STROKE
Stroke (cerebrovascular accident [CVA]) is the sudden loss of neurological function caused by an interruption of blood flow to the brain. Ischemic stroke is the most common type results when a clot blocks or impairs blood flow, depriving the brain from essential oxygen and nutrients. Hemorrhagic stroke occurs when blood vessels rupture, causing leakage of blood in and around brain. Clinically, variety of focal deficits are possible, including changes in the level of consciousness, impairments of sensory, motor, cognitive perceptual, and language functions. To be classified as stroke, neurological deficits must persist for at least 24 hrs.Once blood flow falls below the threshold , for maintainance of electrical activity neurological deficit develops. At this level of blood flow neurons are still viable, if blood flow increases again, function returns and patient will have had a transient ischemic attack (TIA).[1]

 

ETIOLOGY:

• Atherothromboembolism

• Intracranial hemorrhage

• Subarachnoid hemorrhage

• Intracranial small vessel disease

• Arterial aneurysms  

• Arterio-venous malformation

• Haematological disorders (haemoglobinopathies, leukemia) 

 

IMPAIRMENTS

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BODY STRUCTURES AND FUNCTIONS

 

DIRECT

1. Altered sensations- 

   • Pain ( thalamic pain syndrome) characterized by constant severe burning pain with intermittent  sharp pain.

   • Hyperalgesia

   • Loud sound, bright light may trigger pain.

2. Vision 

   • Homonymous hemianopia, a visual field defect, occurs with lesions involving the optic radiation (MCA) or to primary visual cortex (PCA)

   • Visual neglect & problems with depth perception, and spatial relationships

3. Weakness

   • Usually seen in the contralateral side of the lesion 

   • MCA stroke are more common so weakness is largely seen in the UL in clinical practice 

   • Distal muscle are more affected than proximal muscles 

   • Mild weakness of ipsilateral side

4. Alteration of tone 

   • Flaccidity (hypotonicity) is present immediately after stroke

   • Spasticity (hypertonicity) emerges in about 90 percent of cases

5. Abnormal synergy

   • There could be Flexor synergy or Extensor synergy components  seen in bot upper as well as lowerlimb.

6. Abnormal reflexes 

   • Initially, hyporeflexia with flaccidity & later hyperreflexia 

   • May demonstrate clonus, & +ve Babinski

   • Most commonly seen is asymmetric tonic neck reflex (ATNR) 

   • Associated reactions- unintentional movements of hemiparetic limb caused by voluntary action of another limb by stimulation of yawning, sneezing, or coughing.

7. Altered coordination

   • Sensory ataxia/cerebellar ataxia/bradykynesia ( according to the affected structures)

8. Altered motor programming

   • Apraxia- Ideational OR Ideomotor

9. Postural control and balance affection

10. Speech, Language, and Swallowing

    • Aphasia, Dysarthria, Dysphagia

11. Emotional Status 

    • Emotional dysregulation syndrome

    • Depression

12. Perception and Cognition

    • may include disorders of body scheme/body image, spatial relations, and agnosias.

13. Bladder and Bowel Function disturbances

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INDIRECT 

1. Musculoskeletal changes 

   • Loss in ROM, Contractures, Disuse atrophy, Muscle weakness, Osteoporosis

2. Neurological signs

   • Seizures, Hydrocephalus (rare)

3. Deep Vein Thrombosis

4. Reduced Aerobic capacity and endurance

5. Pulmonary function 

   1. Decreased lung volume, pulmonary perfusion, vital capacity.

6. Integumentary

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GOALS

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• Short term 

1. Patient and family education

2. Improve motor learning

3. Improve sensory function

4. Improve strength 

5. Improve movement control

6. Improve functional status

7. Postural control and functional mobility

8. Improve Gait and locomotion

9. Improve flexibility and joint integrity

10. Manage spasticity

11. Improve Balance

12. Improve swallowing and feeding

13. Prevent pressure sores

14. Prevent deconditioning

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• Long term

1. Maintain all short term goals

2. Improve Gait and locomotion

3. Improve aerobic Capacity and endurance

4. Discharge planning

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MANAGEMENT​

Patient Education

• Educate the patient about the condition

• Give factual information, counsel family members about patient’s capabilities & limitations 

• Give information as much as Patient or family can assimilate 

• Provide open discussion & communication

• Be supportive, sensitive & maintain a positive supporting nature 

• Give psychological support 

• Refer to help groups 

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Improve Motor learning

• Strategy development 

• Patient as an active explorer of activity 

• Modify strategy of activity in correct patterns  

• Feedback

  • Intrinsic or extrinsic feedback 

  • Positive & negative feedbacks   

• Practice

  • Repeated practice of functional activity 

  • Practice in different environment   

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Improve sensory function

• Positioning hemiplegic side towards door or main part of room 

• Presentation of repeated sensory stimuli

• Stretching, stroking, superficial & deep pressure, icing, vibration etc. 

• Weight bearing ex & Joint approximation techniques

• Stoking with different texture fabrics

• Pressure application

• Improve other senses like use of visual & auditory 

• PNF tech., use of bilateral UE

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Improve strength

• Strengthening of agonist & antagonistic muscle 

• Graded ex program using free weights, resistance bands, sand bags & isokinetic devices 

• For weak patients (<3/5), gravity-eliminated ex using powder boards, sling suspension, or aquatic ex is indicated

• Gravity-resisted active movements are indicated (>3/5 strength)

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Improve Movement Control

• Dissociation & selection of desired movement patterns 

• Select postures that assist desired movements through optimal biomechanical stabilization & use of optimal point in range

• Start with assisted movement, followed by active & resisted movement

• Task oriented exercise 

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Improve Upper limb function

• Early mobilization, ROM, & positioning strategies

• Relearning of movement pattern & retraining of missing component 

• UL weight bearing exercise 

• Dynamic stabilization exercise 

• Picking up objects, Reaching activities 

• Lifting activities

• Manipulation of common objects 

• Push up ex. in various position

• Kitchen sink exercise 

• Functional movement like hand to mouth & hand to opposite shoulder  

• Advance training –

  • CIMT

  • biofeedback

  • NMES

  • FES

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Improve LL function

• Strengthening muscles in appropriate pattern 

• Suggested activities 

• PNF pattern of LL

• Holding against elastic band resistance around upper thighs in supine or standing positions

• Standing, lateral side-steps

• Exercise to improve pelvic control

• Facilitation of DF

• Cycling & treadmill training 

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Improve functional status

• Bed mobility exercises

• Sitting

• Sit to stand and sit down transfers

• standing

Improve Postural control and functional mobility

• Suggested exercise 

  • Rolling 

  • Supine to sit & sit to supine 

  • Sitting 

  • Bridging 

  • Sit to stand & Sit down 

  • Modified plantigrade 

  • Standing 

  • Transfer 

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Improve Gait and Locomotion

• Initial gait training between parallel bars 

• Proceed outside bars with aids & then without aids 

• Walking forward, backward, sideways & in cross patterns 

• PWBSTT with higher speed improve overall locomotors activity & over ground speed 

• Proper use of orthotics & wheelchair 

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Improve flexibility and joint integrity

• Soft tissue, joint mobilization & ROM exercise 

• AROM & PROM with end range stretch 

• Effective positioning & edema reduction

• Stretching program & splinting 

• Suggested activities

• Arm cradling 

• Table top polishing 

• Self-overhead activities in supine & sitting & reaching to the floor

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Manage spasticity

• Sustained stretch & slow icing of spastic muscle 

• Rhythmic rotations

• Weight bearing exercise 

• Prolonged & firm pressure application 

• Slow rocking movement

• Positioning in anti synergistic pattern

• Rhythmic initiation  

• Air splints 

• Neural warmth 

• Electrical stimulation 

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Improve balance

• Facilitate symmetrical weight bearing on both side 

• Postural perturbations can be induced in different positions 

• Sit or stand on movable surface to increase challenge 

• Reaching activities 

• Dual task training s/a kicking ball in standing, throwing activities, carrying an object while walking 

• Divert attention 

• Single limb stance

• Exercise on trampoline  

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Improve feeding and swallowing

• Proper head position in chin down position 

• Movements of lips, tongue, cheeks, & jaw

• Firm pressure to anterior 3rd of tongue with tongue depressor to stimulate posterior elevation of tongue,

• Puffing, blowing bubbles, & drinking thick liquids through straw

• Food presentation in proper position 

• Texture of food should be smooth 

• Tasty food should be given to facilitate swallowing reflex 

• Stroking the neck during swallowing 

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Improve aerobic capacity and endurance

• Early mobilization & functional activity 

• Treadmill training & cycle ergometer 

• Symptom limited graded ex. training 

  • Ex at 40- 70 % of VO2max, 3 times a week for 20-60 minutes 

• Proper rest should be given 

• Gradually progressed to 30 minutes continuous program

• Regular ex reduces risk of recurrent stroke  

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Discharge Planning

• Family member should participate daily in the therapy session & learn exercises

• Home visits should be made prior to discharge 

• Architectural modifications, assistive devices or orthotics should be ready before discharge 

• Identify community service & provide information to the patient 

REFERENCES
Susan B. O’Sullivan, Thomas J. Schmitz, et al, Physical Rehabilitation, 6th edition, Page no- 645 to 703.