Stroke Rehabilitation Flashcards
what is the definition of a stroke
rapidly developing clinical signs of focal or global disturbance of cerebral function lasting more than 24 hrs or leading to death , with no apparent cause apart that of vascular origin
what is a stroke that lasts less than 24hrs called
transient ischemic attack - tia dosnt cause infarction of the brain -
define stroke
an innteruption of blood supply to the brain which causes permeant damage to the brain tissue and affects brain function
can be physical emotional or cognitive
what are the types of stroke
ischaemic
haemhorrhagic
transient ischameic arrack - tia - warning sign that stroke could happen
what is a ischameic stroke
infarction of the brain cells (80-85%)
occlusive mechanism which cuts off blood supply to the brain tissue
can occur within the cerebral blood vessels
can occur in the body and transported to the brain
can occur within the deep brain tissues
what are the causes of an ischameic stroke
embolism
thrombus
lacunar
blockage of blood vessel due to embolus - blood clot or fatty plaque usually though the carotid artery
most common type of stroke
what is a haemorrhagic stroke
occurs when a blood vessel in or around the brain bursts causing a haemorrhage
(bleed)
types- within thee brain tissue (intracerebral haemhorrhage)
between the brain and the skull
subarachnoid haemhorrhage
often Moree devastating type of stroke (10-15%)
blood vessel has burst - wide spread bleeding on the brain - blood spreads on the brain causing lots of damagee
what is a transient ischameic attack
Also known as a mini stroke
The blood supply is briefly interrupted which last for less than 24 hours without causing cerebral infarction and there is full spontaneous recovery
Temporary symptoms
A warning-sign that part of the brain is not getting enough blood
Increased risk of a more serious stroke in future
Must seek medical attention immediately
what does having a TIA put people at risk of
around 10 percent risk of subsequent stroke in the first year
sustained risk through to 5 years
abcd2 score = age , blood pressure, clinical features , duration and diabetes
Estimation of risk of stroke @ 2 days, 7 days and 90 days.
Scored out of 7- higher score greater risk
Not perfect
For example, a young person with a history of IV drug use and a new murmur presenting with a brief episode of facial tingling might have an ABCD2score of 0 yet may be at high short-term risk of stroke.
what neuroimaging is used for people with strokes
Rapid and cheap
Uses x-rays
Exclude haemorrhage
Suitability for clot-busting drugs or clot-retrieval
May not show sub-acute ischaemia / infarction – e.g. false, negative
Magnetic Resonance Imaging (MRI) scan
More detailed
Non-radioactive
Time consuming and costly
what are the treatment options for different types of strokes
Aspirin, or alternative
Secondary prevention
Ischaemic stroke
Thrombolysis
Thrombectomy
Anti-platelets
Cardiac?
Haemorrhagic stroke
Blood pressure lowering
Review of anticoagulants / antiplatelets
what reduces chances of having a stroke long term
Antiplatelet – clopidogrel
Atrial Fibriliation- when heart isn’t pumping properly causing blood clots
Combined with anticoagulants
Statins
Blood pressure
Lifestyle changes
what is a thrombectomy
More recent development of interventional medicine
Specially-designed clot removal device inserted through a catheter to pull or suck out the clot to restore blood flow
Larger clots or clots not suitable for thrombolysis
Administered up to 6 hours
Highly skilled procedure
what are the common findings for people who have strokes
Prevalence of visual impairment was 92%
sub-population of stroke patients
unknown number of patients not recruited to the study due to a lack of pre-identified visual impairment
Common findings
Low vision
Visual field loss
Visual perception deficit
Eye movement defect
Combination of above
what is the prevalence of having visual problems after having a stroke
58% for all stroke admissions
73% for stroke survivors (7/10 people with a stroke will have a vision problem)
The incidence for new post-stroke visual impairment
48% for all stroke admissions
60% for stroke survivors
what ward based assessmentts are done
Visual Acuity
Reading assessment
Cover Tests
Ocular Motility
Eye movement systems
Visual Fields
Visual inattention
what can a orthoptist offer
In-depth assessment
Advanced knowledge of vision
Referral to ophthalmology / ECLO / LVA service
Advice on CVI registration
Treatment and management of vision and eye movement disorders
Prescribe coloured overlay for glare
Advise to attend optician or arrange domiciliary care- (they come to your home)
what enquires need to be done concerning vision
Enquiries about vision NOW
How was vision before stroke?
Does vision feel normal / worse / affected?
Any double vision / reduced vision
Ask patient to read something at near and distance
Check for accuracy / speed / fluency / head movements
Enquires about visual needs FUTURE
car drivers / avid readers / gardeners / socialites
how is reduced vision managed
Good lighting is essential
Use of contrast to make things stand out: bolder, brighter
Ensure patient has glasses from home
what might reduced/low vision be due to
Uncorrected refractive error
(Out of date glasses, glasses at home, dirty,
ill-fitting, ‘borrowed’)
Nystagmus
Pre-existing ocular pathology- e.g cataracts, glaucoma, amd
what practical things can be done to adapt smartphones/tablets
Good lighting is essential
Use of contrast to make things stand out: bolder, brighter
Ensure patient has glasses from home
what needs to be done about pre-existing care
Patients may have dry eyes, glaucoma, eye infections or other eye conditions.
Patients may forget about eye drops or be unable to administer them. These patients will require assistance from family and hospital staff.
the more posterior the lesion…… the more
Partial or complete, quad or hemi
The more symmetrical the defect the more posterior the lesion- becauss the pathways correspond more
Lesion more anterior could be quadrantopia or hemianopia
what are the different types of visual defects
homonymous hrmianoptia due to lesion or pressure on optic tract
total blindness of right eye due to midline chasmal lesion
right nasal hemianopia due to lesion inkling right perichiasmal lesion
left homonymous hemianopia du to lesion or pressure on optic tract
left homonymous inferior quadranttpia du to involvement of lower right optic radiators
left homonymous superiornquantropia due to involvement of upper right optic radiations
left honoymous hemianopia due to lesion of right occipital lobe
what is the likelihood of recovery from a visual field defect and what is the most common type of visual field defect
Visual field loss due to stroke usually hemianopic (often associated with visual inattention)
Recovery (if occurs expected within 4 – 6/52)
45% recovered (7% full recovery, 38% partial – VIS study)
Partial or complete, quad or hemi
Within first 4-6 weeks beest recovery of visual field loss
Only half recover fully
what visual field assessment needs to be done
Visual fields to confrontation
1m distance
Present your hands at midway
Compare with your own ‘normal’ field
Hands (hemianopia)
Finger counting
Kinetic targets (move out to in)
how are visual field defects managed
Head positioning / bed position
Scanning / use of markers for first and last word when reading
Exaggerated head movements
Lighting
Read right
BIOS Information leaflet
Vision Sim for carers
Driving advice
what are the driving requirements
Group 1 driving is defined in the legislation:
A field of at least 120° on the horizontal measured using a target equivalent to the white Goldmann III4e settings.
The extension should be at least 50° left and right. In addition, there should be no significant defect in the binocular field that encroaches within 20° of the fixation above or below the horizontal meridian.
This means that homonymous or bitemporal defects that come close to fixation, whether hemianopic or quadrantanopic, are not usually acceptable for driving.
if dvlc needs a visual assessment for determine fitness to drive it
requires the method to be a binocular Esterman field test
may request monocular full field charts in specific conditions
exceptionally, may consider a Goldmann perimetry assessment carried out to strict criteria
Fields must be reliable
Esterman binocular chart <20% false-positives
Monocular charts and Goldmann perimetry, fixation accuracy will also be considered.
what Are th exepctional cases for driving
Group 1 drivers whose previous full driving entitlement was removed because of a field defect failing to satisfy the standard may be eligible for individual relicensing consideration as exceptional cases under the following strict criteria:
defect must have been
present for at least 12 months
caused by an isolated event or a non-progressive condition
there must be no other condition or pathology regarded as progressive and likely to be affecting the visual fields
sight in both eyes
no uncontrolled diplopia
no other impairment of visual function
clinical confirmation of full functional adaptation
what reading and writing strategies can be implemented
When reading, rulers and markers can be used to highlight the beginning and end of sentences and to help a patient keep their position along a line of text.
Strategies to help include exaggerated eye and head movements / rotating text into different position.
Vertical reading is more challenging
Requires patient to ‘re-learn’
Practising reading moving text has been shown to improve reading speeds on normal text
what are the different types of classifications of eye movements
smooth pursuits
vergences
saccades
optokinetic (own)
vestibular ocular reflex (VOR)
what are other reading strategies that can be used to help
Typoscopes / line guides
Issue of low vision aids /magnifiers
what needs to be tested when testing smooth pursuits and saccades
Smooth pursuits
Is the patient able to fix and follow into the cardinal positions of gaze?
Are they smooth? Are they jerky?
Do the eyes move fully into the area of gaze?
Saccades
These should be fast and accurate re-fixations between gaze
Can be used to differentiate types of gaze palsies?
Are we under-estimating the number of gaze palsies?
what is the management for intracebral heamorrhage
Blood pressure lowering
Removal of anticoagulant treatments
Reducing intracranial pressure
what can orthoptist offer
Advanced knowledge of vision
Referral to ophthalmology / ECLO / LVA service
Advice on CVI registration
Treatment and management of vision and eye movement disorders
Prescribe coloured overlay for glare
Advise to attend optician or arrange domiciliary care- (they come to your home)
what needs to be noted with regards to vergence and VOR
Vergence
Convergence issues?
VOR
Doll’s head testing
Differential diagnosis of supranuchlear gaze palsies
what different visual innatenton tests can be done
General consensus that a test battery is advantageous-.i.e. do more than 1 test
Multitude of tests to choose from
Limited guidance on interpretation of results
how is visual innatenton managed
Use of general visual stimulation: objects, relatives on neglecting side, family photos etc.
Eye scanning and tracking games – cards, boards games, connect 4, jigsaws, wall games
Coloured stickers/vertical line guides of high contrast when reading
Apps - Visual therapy apps (Visual Attention Therapy App), Eye search
BIOS information leaflet
Bed position
Encourage staff and visitors to always sit on the affected side of the person with neglect.
For people who like looking out the window or into the hallway, have their bed positioned so those things are on their affected side.
Interesting items like colorful lights, photographs, or the television can be placed on the affected side.
People with visual inattention are often highly distractible and find it difficult to sustain their attention. Before they embark on any important tasks, try to reduce environmental distractions such as background noise and extra people. Their inattention is likely to be much worse when they are fatigued.
While challenging the affected side is therapeutic, if you have something very important to show them or tell them, do it on the strong side as not to frustrate the person.
what has been found with regards to visual perception/awareneess
Perceptual deficits accounted for 18% of visual impairment in VIS Study
Largest group of patients with left sided visual inattention/neglect (14%)
Small number had visual hallucinations (2.5%) and object agnosia- when a pt struggles to identify what an object is (2.2%)
what has been found with visual inattention/negelect
Variable signs/symptoms from complete unawareness of anything on one side to missing odd letter/word from a line of text
Important predictor of poor functional recovery and outcome; requires longer in-patient stay
Recovery: greatest in first month post-stroke- quicker adaptation = better rehabilitation
May co-exist with visual field loss
what is cortical blindness
Cortical blindness is the total or partial loss of vision in a normal appearing eye.
Caused by damage to the occipital cortex
In most cases the total loss of vision is not permanent and some vision may recover
Anton – Babinski syndrome – a rare occurrence where people with cortical blindness have little or no insight into their loss of vision. People with this condition often report no loss of vision and are adamant their vision is normal.
what are visual hallucinations often found with
Visual hallucinations / Charles Bonnet syndrome
Often with hemianopia
Under reported
Reassurance helpful
how are eye movement defects managed
Symptoms may include double vision, oscillopsia (moving images) or reading difficulty
Alleviate diplopia using occlusion/eye patch or advice on head postures
Patch can be worn over either eye
