1
Q
What is a stroke?
A
- When blood flow to the brain is interrupted- either by blood clot or bleeding- blood vessels in the brain- cerebral vascular incident
2
Q
Risk factors for stroke
A
high BP
- Athersclerosis (Hardening of the arteries)
- high cholesterol
- Atrial Fibrillation- irregular heart beat
- Diabetes
3
Q
What puts people at a higher risk
A
smokers, obese, excessive alcohol, family history
4
Q
5 warning signs of a stroke
A
- vision problems- sudden trouble seeing in 1 or both eyes
- Weakness- sudden numbness or weakness of the face, arm, leg, esp on one side of the body
- Trouble speaking- sudden confusion, trouble speaking or understanding
- Headaches- severe headache with no known cause
- Dizziness- sudden trouble walking, dizziness, loss of balance or coordination
5
Q
Types of strokes
A
- Ischemic Stroke- 80%
- Thrombosis, embolism, lacunar stroke or penetrating artery disease - Hemorrhagic- 20%
- intracerebral hemorrhage
- subarachnoid hemorrhage
6
Q
Mechanisms of ischemic strokes
A
- Neuron leaks potassium and ATP- fluid build up between blood vessels and neurons- reduced passage of oxygen and nutrients
- Core brain tissue- tissue death as a result of loss of blood supply
- Peripheral areas- temporary dysfunction due to edema
- edematous brain tissue recovers slowly and gradually
brain has the ability to reroute neural pathways
7
Q
what is a Thrombosis
A
Occurs when blood clot forms in one of the arteries supplying the brain causing vascular obstruction
atherosclerosis makes it worse
- gradual pathological degeneration
- rough, irregular fatty deposits form within the intima and inner media of arteries generate thrombus
- ***most common cause for stroke
- few cases from stenosis
- most happen in large vessels
8
Q
signs and symptoms of thrombosis
A
- progressive symptoms
- spread across hours or days
- mild arm numbness, morning paralysis
- onset during sleep or resting at night
- often present with transient ischemic attacks before actual infarction
9
Q
What is an embolism
A
- a clot forms elsewhere breaks off (embolus) and travels up until it reaches an artery too small to pass through
- can happen in any part of the body
- cardiac source emboli=20%
- commonly affect middle and posterior cerebral arteries
10
Q
Embolism- signs and symptoms
A
- occurs during day time activities
- sudden movement which raises blood pressure and loosens the clot
- symptoms are very sudden and maximal at onset
- history of transient attack is rare
- often associated with seizures
11
Q
Ischemic stroke: Penetrating artery disease (Lacunar stroke)
A
- involves deep brain structures- thalamus, internal capsule, basal ganglia, deep white matter, pons
- small infarct accumulates, forming a lacune
-occludes a small branch of large vessels that supply the brains deep structures
-recovery rate similar to other types of strokes - purely motor deficits, esp. weakness, ataxia, purely sensory or both
- not likely affect language cognition or vision
risk factor- hypertention
12
Q
Hemorrhagic stroke- mechanism
A
caused by:
- rupture in a blood vessel
- aneurism- an out-pouching of an artery wall because of its weakness and is prone to rupture at any time
- abnormal presence of blood and increase pressure on neurons- distorts normal architecture of the neurons and blocks passage of nutrients and oxygen
- eventually forms blood clots, after months, clots slowly recede, break down and are absorbed by white blood cells
- if the pressure is not high enough to damage the neurons the brain tissue will heal- sometimes with good prognosis or even feel recovery
- if severe, fatality rate is high
- more common in young people
13
Q
Hemorrhagic stroke: Intracerebral hemorrhage
A
bleeding directly into any part of the brain
- focal- move spherically through the tissue planes
Causes:
hypertension, blood vessel abnormalities, edema, hematoma, swelling
Some disease increase risk:
leukemia (less ability to clot and increased infection), sickle cell anemia, hemophilia, liver disease, use of anticoagulants
14
Q
ICH signs and symptoms
A
develops during activity headache vomiting convulsions decreased level of alertness stupor and coma are common signs of very large hemorrhages and indicate poor prognosis
15
Q
Hemorrhagic stroke: subarachnoid hemorrhage
A
10% of all strokes
90% caused by leakage of blood from aneurysms
-because of arterial pressure, can spread quickly into the CSF surrounding the brain
- other causes: hemophilia, anticoagulants, trauma to the skill or brain
- blood irritates the meninges, increase intracranial pressure
16
Q
SAH- signs and symptoms
A
headache- very severe
vomiting
altered state of consciousness
sleepiness, stupor, agitation, restlessness, coma
bleeding occurs around the brain not actual brain- not cognitive, motor, sensory or visual ability
-lumbar puncture with analysis of CSF is most reliable way to diagnose SAH
17
Q
Medical Management of Stroke- Pre-stroke
A
monitor BP, heart disease, and other conditions that can lead to stroke
- lifestyle and diet
- blood test for sugar levels, cholesterol, clotting
- Doppler test- measures how fast blood is flowing through the neck arteries
- Preventative medication
- surgery to clear blocked arteries
18
Q
Medical Management of Stroke- Post-stroke
A
Surgery to relief pressure on the brain
- medication- anti-coagulants, calcium channel blockers
- angioplasty
- clipping or typing of aneurisms
- prevent DVTs from developing
- prevent respiratory infections
19
Q
Stroke Meds
A
aspirin- proven immediate treatment after an ischemic stroke to reduce the likelihood of having another stroke
- Blood-thinning drugs- warfarin and heparin and plavix
20
Q
3 complications of a stroke
A
- Seizures- brain scars irritate the cortex and cause spontaneous discharge of nerve impulses
- Infection
- Aspiration pneumonia
- changes in bladder function, UTI
- Pressure sores due to impaired sensation and inadequate position changes - Deep Vein Thrombosis (DVT)
- due to prolong immobilization of the legs and bed rest
- clot travels up to the heart and lungs, obstructs pulmonary arteries causing sudden collapse and death
- early mobilization is important*****
21
Q
which artery is most commonly involved in a stroke
A
middle cerebral artery
22
Q
Damage resulting from Middle CA
A
contralateral hemisensory loss, hemeplegia, visual field deficits, visuospatial apraxia, perseveration, poor judgement, emotional problem, apathy
23
Q
Left CVA
A
leads to Broca’s aphasia and wernicke’s aphasia
24
Q
Anterior C. A
A
behavioural disturbance, apraxia, contralateral hemisensory loss, hemiparesis- greatest in foot, inertia of speech, affect communication
25
Posterior C.A
Memory impairment, homonymous hemianopsia, visual agnosia
Left CVA- anomia, agraphia, acalcuia, alexia
26
Right brain vs. Left brain
Left- logic, analysis, sequencing, linear, math, language, facts, names, thinking in words, computation
Right brain- creativity, imagination, holistic thinking, arts, non-verbal, feelings, visualization, tune of songs, daydreaming
27
RIght hemisphere stroke
Visual-spatial perceptual disorders
- left sided neglect, constructional apraxia- inability to plan and initiate the movement
*** May only dress or groom one side of the body, may only eat food on one side of plate, may be unaware of people or cars approaching from left side- safety concern
Emotional
-ppl with right CVA may speak well so abilities can be overestimated
-emotional indifference, impulsivity
- emotional lability
- depression
**lack of insight into own deficits, strained relationships due to impulsivity, communication difficulties can negatively affect social interactions
Communication problems
- aphasia rarely occurs
- difficulty using language properly
28
Left side stroke
Aphasia- 97% of people left hemisphere is dominant for language
-expressive (Broca's aphasia) is most common
Apraxias
-disorder of voluntary movments, despite adequate strength, mobility, sensation, comprehension and coordination
*** apraxia of speech, gait, dressing walking communicating, transferring is difficult- ADLS difficult
Emotional disorders
- depression, frustration and range
29
Lacunar Infarcts
Occurs at the end of arteries and cause small cerebral infarcts
- common with hypertension
- often mistaken for a TIA
- can sometimes be asymptomatic
Syndrome Manifestions:
- Pure motor hemiparesis or pure sensory signs on half of body
- dysarthria
- clumsiness and mild weakness of hand
- dysphasia
- ataxic hemiparesis
*** can effect eating, feeding and fine motor, handwriting, dressing, typing and safety with sensory issues such as water temperature
30
Brain stem
- diverse manifestations, can impact occipital, medial temporal lobes, brainstem or cerebellum
- Medulla: vertigo, nausea, vomiting, sensory loss in ipsilateral face and contralateral limb, dysphasia, dysarthria
- pons: contralateral hemiparesis or paralysis
Cerebellum- unilateral limb ataxia, truncal ataxia, vertigo, headache
midbrain- contralateral hemiparesis, tremor in limb, lateral gaze only, contralateral sensory loss
***eating, feeding, walking, sitting, ADLS- dressing, preparing meals, limb tremor)
31
Wallenberg's syndrome
-a classic brainstem stroke
- Vertebral or cerebellar artery
- pain, temperature loss, dry cold face on the affected side, ataxia, facial sensory loss
- no significant weakness****
- result in coma
- Hemorrhage to brainstem is rare but would be fatal
patients who survive a brainstem stroke usually have a good recovery
32
Vertebrobasilar stroke
vertebral artery and basilar artery
- supply the posterior portions of the brain eg. brainstem, cerebellum. thalamus, some parts of the temporal and occipital lobes
```
occlusion will lead to:
- visual disturbances, coordination of eyes
- ataxia
- clumsy movements of the hands
- difficulty judging distance
- loss of memory
- paralysis of face limbs or tongue
- localized numbness
impaired temperature sensation
dizziness
drooling dysphagia
```
in older adults, osteoarthritis may develop in cervical bones, causing narrowing of cervical canal
33
OT ASSESSMENT/ EVALUATION
- COPM to establish goals
- ADL
- FIM, Barthel Index
- Physical Assessment
MMT, AROM, PROM, goniometry, sensation, proprioception, stereognosis, JAMAR, dynamometer
- Standard assesments
Cognition: MOCA, MMSE, Cognistat, Rivermead Behavioral Memory Test
Visuo-perceptual: rivermead visual-perceptual assessment battery, motor free visual perceptual test, OSOT perceptual evaluation
34
Physical Assessment: Chedoke-McMaster Stroke Assessment
in-patient/day hospital patients from 1 week to several years post-stroke
2 components: impairment inventory and disability inventory
7 stages of motor recovery to guide assessment and treatment
35
Performance Assessment of Self-Care Skills (PASS)
observational assessment
PASS-clinic and PASS-home versions
eg. List of ADL and IADL skillsAsse
functional mobility- bed transfer, toilet transfer
personal self-care- dressing and oral hygiene
IADL- money management, shopping, check book balancing
IADL- meal preparation- oven use
IADL- heavy housework, changing bed linens
36
Assessment of Motor and Process Skills (AMPS)
observational
- measure the quality of IADL performance
- begins with an interview to determine the tasks that are familiar and relevant to the client
- Observe at least 2 IADLS tasks ex. preparing a pot of coffee
37
OT Treatment
Using the CMOP-E to frame treatment areas
- enhance all performance components- physical, motor, cognitive, perceptual, visual, psychosocial etc
- improve ADL and IADL performance
- recommend/teach the use of adaptive equipment
- educate patients and caregiver
- include home program, provide community resources
- encourage participation in the community
- help patients realize their potential, fulfill their roles, and readjust/adapt to new way of life
38
3 treatment approaches
1. adaptive approach- compensatory
- top-down, emphasize intact skill training
- emphasize environmental or task modification
- client driven, repetitive task practice, task-specific
2. Remedial Approach- restorative
- Bottom-up, train component skills
- assumes transfer of training will occur, process-specific
- Generalize to very similar tasks
3. Combination Approach
- Treatment use tasks relevant to client needs
- task designed so that the underlying deficits are challenged via the task (occupation and environment)
39
Examples of assistive device to improve task performance
1. rocker knife
2. elastic lace, lace locks
3. Adapted cutting board
4. pot stabilizer
5. plate guards
6. suction devices to stabilize mixing bowls, cleaning brushes
40
Other contributing factors affecting treatment outcome (upper limb dysfunction)
loss of upper extremity control is very common after stroke 85%
pain, contracture and deformity, joint subluxation, loss of selective motor control, weakness, learned non-use, loss of biomechanical alignment, inefficient and ineffective movement patterns
41
Motor Control
basic units of motor control are reflexes
- as the CNS matures, reflexes become integrated- regulation by higher centres (cortical and subcortical areas); volition control of automatic reflexes
- when the CNS is damaged, eg. in a stroke, the high centers are unable to control reflexive motor activities and modulate reflexive movements- resulting in more primitive movement patterns
- hemiplegia- half the body is paralyzed
hemiparesis- weakness of the left or right side of the body
42
Neurodevelopmental Therapy NDT
Theory:
- During recovery, patients typically overuse the uninvolved side to compensate for loss of sensory and motor function on the hemiplegic side
- Core problems: posture, alignment, balance, strength, tone, and coordination
- Secondary problems: pain, orthopedic problems, and decreased safety
- Treatment program is to avoid abnormal patterns of movement
- relearn normal movement rather than using compensatory movement patterns
- encourage use of both sides of the body
- ***Central principle: alignment and symmetry of the trunk and pelvis are necessary for good alignment of the extremities
43
NDT what are the 4 different approaches
1. Rood approach
2. Brunnstrom
3. proprioceptive Neuromusclar Facilitation (PNF)
4. Bobath
44
Rood, Brunnstrom and PNF approaches
- traditional sensorimotor approaches
Strategies:
1. Sensory stimulation to muscles and joints to evoke specific motor responses
2. Handling and positioning to change muscle tone
- Use of developmental postures to enhance the ability to initiate and carry out movements
45
Bobath
- Provide intervention for adult hemiplegia, children with CP
- Neuro-developmental Treatment (NDT)
46
Rood Approach
- use of sensory stimulation to evoke a motor response (proprioceptive facilitation techniques)- muscles spindles, golgi tendon organs, joint receptors and the vestibular apparatus
- Facilitation (increase muscle tone) by tapping over muscle belly
- Inhibitory (decrease muscle tone) by applying deep pressure to a muscle's tendinous insertion
- incorporate in ADL training
Rood Facilitation and inhibitory techniques:
Cutaneous Facilitation Techniques: light moving touch, fast brushing, icing
Proprioceptive facilitation techniques: heavy joint compression, stretching, tapping, therapeutic vibration
Inhibitory techniques- neural warmth, tendinous pressure, slow stroking, rocking
47
Brunnstrom
Based on the reflex and hierarchical model of motor control
- spastic or flaccid muscle tone and the presence of reflexive movements are part of the normal process of recovery
- Encourages flexor and extensor synergies (coordinative action of 2 or more muscles) during early recovery, assuming synergies will result in voluntary movement
- 6 stages of motor recovery to guide spasticity management
* * spasticity is different than rigidity
48
Proprioceptive Neuromuscular Facilitation
Also based on the reflex and hierarchical model of motor control
- use mass movement patterns to promote movement
- use total patterns (developmental postures)
- uses person's stronger movement patterns to strengthen weaker motions
- Uses manual stimulation and verbal feedback to induce movement
- also incorporates sensory stimulation eg. tactile, auditory and visual inputs to promote motor response
49
Treatment/Activities
- wood sanding
- cleansing blackboard/white board- shoulder flexion, abduction (unilateral while standing)
- wiping a tabletop: reinforce wrist extension when the patient leans forward (unilateral)
- Reach a shopping bag place on the left to retrieve objects that will be placed into a cabinet on the right side (unilateral diagonal)
- Reaching to lift box off high shelf (bilateral symmetrical, while standing)
50
Bobath
a neuro-developmental treatment approach for adult hemiplegia- follow developmental sequence
- aim to reduce spasticity by using inhibitory postures and movements to facilitate normal, autonomic responses
- apply positioning and weight bearing
Dynamic Process
1. Assess and identify functional activity limitation and ineffective movement strategies
2. Assess missing component of movement *manual cues to recover functional use of components of movement and physical handling of key point of control
3. Determine functional outcome
Therapist uses functional activities, apply problem solving strategies rather than fixed protocol, base on core principles
51
Core Principles of babath NDT approach
1. individualized functional outcome
- interventions that are specific to life roles, support systems and underlying impairments
2. Emphasize motor control
- Focus on activities that will increase muscle strength and ROM, improve proprioception, balance, coordination and perception
3. Increase active use of the involved side
- This allows for neural plasticity and reduces the incidence of non-use
4. Provide practice to improve motor
performance leading to motor learning
- appropriate practice schedules, duration and challenge
5. Increase retention and carryover of learned motor skills
- done through using the involved side during functional activities between therapy sessions
6. Interdisciplinary approach
52
Example
Functional activity limitation: unable to reach high shelves and cupboards
Ineffective movement strategy:
- shoulder alleviation of involved side, isometric trunk contraction of uninvolved side, pelvis rotated posteriorly and tilted upward
Missing component of movement:
- bilateral trunk alignment, shoulder abduction etc
Individualized functional outcomes:
1. Symmetrical use of upper extremities for reaching high level surface
2. symmetrical use of lower extremities for reaching when standing
53
Motor learning
aims to produce purposeful movements of the extremities
- the acquisition and modification of learned movement patterns over time
- After CVA or TBI, the brain needs to relearn the motor pattern to perform purposeful movements
Theoretical models;
1. Hierarchical ex. PNF, NDT, Brunnstrom
2. Heterarchical- Dynamic system theory
54
Dynamic system theory
view motor bahviour as a dynamic interaction between person, environment and occupation
Person factor: CVA leads to perceptual, sensorimotor, cognitive problems which affect motor performance
Environment: Characteristics, adapt to modified environment
Task/Occupation: Roles, job, homemaker
Motor relearning program
- a task-oriented approach
- functional training for key motor tasks
- *** incorporate constrain induced movement therapy
55
CIMT
restraint of the unaffected limb to promote increased use of the affected limb- forced use- speed up cortical re-organization after CVA
Learned nonuse
- patient effectively forgets to use the affected side
Strong evidence from research showing the benefit of CIMT during the chronic stage
Some research shows that CMIT may be more beneficial than other therapies during the acute stage
56
CIMT
restraint of the unaffected limb to promote increased use of the affected limb- forced use- speed up cortical re-organization after CVA
Learned nonuse
- patient effectively forgets to use the affected side
Strong evidence from research showing the benefit of CIMT during the chronic stage
Some research shows that CMIT may be more beneficial than other therapies during the acute stage
Neuroanatomy term 2
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