Stroke Rehab - Erika Flashcards
Define stroke
a cerebral vascular event with rapidly developing clinical signs of focal or global disturbances of cerebral function lasting >24hrs
Two subtypes of stroke (with percentages)
- Ischemic (85%) - a. thrombotic (35%) b. Embolic (30%) c. Lacunar (20%)
- Hemorrhagic (15%) - ICH, SAH
Define TIA
symptoms lasting from 1 hour to < or = 24 hours
Stroke is the ___ leading cause of death.
3rd
HD 1, cancer 2
1 in 16 deaths in US due to stroke
Incidence of stroke (new vs recurrent)
780,000; 600,000 new; 180,000 recurrent
______ million stroke survivors inthe US
> 5.8 million
Soemone has a stroke every ____ seconds. someone dies from a stroke every ____ minutes
40 seconds, 3-4 minutes
Ethnicity of stroke:
Blacks (2x) > Hispanics > whites > asians
Name the non-modifiable risk factors of stroke(4)
- Age - single most important (risk doubles each decade after age 55)
- Race/ethnicity (Black 2x> whites
- family history of stroke
- personal history of stroke or TIA - estimated 5% of patients with prior TIA will have stroke within 1 month if treatment not initiated.
Name the modifiable risk factors of stroke. 4 major (5 others)
- HTN (most important) - 7 fold increase. Pts with <120/80 have 1/2 the lifetime risk of stroke
- DM (2x risk)
- CAD/CHF (2x risk)
- smoking (2x risk)
- estrogens, hypercoagulable states, migraine HA, OSA, PFO
Thrombotic strokes affect ____ arteries.
Usually occur during ____
Large arteries
sleep
Thrombotic (35%)
Embolic strokes are most commonly 2/2:
cardiac thrombus due to afib
____ % of cardiogenic emboli go to the brain
75% - usually occurs during waking hours
Define Lacunar stroke
small infarcts (<15mm) usually seen in putamen, pons, thalamus, caudate, internal capsule
20% of strokes are lacunar
Lacunar strokes are due to ____
small vessel disease (deep penetrating arteries)
Lacunar strokes have strong coorelation with _____
HTN 80%
#1 cause of ICH is \_\_\_\_\_ Usually associated with \_\_\_\_\_
HTN, sudden onset HA
Most common location of ICH. Second?
Putamen
cerebellar
SAH most commonly due to
ruptures in saccular (berry) aneurysms
____% of aneurysmal SAH occur in anterior system:
90-95% in anterior circulation
If young, normal BP, low pressure system, think:
AVM - congenital, low pressure systems. Smaller ones are more likely to rupture. if increased pressure
Mortality in the first year after stroke: _____%
25-40%
Risk factors for 30 day mortality: (9)
- stroke severity
- Low GCS
- T2DM
- CAD
- Age
- Delay in medical care
- Brainstem involvement
- Hemorrhagic stroke
- Admission from SNF
_____ occurs in up to 75% of untreated stroke survivors
DVT
___ x increased risk for DVT in plegic limb
10 x
____% mortality rate from PE
10%
DVT ppx safe to use _____ after stroke
24-48h
_____% of stroke patients have neurogenic bladder
40-80%
regarding neurogenic bladder following stroke, ___% regain function (at ___ months)
85%; 6 months
Rule of 4s:
There are 4 structures in the midline beginning with M
There are 4 structures to the side beginning with S
There are 4 cranial nerves in the medulla, 4 in the pons, and 4 above the pons (2 in the midbrain)
The 4 motor nuclei that are in the midline are those that equally divide into 12 and are not 1 or 2 = 3, 4, 6, 12
4 structures in the midline: medial pathway (rule of 4s)
Motor Pathway (corticospinal tract): Contralateral weakness of Arm & Leg
Medial Lemniscus: Contralateral loss of vibration and proprioception
Medial Longitudinal Fasciculus: Ipsilateral internuclear ophthalmoplegia
Motor nucleus and nerve: Ipsilateral loss of CN affected (3,4,6,12)
Weber Syndrome affects:
Usually obstruction of _____
Based on rule of 4s: (3)
- medial midbrain:
Usually obstruction of branches of PCA
Based on Rule of 4’s s/sx:
Contralateral hemiplegia
Contralateral loss of vibration and proprioception
Ipsilateral CN 3 palsy (usually CN 4 too!)
Millard Gubler syndrome affects ____
Obstruction of ____
Based on rule of 4s: (4)
- Ventrocaudal “medial” pons
- circumferential branches of basilar artery
Contralateral Hemiplegia (including face!)
Ipsilateral internuclear ophthalmoplegia
Ipsilateral CN6 palsy
With extension into medial lemniscus= Raymond-Foville Syndrome (add loss of vibration and proprioception on contra side)
Medial medullary syndrome
Caused by obstruction of:
Based on rule of 4s: (4)
penetrating branches of vertebral artery
Contralateral hemiplegia
Contralateral loss of vibration and proprioception
No MLF involvement due to caudal location of CVA
CN 12 palsy (deviation toward side of lesion)
4 lateral structures (rule of 4s)
Spinocerebellar Pathway: Ipsilateral ataxia of Arm & Leg
Spinothalamic Pathway: Contralateral loss of Pain & Temperature of Arm & Leg
Sensory Nucleus of 5th CN: Ipsilateral loss of pain and temp on the face
Sympathetic Pathway: Ipsilateral Horners syndrome (ptosis, miosis, anhydrosis)
Wallenburg syndrome AKA: ____
Obstruction:
Rule of 4s:
Lateral medullar syndrome PICA Ipsilateral ataxia of arm and leg Decreased pain and temp in arm and leg Decrease in pain and temp on ipsilateral face Horners syndrome
Locked in syndrome definition:
Has sparing of _____
Due to ______
Tetraparesis with patients only able to move eyes vertically or blink
Patient is fully conscious due to sparing of the Reticular Activating System
Due to bilateral lesions in ventral pons (basilar artery occlusion
Name the location of these lacunar syndromes: 1 Pure sensory stroke 2 Pure motor stroke 3 Clumsy hand Syndrome 4 Ataxic hemiparesis 5 Hemichorea-Hemiballismus
1 Thalamus
2 Posterior limb internal capsule, corona radiata
3 Basis Pontis, Anterior limb of IC
4 Corona radiata, Internal capsule, Pons, Cerebellum
5Head of caudate, thalamus, subthalamic nucleus
definition of impairment
Any loss or abnormality of psychological, physiological, or anatomical structure or function
definition of disability
Activity limitation that creates a difficulty in the performance, accomplishment, or completion of an activity in the manner or within the range considered normal for a human being
6 categories of impairment (stroke)_
Motor Sensory Visual Language Cognition Affect
4 tools for measuring stroke impairment
National Institute of Health Stroke Scale (NIHSS)
Canadian Neurologic Scale
Chedoke-McMaster Stroke Assessment
Orpington Prognostic Score
designate stroke severity depending on NIHSS
Scored from 0 to 42 0 = no stroke 1-4 = minor stroke 5-15 = moderate stroke 16-20 = moderate/severe stroke 21-42 = severe stroke
regarding prognosis, for each 1 point increase in initial NIHSS:
seful as a prognostic tool
For each 1-point increase in initial NIHSS, likelihood of return to home significantly reduced*
4 ways to measure disability (stroke)
Functional Independence Measurement (FIM) Score
Barthel Index
Rankin Score
Modified Rankin Scale
5 factors to help predict outcomes in stroke rehab patients
2 modifiers to this
1 Severity of Stroke (NIHSS) 2 Age 3 Admission FIM 4 Cognition 5 Pre-morbid functional status (Medical co-morbidities)
MODIFIERS:
1 Nature and degree of social support
2 Type and quality of training and adaptation program provided
efficacy of stroke rehab:
Twenty-six trials (5592 participants) compared stroke unit care with general wards.
Stroke patients who receive organized inpatient care in a SU are more likely to be alive, independent, and living at home one year after the stroke
No systematic increase was observed in the length of inpatient stay
5 criteria of stroke rehab unit
Dedicated stroke team members
Inter-disciplinary model
Regular measure of outcomes and regular team communications (at least weekly rounds)
Routine involvement of patient and family &/or care-givers
Continued education & training programs
3 primary goals of rehab
Prevent complications
Minimize impairments
Maximize function
what 2 things are critical to optimize rehabilitation
Early assessment and intervention
17 factors to address to minimize impairment
Aphasia Apraxia Neuralgia Shoulder problems Depression Equipment Medications Fatigue Sexuality Medical problems Motor weakness Sensory / visual deficits N. Bladder N. Bowel Dysphagia Nutrition/hydration Spasticity
Up to ___% of stroke patients have hemiparesis.
88
Discuss process of motor recovery as a series of events: (4)
- Big muscles before small muscles
- leg before arm
- synergistic before isolated
- Most motor recovery in first 3-6 months. but up to >2 years after stroke
Brunnstroms stages of stroke recovery
- flaccidity - immediately after onset of stroke - no voluntary movement (reflexes come back at 48h)
- Spasticity appears; basic synergy patterns appear
- voluntary control overy synergy. increase in spasticity
- Some movement out of synergy but synergy pattern still dominates.
- More complex movements and isolated movement dominate over synergy
- Disappearance of spasticity
- normal function restored
Main predictor of motor recovery based on clinical exam:
if patient shows isolated hand movements by 4 weeks –> 70-80% functional recovery of the arm.
poor prognosis in motor recovery associated with (3)
No movement of hand at 4 weeks.
prolonged “flaccidity” perior
No movement at stroke onset.
____% of stroke patients will recover the ability to ambulate short distances without assistance
Slightly
80%
50%
10%
Rehab “techniques” for motor recovery
- Proprioceptive neuromuscular facilitation (PNF)
- Bobath approach
- Brunnstrom approach/movement therapy:
- Sensorimotor approach/rood approach
- uses spiral and diagonal components of movements in cardinal planes of motion to facilitate movements with functional relevance.
- (neurodevelopmental technique) goal of NDT is to normalize tone, inhibit primitive patterns of movement, and facilitate automatic voluntary reactions and normal movement patterns
- Uses primitive synergistic patterns in training in attempt to improve motor control through central facilitation.
- Modification of muscle tone and voluntary motor activity using cutaneous sensorimotor stimulation.
In order to apply contraint-induced movement therapy (CIMT): patient must be able to
extend wrist and actively move fingers
shown clinical significant improvement in arm fxn >1 year.
Post stroke depression felt to be secondary to (2)
depletion of catecholamine due to CVA
reactive response to stroke.
up to ___% of stroke patients become depressed
80%
Risk factors for post-stroke depression:
- prior psych history
- significant impairment in ADLs,
- non-fluent aphasia, cognitive impairment, lack of support
best treatment for post-stroke depression
SSRIs - now have some evidence for motor recovery
Post-stroke seizures are most commonly which type?
hemorrhagic vs ischemic
- simple partial seizures
2 hemorrhagic (or large area CVA) - more common in cortical lesions
____% of stroke patients have shoulder pain.
Due to which 5 things?
75-80%
Subluxations, Spasticity, CRPS I - stellate ganglion block is for patient’s with ipsilateral Horner’s. Also tendonitis/rotator cuff tear/frozen shoulder , heterotopic ossification
overall prevalence of dysphagia ____% in stroke
More common in ____ vessel and ____ strokes
Most common abnormality in stroke dysphage?
65%,
large vessel, bilateral strokes
delayed pharyngeal swallowing (*because this phase requires soft palate elevation, laryngeal elevation, and coordinated pharyngeal constriction & cricopharyngeal relaxation= COMPLEX COORDINATED MOTION!)
two major methods of dysphagia compensatory strategies
4 others
Chin Tuck: provides airway protection by preventing the entry of liquid into the larynx by facilitating forward motion of the larynx (also increases pharyngeal pressure to move bolus through
Head Rotation: Closes ipsilateral pharynx which forces bolus into contralateral pharynx and decreases cricopharyngeal pressures. Turn head to PARETIC SIDE.
Others: head tilt, supraglottic swallow, super supraglottic swallow, mendelsohn maneuver
Aspiration pna caused by:
Up to ____% missed by bedside swallow.
____ gold standart to assess swallow
_____% o stroke patients have dysphagia on MBS
penetration of substance into the rachea (then the lung)
60%
MBS
50-70%
RFs for getting aspiration PNA
decreased LOC, trach, emesis, reflux, NG tube prolonged pharyngeal transit time
definition of aphasia:
Type depends on
an impairment of the ability to utilize language
location
what is melodic intonation therapy?
recruits the right hemisphere by incorporating melodies with simple statements. Useful in non-fluent aphasia
Aphasia, Fluent, Comprehends, Repeats
Anomic aphasia
Aphasia: Fluent, Comprehends, cannot repeat
conduction aphasia
Aphasia: Fluent, cannot comprehend, repeats
transcortical sensory
Aphasia: fluent, cannot comprehend, cannot repeat
Wernickes
Aphasia: afluent, comprehends, repeats
transcortical motor
Aphasia: afluent, comprehends, cannot repeat
broca
Aphasia: afluent, cannot comprehend, repeats
mixed transcortical aphasia
Aphasia afluent, cannot comprehend, cannot repeat
global
