives (cont)

5

CVA

Acute onset of neurologic dysfunction due to abnormal cerebral circulation with resulting brain injury.

3rd leading cause of death in USAMost common cause of disability

6

PT Diagnosis:Guide to Physical Therapist Practice◦Practice Pattern◦ Nonprogressive disorder of the CNS -Acquired in

adolescence or adulthood

CVA

7

Risks Factors for Stroke•HTN •Smoking

•High cholesterol •Overweight

•Atherosclerosis •Alcohol use

•Heart disease •Previous stroke or TIA *

•Diabetes•Age *

•Family Hx *•Race *

* Non modifiable risk factors

8

Headache Weakness or numbness Trouble speaking Vision problems Dizziness, unsteadiness

Early Warnings Signs

9

What is a CVA?

Sudden loss of brain function caused by death of brain cells (neurons)

Types:1) Ischemic stroke - interruption of blood flow by blood clot2) Hemorrhagic stroke - rupture of blood vessels

10Arterial Brain Circulation

11

Ischemic Stroke

80% of strokes Thrombotic:

◦ blood clot within cerebral arteries or branches

Embolic◦ Clot formed elsewhere

and travel

Transient Ischemic Attack (TIA)◦ Symptoms less than 24

hrs

12

Meninges ◦Purpose – suspension system◦ Layers

1. Dura Mater 2. Arachnoid mater 3. Pia mater

Spaces or Potential Spaces in between meninges

Subdural hematoma – cerebral veins tear decrease pressure, slower onset of symptoms

- epidural hematoma – meningeal arteries tear and bleed Increase ICP = foramen magnum = brainstem dysfunction

Neurobiology Review

13

Hemorrhagic Stroke20% of strokes

Uncontrolled bleeding in the brain Interruption of the blood flow -

distal Flooding = Increased ICP

Subarachnoid hemorrhage◦ Aneurysm in walls of large

blood vessels Intracerebral hemorrhage

◦ Rupture of cerebral blood vessel

14

Hemorrhagic Stroke

Structural problems with the blood vessels in the brain

Linked to chronic hypertension Aneurysms:

◦ weakening in blood vessel wall => dilation

Arteriovenous malformation (AVM): ◦ Developmental

abnormalities with arteries connected to veins by thin-walled vessels => rupture

15

Type Time elapsed

SeverityAge and general status

Surgery Drug therapy Non-surgical procedures Rehabilitation

Medical Management for Stroke

16

To remove blood clot To repair blood vessel To remove plaque from carotid artery

◦ Carotid endarterectomy◦ Blocked > 70%◦ TIA or stroke

Surgery

17

Thrombolytic therapy (clot busters)◦ Tissue plasminogen activator (t-PA)◦ ISCHEMIC stroke◦ Within 3 hours

Anticoagulant (heparin; coumadin) / Antiplatelet (aspirin) drugs

Medications for HTN, cholesterol etc.

Drug Therapy

18

Angioplasty◦ To widen narrowed blood vessel

Stenting◦ Wire mesh tube insertion◦ To prevent blood vessel from collapsing or

re-narrowing Coiling aneurysms

◦ Filling the blood vessel with a tiny flexible platinum coil

Non-surgical procedures

19

Clinical Presentation of a Patient post CVA

20

Middle cerebral artery (MCA)◦ Temporal, frontal, parietal

Anterior cerebral artery (ACA)◦ Frontal, parietal, basal ganglia

Posterior cerebral artery (PCA)

Vertebrobasilar artery (VBA)◦ Cerebellum ◦ Brainstem: medulla, pons

Syndrome

21

Cerebral edema (increased ICP) Contralateral spastic hemiparesis and

sensory loss Face and UE > LE Aphasia (left hemisphere) Perceptual deficits (right hemisphere) Homonymous hemianopsia (visual field

defect)

MCA Syndrome

22

LE > UE Contralateral hemiparesis Sensory loss Urinary incontinence Apraxia (corpus callosum)

ACA Syndrome

23

Thalamic sensory syndrome (pain) Homonymous hemianopsia Visual agnosia Cortical blindness if bilateral Amnesia (temporal lobe)

PCA Syndrome

24

Locked-in syndrome◦ Tetraplegia◦ Preserved consciousness & sensation◦ Vertical gaze (only voluntary movement)

Cerebellar and cranial n. impairments

VBA (Locked-In) Syndrome

25

Clinical Presentation

CVAPaint a picture…..

26

Motor deficits◦ Abnormal synergy patterns◦ Abnormal tone◦ Abnormal reflexes◦ Paresis◦ Coordination deficits◦ Impaired balance

Pain Visual field deficits

◦ homonymous hemianopsia

CVA

27

Quick, impulsive behaviorsSafety / judgement / unaware of impairments

Difficulty processing visual cuesPerceptual deficits◦Disturbance in body image and body scheme

◦Neglect

Right CVA

28

Slow, cautiousAware of impairments/ realistic

Difficulty processing verbal cues

Aphasia

Left CVA

29

Cognitive Behavioral Communication Perceptual Visual: hemianopsia Neuromuscular

Systems Potentially Involved

30

Cognitive and Behavioral Deficits

31

Receptive aphasia◦ -

Expressive aphasia◦ -

Motor speech/dysarthria◦ -

Auditory deficits◦ -

Communication Deficits

32

Assess unilateral neglect (hemispace)

Perceptual Deficits

33

Apraxia: ◦ Inability to perform purposeful movement

Spatial relationship◦ Eg. Right-left discrimination

Somatoagnosia◦ Impairment in body scheme

Perceptual Deficits

34

Tone – flaccidity or spasticity

Sensory deficits

Neuromuscular Deficits

35

Motor control deficits◦CoordinationTimingSpeedAccuracy Initiation / termination

◦Motor planning

Neuromuscular Deficits

36

Balance◦ Static, dynamic◦ Sitting, standing◦ Motor strategies◦ Berg, POMA

Hemiparesis◦ ROM◦ Strength – agonists and antagonists◦ Synergies – stage of recovery

Neuromuscular Deficits

37

Functional mobility◦Bed mobility ◦Transfers◦Locomotion

Functional Assessment

38

Contractures Mobility deficits Decreased endurance Infection / Pneumonia Deep vein thrombosis (DVT) Shoulder subluxation / pain Shoulder-hand syndrome

◦ (Reflex Sympathetic Dystrophy - RSD)

Secondary Impairments/Body Function Limitations

39

Patient and family Physician Speech/language pathologist OT PT Nurse Case manager Medical Social Worker Neuropsychologist Recreational therapist

Rehabilitation Management

40

Risk factors Arterial circulation Clinical syndromes

◦ ACA, MCA, PCA◦ Right vs left

Clinical presentation Brunnstrom stages of recovery PT EXAMINATION

Summary

Thanks to Dr. Jennifer Furze PT, DPT from Creighton University for sharing content for this lecture

Copyright 2009 Julie Ekstrum PT, DPT, CCS and Jennifer Furze PT, DPT

Special Thanks and Credit