Stroke Management And Rehabilitation

Prepared Mr. Maher Yassen AL

Madhoon

What is a stroke?

-Stroke is an acute loss of circulation to area of the brain with resultant ischaemia and loss of neuronal function.

-It is a type of cardiovascular disease.as it affects arteries leading to and within the brain .

-A stroke occurs when a blood vessel that carries oxygen and nutrients to the brain is

either blocked by a clot or bursts .When that happens, affected region in the brain cannot get the blood,O2, nutirients it needs, and cannot be cleared of waste products it has. so it starts to die.

Introduction

-Stroke is Classified as Haemorrhagic or Ischemic

-Deficits include: Weakness, sensory deficit, language difficulties.

-Recent advances in treatment have significantly improved outcome (eg. thrombolysis, 1995).

-Time is important factor in patient outcome, and current understanding of treatment options is poor.

Clinical categories of stroke

Strokes can be clinically classified Into :*ischemic stroke : accounts for more

than 80% of all strokes*Hemorrhagic stroke : represents 10-15

% of all strokes*ischemic strokes

*Transient ischemic attack (TIA)*Thrombotic CVA (Cerebral thrombosis)

*Embolic CVA (Cerebral embolism)

Controllable or treatable stroke risk factors High blood pressure — High blood pressure (140/90 mm Hg or higher) is the most important risk factor for stroke.  It usually has no specific symptoms and no early warning signs. That’s why everybody should have their blood pressure checked regularly.

Tobacco use — Cigarette smoking is a major, preventable risk factor for stroke. The nicotine and carbon monoxide in tobacco smoke reduce the amount of oxygen in your blood. They also damage the walls of blood vessels, making clots more likely to form. Using some kinds of birth control pills combined with smoking cigarettes greatly increases stroke risk.  If you smoke, get help to quit NOW!

Diabetes mellitus — Diabetes is defined as a fasting plasma glucose (blood sugar) of 126 mg/dL or more measured on two occasions. While

diabetes is treatable, having it still increases a person's risk of stroke .Many people with diabetes also have high blood pressure, high blood cholesterol and are overweight. This increases their risk even more. If you have diabetes, work closely with your doctor to manage it.

Carotid or other artery disease : A carotid artery narrowed from atherosclerosis (plaque buildups in artery walls) & may become blocked by

a blood clot. called carotid artery stenosis .peripheral artery disease : Entails a higher risk of carotid artery disease, which raises their risk of stroke. Peripheral artery disease is the narrowing of blood vessels carrying blood to leg and arm muscles. It's caused by fatty buildups of plaque in artery walls.

Atrial fibrillation: This heart rhythm disorder raises the risk for stroke. The heart's upper chambers quiver instead of beating effectively, which can let the blood pool and clot. If a clot breaks off, enters the bloodstream and lodges in an artery leading to the brain, a stroke results.

Other heart disease — People with coronary heart disease or heart failure have a higher risk of stroke than those with hearts that work normally. Dilated cardiomyopathy (an enlarged heart), heart valve disease and some types of congenital heart defects also raise the risk of stroke.

Transient ischemic attacks (TIAs) :Are "warning strokes" that produce stroke-like symptoms but no lasting damage. Recognizing and treating TIAs can reduce the risk of a major stroke. It's very important to recognize

the warning signs of a TIA or stroke .Certain blood disorders — A high red blood cell count thickens the blood and makes clots more likely. This raises the risk of stroke. Doctors may

treat this problem by removing blood cells or prescribing "blood thinners". Sickle cell disease (also called sickle cell anemia) is a genetic disorder that mainly affects African Americans. "Sickled" red blood cells are less able to carry oxygen to the body's tissues and organs. They also tend to stick to blood vessel walls, which can block arteries to the brain and cause a stroke.

High blood cholesterol — A high level of total cholesterol in the blood (240 mg/dL or higher) is a major risk factor for heart disease, which raises your risk of

stroke .Recent studies show that high levels of  LDL ("bad") cholesterol (greater than 100 mg/dL) and triglycerides (blood fats, 150 mg/dL or higher) increase the risk of stroke in people with previous coronary heart disease, ischemic stroke or transient

ischemic attack (TIA) .Low levels (less than 40 mg/dL) of HDL ("good") cholesterol also may raise stroke risk. Clotting factorsDrinking alcohol : Drinking alcoholic beverages can raise blood pressure and may increase risk for stroke.

Some illegal drugs : Intravenous drug abuse carries a high risk of stroke. Cocaine use has been linked to strokes and heart attacks. Some have been fatal

even in first-time users .Physical inactivity and obesity: Being inactive, obese or both can increase your risk of high blood pressure, high blood cholesterol, diabetes, heart disease and stroke. So go on a brisk walk, take the stairs, and do whatever you can to make your life more active. Try to get a total of at least 30 minutes of activity on most or all days

Uncontrollable or Non-treatable stroke risk factorsIncreasing age: People of all ages, including children, have strokes. But the older you are, the greater your risk for stroke.

Sex (gender): Stroke is more common in men than in women. In most age groups, more men than women will have a stroke in a given year. However, women account for more than half of all

stroke deaths .Women who are pregnant have a higher stroke risk. (WHY ?) Also women taking birth control pills or smoke or have high blood pressure or other risk factors.

Heredity (family history) and race: Your stroke risk is greater if a parent, grandparent, sister or brother has had a stroke. African Americans have a much higher risk of death from a stroke than Caucasians do. This is partly because blacks have higher risks of high blood pressure, diabetes and obesity.

Prior stroke or heart attack: Someone who has had a stroke is at much higher risk of having another one. If you've had a heart

attack, you're at higher risk of having a stroke, too .

ACUTE Stage

The goals of the treatment in acute stage are ..

a.Prevent ignorance or unawareness of the hemiplegic side

b.Decrease the tendency to develop synergy in the chronic stage

c.Prevention of any joint restriction or stiffness

d.Prevention of complications due to immobilizattion like chest complication ,deconditioning of the bone and muscles,etc .

e.Early weight bearing.

f.Psychological counselling.

g.Education to the family.

These goals can be achieved through the following treatment.

* Improving function by promoting natural recovery

* Equipping clients with new compensatory skills

* Substituting lost functions with orthotic and aides

* Prevention of complications

* Modifying clients environment to maximize independence

* Educating and training client and Family

* Modifying risk factors to prevent future strokes

General Goals of Rehabilitation

Rehabilitation should begin as soon as a stroke patient is stable, often within 24 to 48 hours after

a stroke .This first stage of rehabilitation usually occurs

inside the acute-care hospital .At the time of discharge from the hospital, the stroke patient and family coordinate with hospital social workers to locate a suitable rehabilitation arrangement. Many stroke survivors return home, but some move into some type of medical

facility .

When and Where can a stroke patient get rehabilitation?

*Direct Benefits of Early mobilization and rehabilitation therapyPrevent DVT, skin breakdown, contracture formation, constipation, and pneumonia.

It has positive psychological effects on both the patient and the family .

Direct evidence from controlled studies have shown better orthostatic tolerance and earlier improvement of ADL performance.Enhance earlier return of mental, motor, and ADL performance.

*Indirect Benefits of Early mobilization and rehabilitation therapy is suggested bythe superiority of acute care stroke units in reducing mortality and improving functional outcomes.

Early mobilization and early implementation of therapy are intrinsic components of care on stroke units and may have contributed to improved outcomes.

Benefits of Early mobilization and rehabilitation therapy

(Active Rehabilitation Phase)During this phase Clients receives His out of bed sessionsRange from 20-40 days in durationPatient master all BADL and IADLReceives all strengthening and therapeutic exercises.

Receives counseling and education from case manger, psychologist, nursing staff and other team members.

During this phase, the treatment program includes functional mobility training and appropriate therapeutic techniques .

Treatment takes place in individual as well as group sessions.PT emphasize on increasing the patient's functional mobility, areas of sensory-motor dysfunction, which include range of motion, strength/motor control, endurance, balance, and coordination, may need to be addressed at the same time.

Bed mobility: training to increase the patient's ability to move in bed; includes rolling, moving from sit to supine, and scooting.

Transfers: training to enhance the patient's ability to get from one surface to another; includes to and from wheelchair, bed, floor, car, and sit to stand.

Contra-in

Stairs: training to help the patient relearn the safest pattern or technique for ascending and descending stairs; may include using railings, bumping up or down, or using a wheelchair.

Ambulation: training to increase the patient's ability to walk with or without an assistive device as independently and safely as possible in normal movement patterns with decreased deviations in gait.

Wheelchair mobility: training to improve the patient's ability to self-propel or direct propulsion in hospital, home, and community environments; includes wheelchair parts management and breakdown, and propulsion on level and unlevel surfaces and around community barriers.

During this phase the patient's cognition and level of safety awareness can affect his or her ability to meet the long- and short- term goals therefore they should be thoroughly addressed as well.

Arrangement of the patient's room )Fig2.3(

Due to the lesion the patient suffers from sensory deprivation that leads to neglect of the hemiplegic side which can be greatly influenced by the patient's head position . Hence all the forms of the stimulus like the entrance to the room ,the relatives ,television ,etc.

Should be present on the hemiplegic side so that the patient is forced to turn to that side which will stimulate awareness of the hemiplegic side.

Positioning )Figs2.4 to 2.6(

Positioning of the patient in an appropriate way is essential to control the development of spasticity and to help in faster improvement in the later stages . Preferably the patient is positioned sidelying and supine generally avoided.

On the affected side : the shoulder should be protracted and flexed . The elbow and the wrist should be extended . The forearm should be supinated .The pelvis should be in protracted position .The hip and knee should be in slight flexion and the ankle should be in neutral position.

On the sound side :The arm should be rested on the pillow kept in front of the patient. The shoulder girdle should be kept in protraction and slight elevation .The shoulder is kept in slight abduction and flexion with the elbow and wrist in extension position .The forearm should be in supine position .The pelvis should be kept in protraction the hip should be slightly abducted and flexed.the knee should be slightly flexed and the ankls should be in neutral position

It should be noted that the finger should be kept in extension and the web space maintained on both the above occasion.

Supine position is avoided as the primitive reflexes are active and also change of pressure sores are increased . In case supine position is given then the head should be kept in midline on pillow.

Pillow should be kept under the shoulder girdle to keep it protracted the shoulder is kept in abducation and external rotation ,the forearm in supination ,the elbow is extended ,wrist and finger extended

A pillow is kept under the pelvis ,leg kept in neutral rotation the ankle maintained in neutral position ,I e .90degree of dorsiflexion by a pillow and the hip is kept in slight abduction.

Correct positioning is necessary to control the development of spasticity and also to mininmize the influence of synergy in spasticity stage.

Mobilization and StretchingDuring flaccid stage mobilization in the from of gentle passive exercises and stretching of various biarticular muscles should be given as they are very prone to develop tightness.Thus muscles like tendon achilles ,hamstring ,quadriceps ,adductors ,tensor fascia lata,biceps ,wrist flexors ,etc ,should be stretched .Passive exercises should be given of all the movements to all the joints for at least 10 repetitions three to four times in a day

Some forms of splints may be given to maintain the body parts in the desired position.

Commonly dorsiflexion splint or L splint may be given to prevent the foot from going into plantar flexion attitude.

Similarly wrist extension splint is given to maintain the wrist and the fingers in extension position.

Care should be taken to maintain the first web space.

Weight- bearing activities )Fig 2.7(Weight- bearing activities )Fig 2.7(

Weight bearing exercises are necessary to promote development of tone in the muscles and also to maintain the absorption of calcium into the bones . Thus the patient should be given activities like bridging supine on elbows sitting with weight bearing on the affected arm and standing should be given as soon as possible with in the limitation lf the patients general medical status.

Subluxtion of the glenohumeral joint is a very common complication in stroke patient which canbe be prevented by proper positioning andhandling .some form of support may be given to prevent distraction

Fig.2.7..weight-bearing through affected upper limb

Positioning and handling .some from of support may be given to prevent distraction of the joint when the patient assumes an erect

position…generally a shoulder sling or bobath splint is given to prevent this complication .skillful taping also helps in preventing the subluxation vary effectively and in addition also gives room for free movement .it also gives tactile feed back which helps in faster development of tone in the shoulder muscles. Wight bearing exercises for the involved upper limb has also been found to be beneficial in preventing this .shoulder sling is usually avoided as it facilitated the hemiplegic attittude.which the patient may develop in later stages

Blood supply to the BrainSupply to Brain , Face and Scalp is via Rt & Lt Common Carotid and Vertebral arteriesInt. Carotid supplies Anterior 3/5 of Cerebrum except parts of Temp/ Occip lobes.

Decreased flow = frontal lobe symps. (opp body side)Vertebro-basilar supplies post 2/5 of cerebrum, cerebellum and brainstem.Decreased flow = blindness , paralysis, etc.

Transient ischemic attack (TIA)A short-term stroke that lasts for less than 24 hours (Mini-stroke). The oxygen supply to the brain is restored quickly, and classical symptoms of the

stroke disappear completely .A transient stroke needs prompt medical attention as it is a warning of serious risk of a major stroke

Thrombotic CVA (Cerebral thrombosis)60%of all ischaemic strokes :

70% large vessel, 30% small or lacunar vessel.In situ occlusions on atherosclerotic lesions. Typically proximal to major branches.

Thrombogenic factors :Injured endothelial cellsPlatelet activation by sub endotheliumActivated clotting cascade

Inhibition of fibrinolysis and blood stasisFrequently originate from ruptured atherosclerotic plaques but in younger patients always consider : Coag disorders, SC disease, arterial dissection and vasoconstriction secondary to substance abuse.

occurs when a blood clot (thrombus) forms in an artery (blood vessel) supplying blood to the brain .

Furred-up blood vessels with fatty patches of atheroma (arteriosclerosis) may make a thrombosis more likely. The clot interrupts the blood supply

and brain cells are starved of oxygen .

Embolic Strokes.20% of all Ischaemic strokes

Cardiac: AF, recent MI, prosthetic valves, valve disease, endocarditis, mural thrombus, dilated cardiomyopathy.

Arterial: atherothrombolic or cholesterol emboli from extra cranial arterial tree.Very sudden onset

Neuro imaging may show previous infarcts in several vascular territories.

Intra-cerbebral and subarachnoid hemorrhageSubarachnoid hemorrhages: occurs when a blood vessel on the surface of the brain ruptures and bleeds into the space between the brain and the

skull (but not into the brain itself) .Subarachnoid hemorrhages account for about 7% of all strokes.

Intracerebral hemorrhage : is another type of stroke occurs when a defective artery or aneurysmin the brain bursts, flooding the surrounding

tissue with blood .Account for about 10-15 % of all strokes.

Higher mortality rateSimilar presentation : headachelowered GCSseizures, nausea and vomitingraised blood pressureBleed into parenchyma: leakage from small arteriesanticoagulationbleeding diathesescerebral amyloidosiscocaine abuseCommon sites = thalamus, putamen, cerebellum and brainstem

Raised ICP and pressure effects.

Intra-cerbebral and subarachnoid hemorrhageSubarachnoid hemorrhages: occurs when a blood vessel on the surface of the brain ruptures and bleeds into the space between the brain

and the skull (but not into the brain itself) .Subarachnoid hemorrhages account for about 7% of all strokes.

Intracerebral hemorrhage : is another type of stroke occurs when a defective artery or aneurysmin the brain bursts, flooding the surrounding

tissue with blood .Account for about 10-15 % of all strokes.

Higher mortality rateSimilar presentation : headachelowered GCSseizures, nausea and vomitingraised blood pressureBleed into parenchyma: leakage from small arteriesanticoagulationbleeding diathesescerebral amyloidosiscocaine abuseCommon sites = thalamus, putamen, cerebellum and brainstem

Raised ICP and pressure effects .Intraventricular Hemorrhage

General Stroke Warning SignsSudden weakness or numbness of face/arm & leg on one side of bodySudden dimness or loss of vision in only one eyeSudden loss of speech or trouble understanding speechSudden, severe headaches w/o causeUnexplained dizziness, unsteadiness or fallsSigns of a Stroke Acute Hemiparesis, Monoparesis or QuadriparesisComplete or Partial Hemianopia, Monocular or Binocular visual loss, or Diplopia.

Dysarthria or AphasiaAtaxia, Vertigo or NystagmusSudden decrease in consciousness.

Establishing time of onset is critical , especially if considering thrombolytic therapiesCincinnati Prehospital Stroke Scale

3 Components:Facial droop (ask patient to show teeth and smile)Arm drift (ask patient to extend arms, palms down, with eyes closed)Speech (ask patient to repeat long sentence and observe slurring)

Cincinnati Prehospital Stroke Scale3 Components:

Facial droop (ask patient to show teeth and smile)Arm drift (ask patient to extend arms, palms down, with eyes closed)Speech (ask patient to repeat long sentence and observe slurring)

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