Stroke Rehabilitation

Question 1

what is the definition of a stroke

Answer 1

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

Question 2

what is a stroke that lasts less than 24hrs called

Answer 2

transient ischemic attack - tia dosnt cause infarction of the brain -

Question 3

define stroke

Answer 3

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

Question 4

what are the types of stroke

Answer 4

ischaemic

haemhorrhagic

transient ischameic arrack - tia - warning sign that stroke could happen

Question 5

what is a ischameic stroke

Answer 5

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

Question 6

what are the causes of an ischameic stroke

Answer 6

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

Question 7

what is a haemorrhagic stroke

Answer 7

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

Question 8

what is a transient ischameic attack

Answer 8

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

Question 9

what does having a TIA put people at risk of

Answer 9

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.

Question 10

what neuroimaging is used for people with strokes

Answer 10

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

Question 11

what are the treatment options for different types of strokes

Answer 11

Aspirin, or alternative
Secondary prevention

Ischaemic stroke
Thrombolysis
Thrombectomy
Anti-platelets
Cardiac?

Haemorrhagic stroke
Blood pressure lowering
Review of anticoagulants / antiplatelets

Question 12

what reduces chances of having a stroke long term

Answer 12

Antiplatelet – clopidogrel
Atrial Fibriliation- when heart isn’t pumping properly causing blood clots
Combined with anticoagulants
Statins
Blood pressure
Lifestyle changes

Question 13

what is a thrombectomy

Answer 13

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

Question 14

what are the common findings for people who have strokes

Answer 14

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

Question 15

what is the prevalence of having visual problems after having a stroke

Answer 15

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

Question 16

what ward based assessmentts are done

Answer 16

Visual Acuity
Reading assessment
Cover Tests
Ocular Motility
Eye movement systems
Visual Fields
Visual inattention

Question 17

what can a orthoptist offer

Answer 17

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)

Question 18

what enquires need to be done concerning vision

Answer 18

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

Question 19

how is reduced vision managed

Answer 19

Good lighting is essential

Use of contrast to make things stand out: bolder, brighter

Ensure patient has glasses from home

Question 20

what might reduced/low vision be due to

Answer 20

Uncorrected refractive error
(Out of date glasses, glasses at home, dirty,
ill-fitting, ‘borrowed’)
Nystagmus
Pre-existing ocular pathology- e.g cataracts, glaucoma, amd

Question 21

what practical things can be done to adapt smartphones/tablets

Answer 21

Good lighting is essential

Use of contrast to make things stand out: bolder, brighter

Ensure patient has glasses from home

Question 22

what needs to be done about pre-existing care

Answer 22

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.

Question 23

the more posterior the lesion…… the more

Answer 23

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

Question 24

what are the different types of visual defects

Answer 24

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

Question 25

what is the likelihood of recovery from a visual field defect and what is the most common type of visual field defect

Answer 25

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

Question 26

what visual field assessment needs to be done

Answer 26

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)

Question 27

how are visual field defects managed

Answer 27

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

Question 28

what are the driving requirements

Answer 28

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.

Question 28

if dvlc needs a visual assessment for determine fitness to drive it

Answer 28

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.

Question 29

what Are th exepctional cases for driving

Answer 29

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

Question 30

what reading and writing strategies can be implemented

Answer 30

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

Question 31

what are the different types of classifications of eye movements

Answer 31

smooth pursuits

vergences

saccades

optokinetic (own)

vestibular ocular reflex (VOR)

Question 31

what are other reading strategies that can be used to help

Answer 31

Typoscopes / line guides
Issue of low vision aids /magnifiers

Question 32

what needs to be tested when testing smooth pursuits and saccades

Answer 32

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?

Question 33

what is the management for intracebral heamorrhage

Answer 33

Blood pressure lowering

Removal of anticoagulant treatments

Reducing intracranial pressure

Question 34

what can orthoptist offer

Answer 34

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)

Question 35

what needs to be noted with regards to vergence and VOR

Answer 35

Vergence
Convergence issues?

VOR
Doll’s head testing
Differential diagnosis of supranuchlear gaze palsies

Question 36

what different visual innatenton tests can be done

Answer 36

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

Question 37

how is visual innatenton managed

Answer 37

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.

Question 38

what has been found with regards to visual perception/awareneess

Answer 38

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%)

Question 38

what has been found with visual inattention/negelect

Answer 38

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

Question 39

what is cortical blindness

Answer 39

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.

Question 40

what are visual hallucinations often found with

Answer 40

Visual hallucinations / Charles Bonnet syndrome

Often with hemianopia
Under reported
Reassurance helpful

Question 41

how are eye movement defects managed

Answer 41

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