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Stroke Rehabilitation: Contemporary Physical Therapy Management
Session 3
Yamaguchi University – Dept of Physical Therapy31 August – 3 September, 2009Dr. Julie Ekstrum, PT, DPT, CCS
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Cerebrovascular Accident (CVA): Pathology and
PresentationSession 3
Dr. Julie Ekstrum, PT, DPT, CCSCardiovascular & Pulmonary Clinical
SpecialistAssistant Professor of Physical Therapy
Creighton University Omaha Nebraska [email protected]
Copyright 2009 Julie Ekstrum PT, DPT, CCS and Jennifer Furze PT, DPT
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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
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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)
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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
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PT Diagnosis:Guide to Physical Therapist Practice◦Practice Pattern◦ Nonprogressive disorder of the CNS -Acquired in
adolescence or adulthood
CVA
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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
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Headache Weakness or numbness Trouble speaking Vision problems Dizziness, unsteadiness
Early Warnings Signs
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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
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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
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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
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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
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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
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Type Time elapsed
SeverityAge and general status
Surgery Drug therapy Non-surgical procedures Rehabilitation
Medical Management for Stroke
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To remove blood clot To repair blood vessel To remove plaque from carotid artery
◦ Carotid endarterectomy◦ Blocked > 70%◦ TIA or stroke
Surgery
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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
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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
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Clinical Presentation of a Patient post CVA
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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
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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
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LE > UE Contralateral hemiparesis Sensory loss Urinary incontinence Apraxia (corpus callosum)
ACA Syndrome
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Thalamic sensory syndrome (pain) Homonymous hemianopsia Visual agnosia Cortical blindness if bilateral Amnesia (temporal lobe)
PCA Syndrome
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Locked-in syndrome◦ Tetraplegia◦ Preserved consciousness & sensation◦ Vertical gaze (only voluntary movement)
Cerebellar and cranial n. impairments
VBA (Locked-In) Syndrome
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Clinical Presentation
CVAPaint a picture…..
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Motor deficits◦ Abnormal synergy patterns◦ Abnormal tone◦ Abnormal reflexes◦ Paresis◦ Coordination deficits◦ Impaired balance
Pain Visual field deficits
◦ homonymous hemianopsia
CVA
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Quick, impulsive behaviorsSafety / judgement / unaware of impairments
Difficulty processing visual cuesPerceptual deficits◦Disturbance in body image and body scheme
◦Neglect
Right CVA
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Slow, cautiousAware of impairments/ realistic
Difficulty processing verbal cues
Aphasia
Left CVA
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Cognitive Behavioral Communication Perceptual Visual: hemianopsia Neuromuscular
Systems Potentially Involved
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Cognitive and Behavioral Deficits
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Receptive aphasia◦ -
Expressive aphasia◦ -
Motor speech/dysarthria◦ -
Auditory deficits◦ -
Communication Deficits
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Assess unilateral neglect (hemispace)
Perceptual Deficits
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Apraxia: ◦ Inability to perform purposeful movement
Spatial relationship◦ Eg. Right-left discrimination
Somatoagnosia◦ Impairment in body scheme
Perceptual Deficits
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Tone – flaccidity or spasticity
Sensory deficits
Neuromuscular Deficits
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Motor control deficits◦CoordinationTimingSpeedAccuracy Initiation / termination
◦Motor planning
Neuromuscular Deficits
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Balance◦ Static, dynamic◦ Sitting, standing◦ Motor strategies◦ Berg, POMA
Hemiparesis◦ ROM◦ Strength – agonists and antagonists◦ Synergies – stage of recovery
Neuromuscular Deficits
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Functional mobility◦Bed mobility ◦Transfers◦Locomotion
Functional Assessment
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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
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Patient and family Physician Speech/language pathologist OT PT Nurse Case manager Medical Social Worker Neuropsychologist Recreational therapist
Rehabilitation Management
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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