Chapter 23 Stroke (Direct Text)

Question 1

EPIDEMIOLOGY AND RISK FACTORS
A stroke is defined by the WHO as the rapid development of clinical signs of cerebral dysfunction, with signs lasting at least ________ hours or leading to death with no apparent cause other than that of ________ origin. About 795,000 Americans suffer a new or recurrent stroke. This means that, on average, a stroke occurs every 40 seconds. Stroke kills more than 137,000 people a year, which is about 1 of every 18 deaths.

Answer 1

EPIDEMIOLOGY AND RISK FACTORS
A stroke is defined by the WHO as the rapid development of clinical signs of cerebral dysfunction, with signs lasting at least 24 hours or leading to death with no apparent cause other than that of vascular origin. About 795,000 Americans suffer a new or recurrent stroke. This means that, on average, a stroke occurs every 40 seconds. Stroke kills more than 137,000 people a year, which is about 1 of every 18 deaths.

Question 2

It is the No. ________ cause of death behind diseases of the ________ and ________. On average, every 4 minutes, someone dies of stroke. About 40% of stroke deaths occur in males and 60% in females. The 2006 US stroke death rates per 100,000 population for specific groups were 41.7 for white males, 41.1 for white females, 67.7 for black males, and 57.0 for black females.

Answer 2

It is the No. 3 cause of death behind diseases of the heart and cancer. On average, every 4 minutes, someone dies of stroke. About 40% of stroke deaths occur in males and 60% in females. The 2006 US stroke death rates per 100,000 population for specific groups were 41.7 for white males, 41.1 for white females, 67.7 for black males, and 57.0 for black females.

Question 3

The two major types of stroke are ________ (≈83%) and ________ (17%). On further categorizing, 32% are embolic, 31% large vessel thrombotic, 20% small vessel thrombotic, 10% intracerebral hemorrhagic, and 7% subarachnoid hemorrhagic.

Answer 3

The two major types of stroke are ischemic (≈83%) and hemorrhagic (17%). On further categorizing, 32% are embolic, 31% large vessel thrombotic, 20% small vessel thrombotic, 10% intracerebral hemorrhagic, and 7% subarachnoid hemorrhagic.

Question 4

The Framingham Heart Study data revealed 30-day survival rates to be 73% to 81% following cerebral infarction and 36% after intracerebral hemorrhage, although survival figures vary widely in the literature and have generally been improving with time. ________, ________ Americans, and the ________ are at increased risk for developing stroke.

Answer 4

The Framingham Heart Study data revealed 30-day survival rates to be 73% to 81% following cerebral infarction and 36% after intracerebral hemorrhage, although survival figures vary widely in the literature and have generally been improving with time. Males, African Americans, and the elderly are at increased risk for developing stroke.

Question 5

Modifiable risk factors include ________, ________, ________, hyperhomocysteinemia, hypercoagulable states, heart disease, carotid arteriosclerosis, substance abuse, obesity, and a sedentary lifestyle.

Answer 5

Modifiable risk factors include HTN, DM, hypercholesterolemia, hyperhomocysteinemia, hypercoagulable states, heart disease, carotid arteriosclerosis, substance abuse, obesity, and a sedentary lifestyle.

Question 6

SELECTED ISCHEMIC STROKE SYNDROMES
MCA – Deficits can include c/l ________/________ (face and arm worse than leg), c/l ________ ________, and i/l ________ preference.
With dominant hemisphere involvement, ________ aphasia (________ division of MCA to ________ area) and/or ________ aphasia (________ division of MCA to ________ area) can occur, but classically patients can learn from demonstration and mistakes. ________ syndrome (________ lobe) consists of ________ (right–left confusion), dyscalculia, finger agnosia, and dysgraphia.
With nondominant hemisphere involvement, spatial ________ and c/l ________ may be seen; insight/judgment are often affected (likely to need supervision); ADL recovery is often said to be slower.

Answer 6

SELECTED ISCHEMIC STROKE SYNDROMES
MCA – Deficits can include c/l hemiplegia/hypesthesia (face and arm worse than leg), c/l homonymous hemianopia, and i/l gaze preference.
With dominant hemisphere involvement, receptive aphasia (inferior division of MCA to Wernicke’s area) and/or expressive aphasia (superior division of MCA to Broca’s area) can occur, but classically patients can learn from demonstration and mistakes. Gerstmann’s syndrome (parietal lobe) consists of asomatognosia (right–left confusion), dyscalculia, finger agnosia, and dysgraphia.
With nondominant hemisphere involvement, spatial dyspraxia and c/l hemineglect may be seen; insight/judgment are often affected (likely to need supervision); ADL recovery is often said to be slower.

Question 7

Anterior cerebral artery (ACA) – Deficits can include c/l hemiplegia/hypesthesia (leg worse than arm; face and hand spared), alien arm/hand syndrome, urinary incontinence, gait apraxia, abulia (inability to make decisions), perseveration, amnesia, paratonic rigidity (Gegenhalten, or variable resistance to passive ROM), and transcortical motor aphasia (with a dominant hemisphere ACA lesion).

Answer 7

Anterior cerebral artery (ACA) – Deficits can include c/l hemiplegia/hypesthesia (leg worse than arm; face and hand spared), alien arm/hand syndrome, urinary incontinence, gait apraxia, abulia (inability to make decisions), perseveration, amnesia, paratonic rigidity (Gegenhalten, or variable resistance to passive ROM), and transcortical motor aphasia (with a dominant hemisphere ACA lesion).

Question 8

Posterior Cerebral Artery (PCA) – Deficits can include c/l ________ ________, c/l ________, c/l ________, c/l ________, and ________ gaze palsy.
Dominant-sided lesions can lead to ________, ________ anomia, ________ w/o agraphia, and simultagnosia (defunct perceptual analysis).
Nondominant-sided lesions can lead to ________ (cannot recognize familiar faces).

Answer 8

Posterior Cerebral Artery (PCA) – Deficits can include c/l homonymous hemianopia, c/l hemianesthesia, c/l hemiplegia, c/l hemiataxia, and vertical gaze palsy.
Dominant-sided lesions can lead to amnesia, color anomia, dyslexia w/o agraphia, and simultagnosia (defunct perceptual analysis).
Nondominant-sided lesions can lead to prosopagnosia (cannot recognize familiar faces).

Question 9

The central poststroke pain (________-________ or ________ pain) syndrome can occur with involvement of the thalamogeniculate branch.

Answer 9

The central poststroke pain (Dejerine-Roussy or thalamic pain) syndrome can occur with involvement of the thalamogeniculate branch.

Question 10

________ syndrome (penetrating branches to the midbrain) consists of i/l CN ________ palsy and c/l limb weakness).

Answer 10

Weber’s syndrome (penetrating branches to the midbrain) consists of i/l CN III palsy and c/l limb weakness).

Question 11

A b/l PCA stroke can cause ________ syndrome (________ blindness, with ________) or ________ syndrome, which consists of optic ataxia, loss of voluntary but not ________ ________ movements, and an inability to understand visual objects (asimultagnosia).

Answer 11

A b/l PCA stroke can cause Anton syndrome (cortical blindness, with denial) or Bálint’s syndrome, which consists of optic ataxia, loss of voluntary but not reflex eye movements, and an inability to understand visual objects (asimultagnosia).

Question 12

Brain Stem – The lateral medullary (________) syndrome (________ ________ cerebellar artery) consists of ________, ________, ________, dysarthria, dysphonia, i/l ________ syndrome, i/l facial pain or numbness, i/l limb ataxia, and c/l pain and temporary sensory loss.

Answer 12

Brain Stem – The lateral medullary (Wallenberg) syndrome (posterior inferior cerebellar artery) consists of vertigo, nystagmus, dysphagia, dysarthria, dysphonia, i/l Horner’s syndrome, i/l facial pain or numbness, i/l limb ataxia, and c/l pain and temporary sensory loss.

Question 13

The “locked-in” syndrome (________ artery) is due to b/l ________ infarcts affecting the ________ and ________ tracts, but sparing the ________ ________ system. Patients are awake and sensate, but paralyzed and unable to speak. Voluntary ________ and ________ gaze may be intact.

Answer 13

The “locked-in” syndrome (basilar artery) is due to b/l pontine infarcts affecting the corticospinal and bulbar tracts, but sparing the reticular activating system. Patients are awake and sensate, but paralyzed and unable to speak. Voluntary blinking and vertical gaze may be intact.

Question 14

The Anton syndrome (basilar artery) is characterized by ________ blindness with ________.

Answer 14

The Anton syndrome (basilar artery) is characterized by cortical blindness with denial.

Question 15

The ________-________ syndrome is a unilateral lesion of the ________ pons that may involve the basis pontis and the fascicles of cranial nerves ________ and ________. Symptoms include contralateral hemiplegia, ipsilateral lateral rectus palsy, and ipsilateral peripheral facial paresis. When the penetrating branches of the PCA to the midbrain get affected, it could result in ________ syndrome. Symptoms are ipsilateral characterized by the presence of an oculomotor nerve palsy and contralateral hemiparesis or hemiplegia.

Answer 15

The Millard-Gubler syndrome is a unilateral lesion of the ventrocaudal pons that may involve the basis pontis and the fascicles of cranial nerves VI and VII. Symptoms include contralateral hemiplegia, ipsilateral lateral rectus palsy, and ipsilateral peripheral facial paresis. When the penetrating branches of the PCA to the midbrain get affected, it could result in Weber syndrome. Symptoms are ipsilateral characterized by the presence of an oculomotor nerve palsy and contralateral hemiparesis or hemiplegia.

Question 16

Lacunar – The more common syndromes include pure motor hemiplegia (posterior limb ________ ________ [________]), pure sensory stroke (________ or ________ white matter), the ________-________ hand syndrome (basis pontis), and the hemiparesis-hemiataxia syndrome (pons, midbrain, IC, or parietal white matter).

Answer 16

Lacunar – The more common syndromes include pure motor hemiplegia (posterior limb internal capsule [IC]), pure sensory stroke (thalamus or parietal white matter), the dysarthria-clumsy hand syndrome (basis pontis), and the hemiparesis-hemiataxia syndrome (pons, midbrain, IC, or parietal white matter).

Question 17

“Pseudobulbar palsy” is caused by ________ IC and ________ pathway lacunes (loss of volitional bulbar motor control [e.g., dysarthria, dysphagia, dysphonia, and face weakness], but involuntary motor control of the same muscles is intact, e.g., can yawn or cough). ________ lability may be seen.

Answer 17

“Pseudobulbar palsy” is caused by anterior IC and corticobulbar pathway lacunes (loss of volitional bulbar motor control [e.g., dysarthria, dysphagia, dysphonia, and face weakness], but involuntary motor control of the same muscles is intact, e.g., can yawn or cough). Emotional lability may be seen.

Question 18

ISCHEMIC STROKE PHARMACOTHERAPY AND INTERVENTION
Guidelines for Acute Stroke Pharmacotherapy
IV tissue plasminogen activator (tPA) is indicated for acute ischemic stroke within ________ hours of symptom onset.

Answer 18

ISCHEMIC STROKE PHARMACOTHERAPY AND INTERVENTION
Guidelines for Acute Stroke Pharmacotherapy
IV tissue plasminogen activator (tPA) is indicated for acute ischemic stroke within 3 hours of symptom onset.

Question 19

Contraindications for the use of tPA are as follows:
Minor stroke symptoms.
Head CT positive for blood.
BP > ________/________ despite medical treatment
Platelets > ________ k
Blood ________ 400
Stroke/severe brain injury in past ________ months
History of IVH, arteriovenous malformation, or aneurysm
History of GI or GU ________ in past 30 days
Major ________ in past 14 days
________ at onset of stroke
Acute myocardial infarct
Coagulopathy:
1. PT > 15 seconds or INR > 1.7
2. Heparin within 48 hours prior with elevated PTT
3. Patient on warfarin

Answer 19

Contraindications for the use of tPA are as follows:
Minor stroke symptoms/tPA
Head CT positive for blood
BP > 185/100 despite medical treatment
Platelets > 100 k
Blood sugar 400
Stroke/severe brain injury in past 3 months
History of IVH, arteriovenous malformation, or aneurysm
History of GI or GU bleed in past 30 days
Major surgery in past 14 days
Seizure at onset of stroke
Acute myocardial infarct
Coagulopathy:
1. PT > 15 seconds or INR > 1.7
2. Heparin within 48 hours prior with elevated PTT
3. Patient on warfarin

Question 20

Early anticoagulation is likely to be beneficial in acute ________ and large-artery ________ strokes, in patients with severe CHF, and for progressing stroke when the suspected mechanism is ongoing thrombo-embolism. Clinical trials, in general, do not show clear benefits for SC heparin, low-molecular-weight heparin, or heparinoids in the treatment of acute ischemic stroke, but they are recommended for DVT/pulmonary embolism (PE) prophylaxis in the absence of contraindications.

Answer 20

Early anticoagulation is likely to be beneficial in acute cardioembolic and large-artery ischemic strokes, in patients with severe CHF, and for progressing stroke when the suspected mechanism is ongoing thrombo-embolism. Clinical trials, in general, do not show clear benefits for SC heparin, low-molecular-weight heparin, or heparinoids in the treatment of acute ischemic stroke,4 but they are recommended for DVT/pulmonary embolism (PE) prophylaxis in the absence of contraindications.

Question 21

Low-dose ASA (160 to 325 mg) is recommended within ________ hours for patients with acute ischemic strokes not receiving thrombolytics or anti-coagulation. ASA can be safely used with low-dose SC heparin for DVT prophylaxis.

Answer 21

Low-dose ASA (160 to 325 mg) is recommended within 48 hours for patients with acute ischemic strokes not receiving thrombolytics or anti-coagulation. ASA can be safely used with low-dose SC heparin for DVT prophylaxis.

Question 22

In general, elevated BPs in the acute period should not be aggressively managed unless mean arterial BP (which is (SBP + 2DBP)/3) > ________ or SBP > ________ mm Hg.

Answer 22

In general, elevated BPs in the acute period should not be aggressively managed unless mean arterial BP (which is (SBP + 2DBP)/3) > 130 or SBP > 220 mm Hg.

Question 23

Recommendations for Secondary Prevention
Ongoing lifestyle and medical risk factor modifications, such as those identified in the Framingham Heart Studies (a series of >1,000 papers originally identifying ________, HTN, and hypercholesterolemia among others as risk factors for cardiovascular diseases), are warranted.

Answer 23

Recommendations for Secondary Prevention
Ongoing lifestyle and medical risk factor modifications, such as those identified in the Framingham Heart Studies (a series of >1,000 papers originally identifying smoking, HTN, and hypercholesterolemia among others as risk factors for cardiovascular diseases), are warranted.

Question 24

For ________ cerebral ischemic events (strokes or transient ischemic attacks [TIAs]), one of the three following long-term prophylactic options is recommended:

1. ________ 50 to 325 mg qd;
2. ________ 25 mg bid + extended-release ________ 200 mg bid (Aggrenox);
3. ________ (________) 75 mg qd (acceptable for ASA-allergic patients).

Answer 24

For noncardioembolic cerebral ischemic events (strokes or transient ischemic attacks [TIAs]), one of the three following long-term prophylactic options is recommended:

1. ASA 50 to 325 mg qd;
2. ASA 25 mg bid + extended-release dipyridamole 200 mg bid (Aggrenox);
3. Clopidogrel (Plavix) 75 mg qd (acceptable for ASA-allergic patients).

Question 25

The CAPRIE (Clopidogrel versus Aspirin in Patients at Risk of Ischemic Events) trial demonstrated that clopidogrel is slightly better than ASA (5.33% vs. 5.83% overall incident rate) in reducing ischemic events (e.g., ________ and ________) in a study of 19,185 patients with known atherosclerotic disease (8.7% risk reduction vs. ASA, p = 0.045).

Answer 25

The CAPRIE (Clopidogrel versus Aspirin in Patients at Risk of Ischemic Events) trial demonstrated that clopidogrel is slightly better than ASA (5.33% vs. 5.83% overall incident rate) in reducing ischemic events (e.g., MI and stroke) in a study of 19,185 patients with known atherosclerotic disease (8.7% risk reduction vs. ASA, p = 0.045).

Question 26

For cardioembolic cerebral ischemic events, oral anticoagulation with a target INR of ________ (range ________ to ________) is recommended. INRs > ________ are associated with a higher risk of brain hemorrhage that outweighs the potential benefits.

Answer 26

For cardioembolic cerebral ischemic events, oral anticoagulation with a target INR of 2.5 (range 2.0 to 3.0) is recommended. INRs > 3.0 are associated with a higher risk of brain hemorrhage that outweighs the potential benefits.

Question 27

The NASCET (North American Symptomatic Carotid Endarterectomy Trial) study demonstrated a 6 to 10× reduction in the long-term risk of stroke following carotid endarterectomy (CEA) versus medical management alone for patients with recent stroke or TIA with extracranial internal carotid artery stenosis of 70% to 99%. The benefit, however, was largely dependent on the ________ of the surgeon. CEA for stenosis >70% was not supported. ASA, 81 to 325 mg qd, is recommended before and after the CEA. Guidelines for incidentally discovered asymptomatic carotid stenosis are less clear.

Answer 27

The NASCET (North American Symptomatic Carotid Endarterectomy Trial) study demonstrated a 6 to 10× reduction in the long-term risk of stroke following carotid endarterectomy (CEA) versus medical management alone for patients with recent stroke or TIA with extracranial internal carotid artery stenosis of 70% to 99%. The benefit, however, was largely dependent on the skill of the surgeon. CEA for stenosis >70% was not supported. ASA, 81 to 325 mg qd, is recommended before and after the CEA. Guidelines for incidentally discovered asymptomatic carotid stenosis are less clear.

Question 28

Patent foramen ovale (PFO) is relatively common in the general population, but its prevalence is higher in patients with ________ stroke (i.e., stroke with no identifiable cause). Importantly, paradoxical embolism through a PFO should be strongly considered in young patients with cryptogenic stroke. There is no consensus on the optimal management strategy, but treatment options include antiplatelet agents, warfarin sodium, percutaneous device closure, and surgical closure.

Answer 28

Patent foramen ovale (PFO) is relatively common in the general population, but its prevalence is higher in patients with cryptogenic stroke (i.e., stroke with no identifiable cause). Importantly, paradoxical embolism through a PFO should be strongly considered in young patients with cryptogenic stroke. There is no consensus on the optimal management strategy, but treatment options include antiplatelet agents, warfarin sodium, percutaneous device closure, and surgical closure.

Question 29

POSTACUTE MEDICAL COMPLICATIONS
The major causes of death poststroke are the stroke itself (i.e., progressive cerebral ________ and ________), ________, ________ disease, and ________ ________. Complications noted during the postacute stroke rehabilitation period include pneumonia and pulmonary aspiration (51% to 78%), falls (22% to 73%), urinary incontinence (37% to 79%), DVT (up to 45%), musculoskeletal pain, and central poststroke pain.

Answer 29

POSTACUTE MEDICAL COMPLICATIONS
The major causes of death poststroke are the stroke itself (i.e., progressive cerebral edema and herniation), pneumonia, cardiac disease, and pulmonary embolism. Complications noted during the postacute stroke rehabilitation period include pneumonia and pulmonary aspiration (51% to 78%), falls (22% to 73%), urinary incontinence (37% to 79%), DVT (up to 45%), musculoskeletal pain, and central poststroke pain.

Question 30

Urinary incontinence typically improves but may still be present in 15% to 20% after ________ months. Treatment can include ________-________, fluid intake regulation, and treatment of UTIs.

Answer 30

Urinary incontinence typically improves but may still be present in 15% to 20% after 6 months. Treatment can include timed-voiding, fluid intake regulation, and treatment of UTIs.

Question 31

________ subluxation, seen in 30% to 50% of patients, may play a role in poststroke shoulder pain. Arm trough or lapboard use while sitting, stretching of the shoulder depressors/internal rotators, and avoiding pulling on the affected arm during transfers can be key aspects of management during the early rehabilitation phase. If spasticity becomes severe, a ________ phenol/botulinum toxin injection can sometimes be helpful.

Answer 31

Glenohumeral subluxation, seen in 30% to 50% of patients, may play a role in poststroke shoulder pain. Arm trough or lapboard use while sitting, stretching of the shoulder depressors/internal rotators, and avoiding pulling on the affected arm during transfers can be key aspects of management during the early rehabilitation phase. If spasticity becomes severe, a subscapularis phenol/botulinum toxin injection can sometimes be helpful.

Question 32

Factors that predict transfer to acute medical facilities are elevated admission ________ count, low admission ________ level, greater neurologic deficit, and history of cardiac arrhythmia.

Answer 32

Factors that predict transfer to acute medical facilities are elevated admission WBC count, low admission hemoglobin level, greater neurologic deficit, and history of cardiac arrhythmia.

Question 33

MOTOR RECOVERY FOLLOWING STROKE
Twitchell gave the first systematic clinical description of motor recovery following stroke. In particular, tone and “________” movements, characterized by a tight coupling of movement at adjacent joints (later termed “________” by Brunnstrom), were noted to develop before isolated voluntary motor control was reestablished. In addition, it was noted that motor control returned ________ before ________ and ________ function recovered earlier and more completely than ________ function.

Answer 33

MOTOR RECOVERY FOLLOWING STROKE
Twitchell gave the first systematic clinical description of motor recovery following stroke. In particular, tone and “stereotypic” movements, characterized by a tight coupling of movement at adjacent joints (later termed “synergy” by Brunnstrom), were noted to develop before isolated voluntary motor control was reestablished. In addition, it was noted that motor control returned proximally before distally and LEx function recovered earlier and more completely than UEx function.

Question 34

Poor prognostic indicators included severe proximal spasticity, proprioceptive facilitation response not present by 9 days, onset of movement at >2 to 4 weeks, absence of voluntary hand movement at 4 to 6 weeks, or a prolonged flaccid period. Full recovery, when it occurred, was usually complete within 12 weeks (Fig. 23-1).

Answer 34

Poor prognostic indicators included severe proximal spasticity, proprioceptive facilitation response not present by 9 days, onset of movement at >2 to 4 weeks, absence of voluntary hand movement at 4 to 6 weeks, or a prolonged flaccid period. Full recovery, when it occurred, was usually complete within 12 weeks (Fig. 23-1).

Question 35

Brunnstrom later formalized the stages of motor recovery:

1. ________ limb.
2. Some ________ with weak flexor and extensor ________.
3. Prominent ________; voluntary motion occurs within synergy patterns .
4. Some selective activation of muscles outside of synergy patterns. Spasticity reduced.
5. Most limb movement independent from limb ________; spasticity further reduced but still present with ________ movements.
6. Near-normal ________ with isolated movements.
7. Restoration to normal.

Answer 35

Brunnstrom later formalized the stages of motor recovery:

1. Flaccid limb.
2. Some spasticity with weak flexor and extensor synergies.
3. Prominent spasticity; voluntary motion occurs within synergy patterns.
4. Some selective activation of muscles outside of synergy patterns. Spasticity reduced.
5. Most limb movement independent from limb synergy; spasticity further reduced but still present with rapid movements.
6. Near-normal coordination with isolated movements.
7. Restoration to normal.

Question 36

NEUROPHYSIOLOGICAL THERAPIES
Neurodevelopmental approach/Bobath approach:
The most commonly used approach (“hands-on” approach, touch and pressure applied by therapist). The goal is to normalize ________, inhibit ________ patterns of movement, and facilitate selective automatic, voluntary reactions and subsequent normal patterns. Suppress abnormal muscle patterns, which is contradictory to ________ approach. Proximal key points include shoulders and pelvis; distal key points include upper and lower extremities (typically the hands and feet).
Focuses on the relationship between sensory input and motor output.

Answer 36

NEUROPHYSIOLOGICAL THERAPIES
Neurodevelopmental approach/Bobath approach:
The most commonly used approach (“hands-on” approach, touch and pressure applied by therapist). The goal is to normalize tone, inhibit primitive patterns of movement, and facilitate selective automatic, voluntary reactions and subsequent normal patterns. Suppress abnormal muscle patterns, which is contradictory to Brunnstrom’s approach. Proximal key points include shoulders and pelvis; distal key points include upper and lower extremities (typically the hands and feet).
Focuses on the relationship between sensory input and motor output.

Question 37

Proprioceptive neuromuscular facilitation (PNF)
Developed by Kabat in the 1940s for the treatment of paralysis. Knott and Voss applied PNF to all types of therapeutic exercises and began presenting the technique in workshops in 1952.
It is often a combination of passive ________ and ________ contractions.
Uses ________ and ________ components of movement with the goal of facilitating movement patterns that will have more functional relevance than the traditional technique of strengthening individual group muscles.
Resistance is used during spiral and diagonal movement patterns with the goal of facilitating irradiation of impulses to other parts of the body associated with the primary movement.

Answer 37

Proprioceptive neuromuscular facilitation (PNF)
Developed by Kabat in the 1940s for the treatment of paralysis. Knott and Voss applied PNF to all types of therapeutic exercises and began presenting the technique in workshops in 1952.
It is often a combination of passive stretching and isometric contractions.
Uses spiral and diagonal components of movement with the goal of facilitating movement patterns that will have more functional relevance than the traditional technique of strengthening individual group muscles.
Resistance is used during spiral and diagonal movement patterns with the goal of facilitating irradiation of impulses to other parts of the body associated with the primary movement.

Question 38

Brunnstrom approach
Uses ________ ________ patterns in training in an attempt to improve motor control through ________ facilitation.
Synergies and primitive refluxes are considered normal processes of recovery.
Enhances specific synergies through the use of cutaneous proprioceptive stimuli and central facilitation using Twitchell’s recovery.

Answer 38

Brunnstrom approach
Uses primitive synergistic patterns in training in an attempt to improve motor control through central facilitation.
Synergies and primitive refluxes are considered normal processes of recovery.
Enhances specific synergies through the use of cutaneous proprio-ceptive stimuli and central facilitation using Twitchell’s recovery.

Question 39

Rood approach/sensorimotor approach
Uses ________ stimulation to modify muscle tone and voluntary motor activity.
Inhibitory or facilitatory input through the use of quick stretching, icing, fast brushing, slow stroking, tendon tapping, and vibration and joint compression to promote contraction of proximal muscles.

Answer 39

Rood approach/sensorimotor approach
Uses sensorimotor stimulation to modify muscle tone and voluntary motor activity.
Inhibitory or facilitatory input through the use of quick stretching, icing, fast brushing, slow stroking, tendon tapping, and vibration and joint compression to promote contraction of proximal muscles.

Question 40

Constraint-induced movement therapy
Constraint-induced movement therapy (CI or CIMT) is a technique pioneered by UAB behavioral neuroscientist Edward Taub. Requires the patient to be able to ________ their ________ and ________. The focus of CI lies in forcing the patient to use the affected limb by restraining the unaffected one. The affected limb is then used intensively for either 3 or 6 hours a day for at least 2 weeks.

Answer 40

Constraint-induced movement therapy
Constraint-induced movement therapy (CI or CIMT) is a technique pioneered by UAB behavioral neuroscientist Edward Taub. Requires the patient to be able to extend their wrist and fingers. The focus of CI lies in forcing the patient to use the affected limb by restraining the unaffected one. The affected limb is then used intensively for either 3 or 6 hours a day for at least 2 weeks.

Question 41

FUNCTIONAL OUTCOME FOLLOWING STROKE
A common observation is that physical performance, functional ability, and quality of life are considerably better after rehabilitation and during long-term care than immediately after the stroke. Outcomes after a stroke can be assessed via medical ________, ________, level of ________, length of hospital stay, cost of care, functional limitations, placement at the time of discharge and follow-up, amount of handicap or social functioning, quality of life, and life satisfaction.

Answer 41

FUNCTIONAL OUTCOME FOLLOWING STROKE
A common observation is that physical performance, functional ability, and quality of life are considerably better after rehabilitation and during long-term care than immediately after the stroke. Outcomes after a stroke can be assessed via medical morbidity, mortality, level of impairment, length of hospital stay, cost of care, functional limitations, placement at the time of discharge and follow-up, amount of handicap or social functioning, quality of life, and life satisfaction.

Question 42

The Framingham Heart Study not only showed that 78% of 148 stroke survivors were ________ in mobility skills, 68% were independent in the performance of self-care activities, and 84% were living in home environments, but also saw reductions in vocational function, socialization outside the home, and pursuit of interests and hobbies.

Answer 42

The Framingham Heart Study not only showed that 78% of 148 stroke survivors were independent in mobility skills, 68% were independent in the performance of self-care activities, and 84% were living in home environments, but also saw reductions in vocational function, socialization outside the home, and pursuit of interests and hobbies.

Question 43

More recently, the Auckland Stroke Outcomes Study showed that of 418 five-year stroke survivors, two-thirds had good functional outcome in terms of neurologic impairment and disability (defined as modified ________ score

Answer 43

More recently, the Auckland Stroke Outcomes Study showed that of 418 five-year stroke survivors, two-thirds had good functional outcome in terms of neurologic impairment and disability (defined as modified Rankin score

Question 44

Admission functional ability is the strongest and most consistent predictor of discharge,14 and significant predictors of functional status at the time of discharge were admission functional status score and onset admission interval.15 Paolucci et al. provided further evidence of better functional prognosis in stroke survivors with hemorrhagic stroke versus ischemic stroke. The Copenhagen Stroke Study showed that those with severe strokes are characterized by younger age, the presence of a spouse at home, early neurological recovery, and decreasing body temperature.

Answer 44

Admission functional ability is the strongest and most consistent predictor of discharge,14 and significant predictors of functional status at the time of discharge were admission functional status score and onset admission interval.15 Paolucci et al. provided further evidence of better functional prognosis in stroke survivors with hemorrhagic stroke versus ischemic stroke. The Copenhagen Stroke Study showed that those with severe strokes are characterized by younger age, the presence of a spouse at home, early neurological recovery, and decreasing body temperature.

Question 45

A Very Early Rehabilitation Trial (AVERT), a phase II randomized controlled trial made up of 71 patients with an average age of 74 years, concluded that earlier and more intensive mobilization after stroke may ________-________ return to unassisted walking and improve functional recovery. In general, about 75% to 85% of stroke patients are discharged home after formal acute rehabilitation care.

Answer 45

A Very Early Rehabilitation Trial (AVERT), a phase II randomized controlled trial made up of 71 patients with an average age of 74 years, concluded that earlier and more intensive mobilization after stroke may fast-track return to unassisted walking and improve functional recovery. In general, about 75% to 85% of stroke patients are discharged home after formal acute rehabilitation care.

Question 46

Overall, the prognosis for a stroke survivor is good. Approximately 80% of stroke survivors walk within a ________ following stroke, 85% recover normal swallowing, 40% are able to return to work, and 90% are able to return home. The Copenhagen Stroke Studies20,21 are an extensive, ongoing series of papers with descriptions of stroke rehabilitation outcomes. One recurrent theme is that short-term and long-term morbidity/mortality and rehabilitation outcome are positively affected by special stroke units (vs. general medical or neurologic units).20 Generally, length of hospital stay is also significantly reduced.

Answer 46

Overall, the prognosis for a stroke survivor is good. Approximately 80% of stroke survivors walk within a year following stroke, 85% recover normal swallowing, 40% are able to return to work, and 90% are able to return home. The Copenhagen Stroke Studies20,21 are an extensive, ongoing series of papers with descriptions of stroke rehabilitation outcomes. One recurrent theme is that short-term and long-term morbidity/mortality and rehabilitation outcome are positively affected by special stroke units (vs. general medical or neurologic units).20 Generally, length of hospital stay is also significantly reduced.

Question 47

Another theme is that initial stroke recovery is generally the most important factor in both neurologic and functional recovery. The best neurologic recovery is seen by 11 weeks for 95% of patients; most ADL recovery (by ________ Index) is by 12.5 weeks with daily PT/OT, but recovery could take 2 years or more.21 Although the prognosis in patients with mild or moderate stroke is usually excellent, periodic rehabilitation interventions may be necessary to maintain function.

Answer 47

Another theme is that initial stroke recovery is generally the most important factor in both neurologic and functional recovery. The best neurologic recovery is seen by 11 weeks for 95% of patients; most ADL recovery (by Barthel Index) is by 12.5 weeks with daily PT/OT, but recovery could take 2 years or more.21 Although the prognosis in patients with mild or moderate stroke is usually excellent, periodic rehabilitation interventions may be necessary to maintain function.