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Flashcards in Recovery Related Issues Deck (31):
1

2 Types of Recovery

Natural/Spontaneous and Post-natural

2

Natural/Spontaneous Recovery

maximal, rapid, dramatic; duration of 3-12 weeks; treatment can make the patient progress even faster

3

Post Natural Recovery

patient continues learning, but is much slower and less dramatic 6 months is the limit

4

Physiology of Acute Phase

Visible microscopic changes in 24-48 hours

Edema in large infarcts

Increased intracranial pressure and tissue compression by 3rd day

Brain response to ischemia by autoregulatory mechanisms (vasodilation, diaschisis, circle of willis)

Bilateral reduction of blood circulation (depression of the neural metabolism) 

Auto-regulatory Mechanisms: robbing Paul to pay Peter, if the brain needs blood it tries to find it from other areas

5

Acute Phase

No collateral circulation - quick loss of energy is needed to maintain the ionic balance, if this doesn't happen it leads to cellular energy loss

 

Cellular Energy Loss

- Release of glutamate and aspartate

- Excitatory-toxicity to calcium channels

- Excessive calcium to many destructive enzymes  

- Inflammatory changes followed by Chromatolysis and Necrosis

6

Chromatolysis

10-18 days Disintegration of micro-molecules, nissl bodies, and nucleolus displacement

Everything becomes liquified

After the 18 days, if the cell is healthy it will come back, if not it will die.

7

Second Week, post stroke

Diminished swelling

Capillaries and astrocyte invasion

Necrotic tissue liquefaction

Phagocytosis of tissue-macrophagic cells (eats up debris)

Phagocytosis - can take up to 3 months if its a large lesion.

8

Astrocyte Scar

Small lesion, post stroke

9

Cystic Cavity Formation

Occurs in 3-6 months Lg. Lesion Basis for pessimism

10

Sequence of Necrotic Process

A image thumb
11

Repair Process

Structure/Function/Reaction 

A image thumb
12

Early & Late Reactions and the Functional Results

A image thumb
13

Core Cells

Core cells are dead and can't be saved

 

14

Penumbra Cells

Penumbra Cells are the cells that surround the core cells. 

The ischemic penumbra has idle neurons (electrically silent but metabolically ready for membrane potentials

idle neurons may survive for 20 mins without collateral circulation and 6-8 hours with collateral circulation

15

Means of Reperfusion 

Stent

tPa (clot-dissolving medication)

Merci retrieval system (remove the clot)

16

Factors Contributing to Natural Recovery

 Reperfusion with Collateral circulation - Collateral circulation is very closely related to the circle of Willis 

Recovery from diaschisis - In the beginning the whole brain is reacting negatively, but after 2-3 weeks the swelling lowers; this is long-distance recovery

Recovery from Structural Disconnections - the pathways have been disconnected/some are broken

Intra-hemispheric reorganization

edema attenuation - reduced pressure 

cell recovery in penumbra

17

Positive Recovery Profile 

Wertz, 1987

Tx benefits patients with single LH thrombo-embolic infarct, mild-moderate loss

post-onset period of 3 or less months, if given 3 hrs/week for 5 months

intensive Tx beneficial if 8-10 hrs/week for 3 months, begin in less than 6 months post-onset

18

Culton Spontaneous Recovery

Found Support for natural restitution 

These patients didn't have any treatment

Non-chronic patients:
Most dramatic difference in results between the first and second tests

 

Chronic patients:

Testing between all the different times are very similar

 

This tells us that something is happening within the brain even without treatment


 

19

Vignolo, 1965

Developed the Token Test

Pts with mild-moderate loss will do better than those with profound loss

People who are young (under 50)  improved the best 

20

VA Cooperative Study on Aphasia 

Wertz 1981

Patients randomly assigned to individual or group therapy

both groups improved beyond 26 weeks post-onset

recovery continued beyond spontaneous recovery period

individual Tx was better overall, but both groups improved

21

Kertesz & McCabe Recovery Patterns 

Anomics had full recovery

Broca and Conduction with best recovery

Globals with poor recovery

Wernicke bimodal recovery (little recovery in patients with jargon, better without jargon)

evolution into different aphasia types

22

Lomas & Kertesz

Patterns of Spontaneous Recovery

Patients divided into 4 groups: LFLC (globals), LFHC (Broca's), HFLC (Wernicke's), HFHC (anomics)

 equal improvements noted for all language tasks for groups with high comprehension

selective improvement in comprehension and imitation for patients with low comprehension

23

Anna Basso

Prognostic Factors in Aphasia

Review of literature on prognostic factors, including age, sex, handedness, etiology, site and extent of lesion, severity and type of aphasia, restitution

 

Age relationship to recovery - Good predictor of recovery

 

Gender relationship to recovery - No significant difference in the severity and recovery rate across genders

 

Personality relationship to recovery - Pleasant and cooperative help in recovery

24

Basso

Initial Severity Relationship to Recovery (1-10 weeks) 

good predictor of aphasia outcome

greater initial severity is a negative recovery sign

mild initial aphasia has good recovery (95% plateaued within 2 weeks)

moderate initial aphasia 95% plateaued within 6 weeks

severe initial aphasia 95% plateaued within 10 weeks

 

Sparing of critical cortical area - Greater prognostic significance

25

Basso Extent of Recovery

Good for patients with anomia and conduction aphasia

fair/good for patients with Broca and Wernicke

poor for patients with global

26

Basso Rate of Recovery

Fast for patients with conduction and Wernicke

intermediate for patients with Broca

slow for patients with anomia and global

27

Basso Recovery Pattern

Anomic aphasia is a common end-stage for both recovering fluent and non-fluent aphasics

28

Overview of Contributing Factors (General) 

Site and Lesion Size - the larger the lesions, the poorer the prognosis

Lesion Nature - Multiple lesions render a poor prognosis 
Bilateral lesions - aphsasic residuals 
Silent stroke - 11% of patients with silent lesions prior to first stroke

Multiple strokes = bad prognosis 

29

Overview of Contributing Factors in a Natural & Trained Restitution 

Age - younger = better


personality - postive = better


severity - profound loss of lang. at initial eval. = bad prognosis


Motivation - education = bad candidate because you question everything. Motivation = doesn't really translate into better results


handedness - better recovery in left handedness following LH stroke


time post onset - less than 6 months = better


gender - no effect


social milieu - Pts. who are socially active do better


general health - Someone who has only stroke has better prognosis than someone who is complicated health wise


personality - positive = better


lesion size - bigger = worse


lesion nature - poor for multiple lesions

30

Aphasia Recovery & Bilingualism 

 

Synergetic patterns = Nearly 50%
1. Parallel (41%) : both languages impaired similarly in the

beginning and recovered at the same rate ​
2. Differential (9%) : Both languages impaired to different

degrees, but improved at the same rate

Selective Recovery = (27%) only one lang. improves

Successive = (6%) One recovers after the other

Antagonistic = (4%) one lang. progressed whiel the other regressed

Alternate antagonistic = Different lang. prevails at different periods 


If you provide tx in mother language it doesn't generalize to L2, but if you provide tx in L2 it generalizes to L1.

 

 

31

Aphasia Recovery & Bilingualism

Robot's and Pitre's Rules

Robot's Rule = Primary Language

Pitre's Rule = Most frequent language