Cerebral vascular accident (stroke)

Objective:
*Definition of CVA * Statistics * Types of Stroke * Causes of stroke * Early warning signs of stroke * Stroke Risk Factors * Medical Examination of CVA * How to check stroke * Common sites for lesions to occur are at * CLINICAL FINDINGS * Direct & Indirect Impairments of Stroke * Rehabilitation * Strokes outcomes

Definition of CVA:

Stroke or CVA is an acute onset of neurological dysfunction due to an abnormality in cerebral circulation with resultant signs and symptoms that correspond to involvement of main areas of the brain. It can be ischemic (80%), typically resulting from thrombosis or embolism, or hemorrhagic (20%), resulting from vascular rupture (eg, subarachnoid or intracerebral hemorrhage).

Statistics:

CVA is the third most common cause of death after heart disease & cancer. It is the most important cause of sever disability in people. 500,000 CVAs in USA per year. 150,300 death from CVA or complications. 30% die in acute stage. 30% - 40% severely disabled.

Types of Stroke:

* Transient Ischemic attack (TIA) : it is called also ministroke. It is a short term stroke that lasts for less than 24 hours. The oxygen supply to the brain is quickly restored & symptoms disappear. It needs prompt medical attention as it indicates a serious risk of major stroke.

* Cerebral Thrombosis: When blood clot, it forms thrombus in an artery that supplies blood to the brain so it make blockage & prevent blood flowing to the brain & causes starvation of oxygen in the brain cells.

* Cerebral embolism: is blood clot that forms elsewhere in the body before travelling through the blood vessel & lodging in the brain. It starves cells of oxygen as it cause occlusion of an artery supplying blood to the brain. Note: Both embolic & thrombotic stoke are kinds of ischemic stroke. Thrombosis is progressive occlusion while Embolism is sudden occlusion. * Cerebral hemorrhage: is when a blood vessel bursts inside the brain & bleeds.

Causes of stroke
1) vascular problems: Thrombotic Embolic Haemorrhagic. 2) Infective: Encephalitis Brain abscess Menegitis 3) Neoplastic: Meningioma Gliomas

4) Traumatic : Cerebral laceration Epidural haematoma Subdural haematoma 5) Congenital: Cerebral palsy Congenital aphasia

Early warning signs of stroke:

Sudden severe headaches with no known cause. Sudden weakness or numbness of the face, arm or leg on one side of the body. Loss of speech, or trouble talking or understanding speech. Sudden dimness or loss of vision, particularly in only one eye. Unexplained dizziness, unsteadiness or sudden falls. Confusion. May be vomiting, convulsion, & involuntary urination or defecation.

Stroke Risk Factors:

Increased age. Men> Women. Genetic predisposition. Elevated hematocrit Transient ischemic attacks. Diabetes Mellitus Cardiac surgery ( Heart diseases) Smoking Unbalanced diet ( Obesity) Estrogen-containing contraceptive pill Blood disorders such as polycythemia, sickle-cell anemia

Medical Examination of CVA?

* Brain imaging by: CT scan. MRI PET ( positron emission tomography) * Cardiac Function Tests.

MRI

CT-scan

PET

How to check stroke?

The

stoke association suggest the face-arm-speech test: *Facial weakness: can person smile? Has the mouth or eye drooped. *Arm weakness: can the person raise both arms? *Speech problems: can the person speak clearly & understand you?

Factors that determine the severity of neurological deficits that results from CVA:

Location and extent of lesion Amount of collateral blood supply Early acute care management

Common sites for lesions to occur are at:

Origin of common carotid artery Common carotid artery transition into MCA Main bifurcation of MCA Junction of vertebral arteries with the basilar artery

CLINICAL FINDINGS
The

main neurological deficit resulting from any type of stroke is a reflection of the size and location of the lesion and the amount of collateral blood flow. The symptomatology will depend on the rapidity of occlusion. Unilateral neurological deficits results from interruption of the carotid vascular system whereas bilateral neurological deficits usually results from interruption of blood supply to the basilar system

Direct & Indirect Impairments of Stroke:

Direct

impairments of Stroke: 1) Somatosensory deficits: Sensation is frequently impaired ( hypothesia or hyperthesia) but rarely absent on the hemiplegic side. It can include superficial or deep loss of sensation. The type and extent of the deficit is related to 1- location of lesion. 2extent of lesion. Pattern is usually face>U.E>L.E

2) Pain: Caused by: *severe headache *damage of the superficial sensation resulting in pain *muscle imbalances. 3) Visual deficits: Include: *PCA occlusion *Diplopia *vertigo

4) Motor deficits:
Alteration in tone: *starts with flaccidity and continues to spasticity. Abnormal reflexes. Muscle paresis: * due to changes in motor control areas of the brain ( pyramidal track, cerebellum, central motor region of the frontal lobe) Or due tolack of mobility. Disturbances in postural control and balance: *both static and dynamic balance will be compromised. Due to motor and sensory dysfunction

4) Speech and language disorders:

if lesion in: *Dominant hemisphere =aphasia. *Brocas area =expressive aphasia *Wernicks area =receptive aphasia. *Both areas =global aphasia. *Primary motor cortex in the frontal lobe, or the primary sensory cortex in the parietal lobe of in the cerebellum=Dysarthia

5) Dysphagia. 6) Cognitive dysfunction. 7) Affective disorders: * either will become emotionally liable to others or aggressive. 8) Seizures 9) Bladder and bowel dysfunction: *due to involvement of areas controlling the bladder of due to hyper/ hyporeflexia of the bladder

Indirect impairments of Stroke:

1) Skin Breakdown: due to pressure, friction, shearing, maceration. 2) Decreased flexibility. 3) Shoulder sub-laxation. 4) Functional disability.

CEREBRAL VASCULAR ACCIDENT

TREATMENT TECHNIQUES

Rehabilitation may consist of various types of therapy including: Physiotherapy to improve muscle control, co-ordination and balance speech therapy to retrain facial muscles and language, and help with feeding and swallowing disorders; and occupational therapy to improve handeye co-ordination and skills needed for daily living tasks, such as bathing and cooking.

Cont. Rehabilitation Team:

physicians such as a neurologist and physiatrist critical care nurses rehabilitation nurses dietitians social workers and chaplains Psychologists. case managers

What are the goals of Rehabilitation?

To

help patient to be as independent and productive as possible. To maintain and improve a person's physical condition. To prevent such secondary problems as stiff joints, falls, bedsores and pneumonia.

 With

intensive rehabilitation, an individual can resume a near normal life style.

Physical impairments tend to improve over time with specialized physical therapy treatment.

Treatment should reflect INDIVIDUALITY.

Typical Time History for stroke Rehabilitation: Acute Stage:

Definition:
The immediate period the CVA Typical Management: Provide communication & explanation for the pt. Concentrate on basic problems such as respiratory function , cough & swallowing. Routine skin care, Joint care Positioning

Intermediate Stage:

Definition:
The period with commences once the patients ,is medically stable, conscious, & actively engaged in rehabilitation team.

Typical Management:
Active engagement in PT intervention plan. Formulation of self adherence treatment strategies.

Discharge And Transfer Stage:

Definition:
The period immediately prior to & following discharge from formal Rehabilitation.

Typical Management:
Modification

of pts environment. Management of transfer of skills between environments. Monitor self treatment strategies.

Rehabilitation Interventions:
Motor Control training: Use of facilitation approaches,which include:

Neurodevelopmental technique (NDT): Concept: stroke patients have abnormal reflexes and poor postural control. Aim: 1- promote normal postural reaction (equilibrium, righting). 2- Inhibit abnormal tonic reflexes. Movement therapy in Hemiplegia: Aim: relearn movement control through functional activity. PNF: Compensatory Training (Functional) Approach: Aim: resume functional activity by the use of the uninvolved or less involved side. concept 1)learning new pattern of movement 2) modification of the environment.

Physiology of PNF stretching

The mechanism for PNF stretching relies effectively on being able to switch off protective muscle sensors, proprioceptor cells. Within muscle cells are muscle spindles that assess how fast and how far a particular muscle is being stretched. When activated this spindle produces a stretch reflex that results in the muscle contracting to prevent the joint from overstretching. A second sensor is involved in PNF stretching, the Golgi Tendon Organ which measures how much tension is being placed on a particular tendon. When the Golgi Tendon Organ is activated then it relaxes the muscle associated with the tendon.

When the muscle is contracted (whilst in a stretched state) the tension generated by the contraction activates the golgi tendon organ. Voluntary contraction during a particular stretch raises tension on the muscle, switching on the golgi tendon organs more than just stretching. When the contraction phase finishes, the muscle is more unresponsive from contracting against the following passive stretch. Proprioceptive neuromuscular facilitation (PNF) was developed around 1950 as a method of treating paralysis and stroke patients by Herman Kabat and a couple of physical therapists Margaret Knott and Dorothy Voss. PNF stretching is considered to be the most effective method of increasing static flexibility.

PNF stretching refers to several isometric relaxation stretching approaches for which a particular muscle group is stretched (normally passively), then isometrically contracted against resistance whilst the muscle is in a stretched position and finally passively stretched through an increased range of motion. PNF stretching is usually performed with a partner who can provide resistance against the isometric contraction. After the isometric contraction then the partner can passively take the joint towards the limit of the joints range of motion. However a PNF stretch is possible without a partner. The most usually employed approach of a PNF stretching is referred to as the hold-relax method (also known as contract-relax).

PNF Techniques:
Hold Relax: most familiar. Also called Contract-Relax Involves the therapist asking the patient to fire the tight muscle isometrically against the therapist's hand for roughly 20 seconds. Then, the patient relaxes and the therapist lengthens the tight muscle and applies a stretch at the newly found end range. This technique utilizes the golgi-tendon organ, which relaxes a muscle after a sustained contraction has been applied to it for longer than 6 seconds. Verbal cues for the patient performing this exercise would include, "Hold. Hold. Don't let me move you. Contract-Relax with Agonist Contract (CRAC): Also called Hold-Relax Contract. Same as Hold-Relax, patient isometrically contracts the tight muscle against the therapist's resistance. After a 20 second hold has been achieved, the therapist removes his/her hand and the patient concentrically contracts the antagonist muscle (the muscle opposite the tight muscle, the non-tight muscle) in order to gain increased range of motion. At the end of this new range, the therapist applies a static stretch before repeating the process again.

Hold-Relax-Swing/Hold-Relax Bounce: These are similar techniques to the Hold-Relax and CRAC. They start with a passive stretching by the therapist followed by an isometric contraction. The difference is that at the end, instead of an agonist muscle contraction or a passive stretching, involves the use of dynamic stretching and ballistic stretching. It is very risky, and is successfully used only by people that have managed to achieve a high level of control over their muscle stretch reflex. Rhythmic Initiation: Developed to help patients with Parkinsonism overcome their rigidity. Begins with the therapist moving the patient through the desired movement using passive range of motion, followed by active-assistive, active, and finally active-resisted range of motion. Rhythmic Stabilization: Also known as Alternating Isometrics, this technique encourages stability of the trunk, hip, and shoulder girdle. With this technique, the patient holds a position while the therapist applies manual resistance. No motion should occur from the patient. The patient should simply resist the therapist's movements. For example, the patient can be in a sitting, kneeling, half-kneeling, or standing position when the therapist applies manual resistance to the shoulders. Usually, the therapist applies simultaneous resistance to the anterior left shoulder and posterior right shoulder for 2-3 seconds before switching the resistance to the posterior left shoulder and the anterior right shoulder. The therapist's movements should be smooth, fluid, and continuous

Plan of Treatment of Stroke Patient in the acute stage include: Positioning ROM Tone Reduction: use of common inhibitory techniques: 1- prolonged pressure 2- prolonged icing/ heating 3- prolonged stretch 4- prolonged joint approximation 5- prolonged weight bearing

 Reestablishing

postural control and improve functional mobility By:

1) Rolling 2) Supine-to-sit transitions 3) Sitting 4) Bridging 5) Sitting-to-stand transitions 6) Standing, transfers and walking.

Improve

U.E and L.E control By:

1) Weight bearing 2) functional activity 3) PNF

 Improve

Balance: (both static and dynamic). Static by: *prolonged maintenance of position.
* weight bearing.

Dynamic by:

*ball
* balance board *transitional activity

(stepping and walking)

Improve

Gait:

*Stat with side walking~~ forward~~ backward

Electrotherapeutic

Modalities:

By: EMG or NMS

Patient

and family education.

TO IMPROVE STABILITY

Exercise Techniques:
Alternating Isometrics Rhythmic Stabilization Slow ReversalHold

Vibration Resistance Joint Approximation Tapping Manual Contacts

Vibration:

TO IMPROVE SKILL
Walking - braiding Grasp and manipulate with hands

Exercise Techniques:
Slow Reversals Slow ReversalHold Timing for Emphasis Resisted Progression

TO IMPROVE MOBILITY

Exercise Techniques:

Quick Stretch Light Tough Quick Icing Light Pinching Dynamic Verbal Commands

Active Assisted Hold-Relax Active Motion Slow Reversals Agonist Reversal PNF Techniques Rhythmic Initiation Repeated Contraction

Strokes outcomes:

The outcome of rehabilitation of a CVA will be different for each patient in areas of deficit and in the amount of recovery. Some patients will recover completely from the affects of a CVA.

What do outcomes affected by?

past CVA, cardiac disease, arterial disease, venous insufficiency, respiratory disease & cognitive status (Alzheimers disease) . age & marital status . therapy for family & pt. to cope with changes in pt. status.

Conclusion:
Stroke often leaves patients with predominantly unilateral functional limitations of the arm and hand. Although recovery of function after stroke is often achieved by compensatory use of the less affected limb, improving use of the more affected limb has been associated with increased quality of life.

References:
http://en.wikipedia.org/wiki/Stroke http://www.slideshare.net/internist69/c erebro-vascular-accident-cvapresentation/ Physical Management in Neurological Rehabilitation book, Maria stokes, 2nd edition. Neurological Rehabilitation, optimizing motor performanec, janet carr,. http://www.elderoptionsoftexas.com/im ages/heartland_therapy.gif