Stroke Flashcards
Difference in stroke between Indigenous and non-Indigenous populations
Indigenous Australians have a 1.7x higher stroke rate, 2x higher hospitalisation, 1.6x higher death rate
Types of stroke and their percentage
Ischemic: 87%
Haemorrhagic: 13%
Risk factors for both types of stroke
High BP
Smoking
Diabetes
Physical inactivity
Obesity
High cholesterol
Atrial Fibrillation
Excessive alcohol consumption
Age
Risk factors for ischemic stroke
Atherosclerosis
Atrial fibrillation
Prior ischemic strokes
Risk factors for haemorrhagic stroke
Bleeding disorders
Vascular malformations
Use of anticoagulants
Signs and symptoms of a stroke
FAST
Face droop
Can’t use Arms
Slurred speech
Time
Numbness, strong headache, vertigo and loss of balance, violation of speech, understanding and sight
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
There’s a 98% chance of walking after stroke if a patient can…
independently sit for 30 seconds and visibly contract muscles in the legs (with or without movement) within 72 hours
There’s a 98% chance of regaining upper limb function after stroke if a patient can…
exhibit some finger extension, some shoulder abduction within 72 hours
Medical treatment of stroke
Thrombolysis: Recombinant tpA
Aspirin
Endovascular thrombectomy
Decompressive surgery (Craniectomy)
Medical prevention of stroke
antithrombotic agents
antiplatelet agents
slow clotting
anticoagulant agents
prevent clotting
advice about risk factors - lifestyle modification
Patient presents <4.5hrs from symptom onset of stroke
tpA - Thrombolysis
Patient presents 6-24hrs from symptom onset of stroke
Endovascular thrombectomy
Why don’t you use tpA after 4.5hrs
tpA thins blood so don’t want to use it after 4.5hrs as there is a high risk of doing further damage
Risk of using tpA
risk of symptomatic Intracerebral Hemorrhage (ICH)
larger more proximal clots are more resistant to tpA
What is thrombectomy
mechanical retrieval of a clot
when is thrombectomy indicated
used for proximal large artery occlusions
Non-medical management of stroke
Doctors
Nurses
Physio’s
OT’s
Speech therapists
Social workers
Psychologists
Dieticians
What is neuropasticity
lifelong capacity of the brain to learn new ways of doing things based on new experiences and learning
What is adaptive plasticity
increased function/neural ability to perform a task
neurophysiological changes that improve the ability to perform tasks
What is maladaptive plasticity
decreased function, impaired ability to perform tasks
plasticity that is unhelpful
examples of unhelpful/maladaptive plasticity
chronic pain, allodynia
8 factors that influence neuroplasticity
use dependent and specific
repetition and intensity: reps required for lasting neural change, greater intensity induces neuroplasticity
time sensitive
task importance, motivation, feedback and attention: more neuroplasticity when training relevant + important tasks, feedback increases quality, attention and focus increase capacity to learn
environment: sensory, cognitive, motor and social stimulation facilitate increased neuroplasticity
adjuvant or adjunct therapies: priming (motor imagery, mental practice, stimulation based therapy) increases neuroplasticity
patient characteristics: younger people more neuroplasticity, stress impairs neuroplasticity
pharmacology: GABA receptor agonists used for anxiety, seizures, spasticity reduce neuroplasticity
Differentiate between use dependent and learning dependent plasticity
Use dependent: use it or lose it. Reorganisation of cortical regions as a result of motor practice
Learning dependent: reorganisation of cortical regions as a result of skill acquisition. Involves task specific training, goal setting, active problem solving, new skills
in Stroke patients what can we do to elicit use dependent plasticity and learning dependent plasticity
intensive task specific practice
What does intensive task specific practice involve
Meaningful and real world relevant training
Clear short, medium, long term SMART goals
Practice intensity: reps and time, level of supervision, level of difficult
Practice specificity: part/whole task
Practice variability: modify task, environment with relevance
Teach/communicate through demonstrations, instructions and feedback
Primary impairments for stroke (motor, non-motor)
Motor
- decreased strength
- decreased coordination
- spasticity
Non-motor
- vision
- sensation
- proprioception
- speech/language
- perceptual-cognitive function
Secondary impairments in stroke (motor, non-motor)
Motor
- decreased muscle length
- swelling
- SH subluxation
- CV fitness
Non-motor
- depression
- fatigue
- pain
What are the 3 practice variables that influence motor skill acquisiton
Practice intensity
Practice specificity
Practice variability
What does practice intensity involve
Learning motor skill requires repetitions
What strategies can you use to increase the amount of practice (practice intensity)
set up patient for independent and semi-supervised practice
use exercise booklets and wall charts
incorporate training into daily living
train carers/family/nursing staff to assist in training
pair up with training partner
group therapy
Considerations for practice specificity
Movements practiced should be similar and in the correct context while the skill is being practice.
Must consider action, task, skill and environmental context
environment specific: objects/equipment, moving or static
When would you use exercises with low contextual interference
good for beginners. non-repeated blocks of trials of each task variation
When would you use exercises with high contextual interference
good for experts. random order of trials of all task variations
What is practice variability
the variability in movement and context characteristics the learner experiences while practicing a skill
Types of communication
instructions: long and short sentences, non-verbal
demonstrations
feedback
How frequently would you provide instructions
depends on attentional capacity of patient and characteristics/interaction between task and patient
When would you use each type of instruction
Long sentence: before movement
Short sentence: during movement
Non-verbal cues: during movement
Types of demonstrations
Skilled demonstration by expert
Unskilled demonstration by beginners - encourages more active problem solving
When would you use demonstrations
before and during practice
feedback should be
timely (reinforce learning)
Descriptive (what occurred and how it could be better)
Types of feedback
visual
auditory
proprioception and tactile
knowledge of results
knowledge of performance
intrinsic feedback
extrinsic feedback
qualitative
quantitative
internal attention focus
external attention focus
Motivational strategies
ensure relevance of training exercises to the patients goal/motor skill
ensure goals are SMART
provide encouraging feedback
Assess outcome measure regularly to track progress
Consider reward systems and feedback
ways to advance a task
resistance
more reps, frequency, duration
greater ROM
more DoF
Increased cognitive components
Distractions
variability
increased distance/amplitude, speed, direction of mvmt
part task –> whole task
decrease BoS
softer support
increase attentional demands
How do you analyse the movement of a stroke patient
determine missing components and compensation strategies and then determine impairments and their causes
Goal directed movement depends on … for the upper limb
object position in space
object characteristics
what you do with the object
phases of reaching and manipulation
transportation phase: hand moves to target
Manipulation phase: what you do with object once you reach it
what joints are important in the transportation phase
shoulder, elbow and wrist
what joints are important in the manipulation phase
distal aspects of UL
hand eye coordination
Essential components of reaching
Protraction and elevation of shoulder
ER, flexion, abduction, extension of shoulder
extension/flexion of elbow
pronation/supination of forearm
extension and radial deviation of wrist
extension of fingers and abduction of thumb (opening of hand)
Essential component of manipulation
flexion/extension of wrist and fingers
flexion and abduction (conjoint rotation) of thumb and fingers
closure of thumb and fingers (MCP joint flexion and IPJ in some extension)
Cupping of hand
independent finger movements
some patterns of compensation in UL impairment
inactivity of shoulder abductors + flaccid RC: patients can’t set scapula and elevate shoulder as result (hike)
distal muscles often affected
general resting posture in hemiparetic arm: IR, adduction, elbow flexion, forearm pronation, thumb adduction, finger and wrist flexion
coactivation of muscles and poor control of synergistic muscles: lack of coordination between segments
Potential compensatory strategies for reaching
hip flexion, excessive elevation, abduction and IR of shoulder when reaching forward
lateral flexion of trunk to intact side
excessive elbow flexion, pronation of forearm and wrist flexion
increased trunk contribution to movement
slower, less accurate and more segmented
use of intact arm for all reaching tasks
potential compensatory strategies for manipulation
excessive wrist flexion when grasping and manipulating objects
excessive aperture for grasp and release
excessive force when grasping
extension of CMC joint of thumb and pronation of forearm for grasp and release
use of intact hand
underlying impairment for lack of shoulder elevation (missing essential component)
weak RC muscles
lack of scapulohumeral rhythm so inability to stabilise scapula
underlying impairment for lack of supination (missing essential component)
pronator tightness
supinator weakness
underlying impairment for lack of wrist extension (missing essential component)
extensor weakness
flexor tightness
underlying impairment for lack of shoulder flexion/protraction (missing essential component)
Protractor/shoulder flexor weakness
IR Tightness
underlying impairment for lack of elbow extension (missing essential component)
elbow flexor tightness
elbow extensor weakness
Devices/programs used to increase repetitions and independence and improve neuroplasticity
CIMT
Robotics
Assistive devices
Inclusion criteria for CIMT in UL Stroke
10 degs of active wrist extension
10 degs thumb abduction
10 degs finger extension
minimal cognitive/perceptual deficits
When is mirror therapy suitable for UL stroke patients
patients with flaccid hand as it provides a visual illusion of movement to promote motor recovery
provides feedback that the hand is actually functioning
other treatments for stroke rehab in the UL
VR
Robotics
Video games and mental practice
Essential components of bridging to shifting
flexion of hips
flexion of knees
dorsiflexion of ankles
hip extension
hip abduction or adduction
triceps / upper extremity muscles
Essential components of rolling over in bed
rotation and flexion of the neck
hip and knee flexion
flexion and protraction of the shoulder
rotation with the trunk
common adaptive strategies of rolling over in bed
wriggling instead of turning
pulling with intact arm
Essential components of SOEOB
Lateral flexion of neck
lateral flexion of trunk and SH abduction + elbow extension of lower arm
legs lifted and lowered over side of bed
common adaptive strategies of SOEOB
flexion and rotation of the neck forward
excessive pushing up on intact arm
hooking intact leg under affected leg
falls backwards
Essential components of sitting
ankles plantargrade
Feet and knees close together
weight evenly distributed
flexion of knees/hips with extension of trunk (i.e. shoulders over hips)
head balanced on level shoulders
common adaptive strategies of sitting
widening of BOS i.e. feet and/or knees too far apart or one or both hips ER, using arms for support
shifts weight to intact foot/buttock
flexes forward when the task requires the body weight to be shifted sideways
shuffles feet
uses arms for balance
avoids balance threat by decreasing movement speed and amplitude and/or holding stiffly and/or holding breath
Essential components of STS
Pre-extension phase (flexion momentum + momentum transfer)
- rapid trunk flexion by flexion at the hips and an extended trunk
- posterior feet movement (ankle DF)
Extension phase
- movement of the knees forward (relative DF)
- hip extension (gluteal complex)
- knee extension (quads)
Stabilisation phase
- reactive postural movements + knee/hip/ankle control
Common adaptive strategies in STS
pre extension phase
- weight borne through intact side
- wide BOS
extension phase
- falls backwards
- pushes through arms
- weight borne through intact side
- final alignment flexed
common impairments for STS
Weak LL muscles - quads, hammies, iliopsoas
Weak trunk
limited ROM - ankle and knee
Part task training for STS
strengthen knee/hip flexion and knee/hip extension
Practice moving bottom forward
train increase in knee flexion
train increase in hip flexion
Whole task training for STS
train on hard chair
train on high chair
train with assist
train in a quiet room
add speed, cognitive task, physical task
Equipment used to assist with bed mobility
bed rails
leg lifters
slide sheets
transfer boards
Essential requirements of walking
Progression: progress COM over new BOS each time we step
Postural control: need to control body against gravity to move COM forward
Adaptation: adjust movement to demands of environment
Stance : Swing ratio
60% stance
40% swing
Stance phases
initial contact
loading response
mid stance
terminal stance
pre-swing
Swing phases
initial swing
mid swing
terminal swing
Initial contact
coming from swing so need to decelerate and prepare for extension
Hip extensors, knee flexors and ankle dorsiflexors work eccentrically to decelerate leg
Loading response
shifting weight to landing leg. Phase of shock absorption
Hip extensors, knee extensors and tib ant work eccentrically to help with shock absorption
Mid stance
Drive COM forwards. In SL stance so need to control pelvic alignment (glute med)
Glute med and plantarflexors are main drivers inthis phase
Knee and hip extension (reduced activity due to GRF in middle of joint)
Terminal stance
Stretch flexors in preparation for swing to generate energy
Plantarflexors working eccentrically, quads and hamstring generate energy to maintain knee and hip extension,
Pre-Swing
everything stretched from terminal phase generates energy in this stage. Convert to strong concentric contractions
Hip flexors drive leg forwards
hamstrings maintain knee flexion
activation of tib ant to counter strong PF generated during push off
Mid-Swing
leg acts as pendulum
hip flexors, dorsiflexors and hamstrings activated
Terminal Swing
Deceleration of swinging limb
Hip extensors contract
Knee flexors contract eccentrically to slow knee extension
Dorsiflexors contract to prepare for heel contact
Walking Essential Components
Initial alignment
- ankles dorsiflexed
- hips neutral
- feet shoulder/hip width apart
Stance
- extension of hip throughout
- flexion of knee on heel strike. Extension in midstance, flexion prior to toe off
- DF until end of stance. Fast PF (push off)
Swing
- flexion of knee. Knee extends to heel strike
- flexion of hip
- DF of ankle
Common compensatory movements in walking
Walking slowly and increased time in double support
Short step lengths
Trunk inclined forwards during stance
Wide BoS
Toes not clearing the ground during swing
Trunk inclined backwards at the end of swing
Compensation from weak propulsion in terminal stance
excessive hip or knee flexing
circumducting the leg
lifting opposite leg by going into plantarflexion
Equipment and technology used to increase reps and intensity and efficiency of walking
BWS
robotics
AFOs
VR
Circuit class
