Masterclass - Stroke Flashcards
State facts on stroke in Australia and differences between indigenous and non-indigenous populations
- 3rd leading cause of death in Aus (~56k annually)
- Financial cost of $5B annually
- 65% of stroke survivors suffer a disability requiring ADL assistance
- 30% of stroke survivors <65 yrs old
- Indigenous 1.7 x more likely for stroke
- Indigenous 2 x more likely to be hospitilized
- Indigenous 1.6 x higher death rate
- 3x more likely to die or be dependent at discharge
- Lower quality of care for indigenous due to quality and provision of care in rural areas (no stroke care unit) + delayed health assessments
State percentage of ischemic/haemorrhagic strokes and risk factors for each and both.
Ischemic: 87%, Haemorrhagic stroke: 13%
Risk factors for both:
- High blood pressure
- Smoking
- Diabetes
- Physical inactivity
- Obesity
- High cholesterol
- Atrial fibrillation
- Excessive alcohol consumption
- Age
Risk factors for Ischemic:
- Atherosclerosis
- Atrial fibrillation
- Prior ischemic strokes
Risk factors for Hemorrhagic:
- Bleeding disorders
- Vascular malformations
- Use of anticoagulants
List the signs and symptoms of someone having a stroke
FAST
- Face droop
- Can’t use arms
- Slurred speech
- Time to call 000
State the prognosis after stroke to the same detail as the Masterclass
70% of stroke patients are dead or disabled 5 years after the event
Mortality:
Ischemic Stroke
o 1 month: 15%
o 1 year: 25%
o 5 years: 50%
Haemorrhagic Stroke
o 1 year: 55%
o 5 years: 70%
Predictors of survival at 3 and 12 months post stroke
- Age
- Verbal component of the Glasgow Coma Scale
- Arm power
- Ability to walk
- Pre-stroke dependency
Walking after stroke
- 98% chance if (within 72 hours) a patient can
o Independently sit for 30 seconds and visibly contract muscles in the legs (with or without movement)
o Only 27% chance if patient cannot do above
Upper limb function
- 98% chance if (within 72 hours) a patient can
o Exhibit some finger extension
o Some shoulder abduction
o Only 25% if patients could not do the above
Define and describe (neurophysiologically) adaptive and maladaptive plasticity and provide an example of each.
Neuroplasticity: lifelong capacity of the brain to learn new ways of doing things based on new experiences and learning
Adaptive plasticity: neurophysiological changes that improve the ability to perform tasks (e.g. reorganisation of motor maps following task specific training). Increased function/neural ability to perform a task
Maladaptive plasticity: changes that impair function such as learned non-use of chronic pain. Decreased function, impaired ability to perform tasks, learned non-use. Plasticity that is unhelpful (chronic pain, allodynia)
List and describe 8 factors that influence neuroplasticity
1) Use dependent and specific
2) Repetition and intensity
3) Time sensitivity
4) Task importance, motivation, feedback and attention
5) Features of the environment
6) Ajuvant or adjunct therapies
7) Patient characteristics
8) Pharmacology
Differentiate between use-dependent and learning dependent plasticity
Use dependent: reorganisation of cortical regions as a result of motor practice. Use it or lose it principle.
Learning dependent: cortical reorganisation from acquiring new skills, involving active problem solving. Often involves task specific training, goal setting, active problem solving, new skills
Describe intensive task specific practice in the context of increasing neuroplasticity
Meaningful and real world relevant training with high repetitions to strengthen neural pathways
Set clear explicit short, medium and long-term SMART goals, Practice intensity should be increasing, Practice should be task specific, and variable
Describe the medical management for acute stroke including indications and considerations for treatment using tpA
Thrombolysis
Primary treatment is patient presents <4.5hrs from symptom onset. Reduction in benefit over time since stroke
Treatment has risk of symptomatic ICH
Thrombolysis thins blood so don’t want to use it after 4.5hrs – high risk of doing further damage
Larger more proximal clots are more resistant to thrombolysis
Describe the medical management for acute stroke including indications and considerations for treatment using Endovascular thrombectomy
Tube is inserted through a distal artery (e.g. femoral) and using a wire, the clot is secured, and pulled out. Only used in big arteries
Can be performed up to 24hrs after lesion
Performed at limited sites
Can only be used in proximal occlusion sites
Describe the medical management for acute stroke including indications and considerations for treatment using Craniectomy/craniotomy
Surgical decompression to relieve pressure from brain swelling
Describe the 3 practice variables that influence motor skill acquisition.
Practice intensity
Practice specificity
Practice variability
Outline how a PT can increase the amount of repetitive task specific practice
Practice intensity: set up patient for independent and semi supervised practice, use exercise booklets, incorporate training into daily living, train carers/family/nursing staff/physio assistant to assist in training, pair up with training partner, group therapy
Outline considerations for practice specificity
Movements should be similar and in the correct context while the skill is being practiced. Consider the action, task, skill and environmental context
Discuss when (and why) you would use exercises with low and high contextual inference
Higher contextual interference results in
- Poorer performance and greater attention DURING practice
- Better performance during retention and transfer tests AFTER practice
BUT
- Higher contextual interference does not appear to enhance learning in children and people with low skill levels
High contextual interference: random order of trials of all task variations = good for experts
Low contextual interference: non-repeated blocks of trials of each task variation = good for beginners
Discuss considerations for providing instructions and demonstrations to patients
- Use clear, concise verbal cues, tailored to the patient’s attentional capacity.
- Demonstrations are effective for learning new movement patterns and should be given frequently, both before and during practice. Both skilled demonstrations by experts and unskilled demonstrations by beginners.
- Should also provide timely and descriptive feedback
Outline the different types of augmented feedback (with examples) and how these can be used in rehabilitation
- Visual: mirrors, videos, demonstrations, EMG biofeedback, videos
- Auditory: instructions, metronome, clapping, EMG biofeedback
- Proprioceptive/tactile: manual handling, Lokomat, Orthoses, taping
Differentiate between knowledge of performance vs knowledge of results, Quantitative vs qualitative feedback, internal vs external focus, intrinsic vs extrinsic feedback and discuss when each could be used
Knowledge of performance: provides information about the movement characteristics leading to a performance outcome
-Eg. Force steadiness, amount of sway
Knowledge of results: provides information about the outcome of performing a skill or about achieving the goal of the performance
- Eg. Number of reps, knee flexion ROM, walking speed, distance walked
Quantitative: augmented feedback that includes a numerical value related to the magnitude of a performance characteristic
Qualitative: augmented feedback that is descriptive in nature and indicates the quality of performance
Internal focus: instructions that direct attention to the movement themselves
- Eg; ‘feel the muscle contracting when you perform the movement’
External focus: instructions that direct attention to the effect of movement on environment
- Eg. Shift your weight toward the table
Intrinsic feedback: direct feedback that you get from an action. A patient may successfully execute a movement but realise they need to improve the process (through body and relative to body)
Extrinsic feedback: feedback from a person or data such as a video or balance board device
Discuss motivational strategies for increasing patient compliance/performance.
- Ensure relevance of training exercises to the patient’s goal or motor skill
- Ensure goals are identifiable and specific
- Provide encouraging feedback
- Regularly assess outcome measures
- Consider reward systems and feedback
