PHYSIOTHERAPY MANAGEMENT OF POST STROKE PATIENT.

PHYSIOTHERAPY MANAGEMENT OF STROKE PATIENTS.

1. PHYSIOTHERAPY MANAGEMENT OF STROKE PRESENTED BY: NAME : EJIKE JONAS NWOKOLO COURSE : MPT(NEUROLOGY) 2 ND YEAR.

2. INTRODUCTION Stroke is an acute onset of neurological dysfunction due to an abnormality in cerebral circulation with resultant signs & symptoms which corresponds to involvement of focal areas of the brain Stroke is defined by WHO as the sudden onset of neurological deficits due to an abnormality in cerebral circulation with the signs and symptoms lasting for more than 24 hours or longer .

3. TRANSIENT ISCHAEMIC ATTACK It is defined as the sudden onset of neurological deficits due to an abnormality in cerebral circulation with the signs and symptoms lasting for less than 24 hours. EPIDEMIOLOGY: Third leading cause of death The incidence of stroke is about 1.25 times greater for males than females Most common cause of disability among adults.

4. ETIOLOGY Atherothromboembolism Atherosclerosis Cerebral Thrombus Cerebral embolus Embolism from the heart (cardiac origin) Intracranial hemorrhage Subarachnoid hemorrhage Intracranial small vessel disease Arterial aneurysms Arterio -venous malformation Haematological disorders ( haemoglobinopathies , leukemia )

5. MISCELLANEOUS RARE CAUSES OF STROKE Infective endocarditis HIV infection Tumour Perioperative stroke (due to hypotension and boundary zone infarction, trauma to and dissection of neck arteries, paradoxical embolism, fat embolism, ) Migraine Chronic meningitis Inflammatory bowel disease (ulcerative and Crohn's colitis) Hypoglycemia Snake bite, fat embolism etc.

6. RISK FACTORS OF STROKE NON-MODIFIABLE MODIFIABLE Ageing gender Positive family history Genetic factors(African American). Circadian and seasonal factors (peaks between 10 am till noon) . POTENTIALLY MODIFIABLE Well accepted: Arterial fibrillation Vavular disease Left artrial thrombosis MI. Heart disease Diabetes mellitus Hypertension TIA Peripheral artery disease Hyperlipidemia Blood pathology; -increased haematocrit -Clothing abnormalities -sickle cell anaemia Smoking Obesity Lack of physical exercise or sedentary life style Diet & excess alcohol consumption Oral contraceptives Infection (meningeal infection) Psychological factors Vasectomy

7. TYPES OF STROKE ISCHAEMIC STROKE Thrombotic: more common. Usually occurs in the sleeping hours. Ischemia results in irreversible cellular damage with a core area of focal infarction within minutes Characterised by gradual onset of symptoms Embolic: Occurs in the waking hours of the day. Sudden onset of symptoms preceded by giddiness in most conditions HAEMORRHAGIC STROKE • Haemorrhagic stroke may may be associated with: Intracranial haemorrhage Subarachnoid haemorrhage Signs of raised ICP will be evident with a history of a traumatic accident May have history of hypertension.

8. DEPENDING ON THE SEVERITY Mild stroke: symptoms subside with no deficit in a week period • Moderate stroke: symptoms recover in a period of 3 - 6 months with minimal neurological deficits • Severe stroke: there is no complete recovery of the symptoms even after 1 years. Always ends up with severe neurological deficits DEPENDING ON DURATION OF THE SYMPTOMS Acute stroke:Up to a period of one week or until spasticity develops • Sub acute stroke: After the development of spasticity & last for a period of 3-12 months • Chronic stroke: More than 12 months

9. SIGNS AND SYMPTOMS OF STROKE Sudden numbness or weakness of face, arm Hemiparessis / quadreparesis Hemi neglect Limb/ truncal ataxia Sudden confusion Aphasia,dysarthria impaired understanding Sudden blurring of vision,diplopia Incoordination Loss of balance Sudden severe headache Sudden feeling dizziness Less commonly: • Sudden nausea, fever, & vomiting. • Brief loss /decreased consciousness (fainting, confusion, convulsions,coma ).

10. DIAGNOSIS OF STROKE CT SCAN Standard for eveluation of acute stroke and to rule out other conditions such as tumor , abscess,haemorrhages and other brain lesion. MRI SCAN Allows for a better evaluation of the course of the acute treatment. Identifies infarction and rules out other conditions and identifies late haemorrhage . CEREBRAL ANGIOGRAPHY Involves injection of radiopaque dye into blood vessels with subsequent radiography . • It provides visualization of vascular system and (carotid stenosis, AVM).

11. MEDICAL MANAGEMENT OF STROKE THROBOLYTIC DRUGS( Alteplase [ Activase or tPA ]): Desolves clots and reestablish blood flow. ANTICOAGULANTS:( warfarin [Coumadin], heparin, dabigatran etexilate [ Pradaxa ) helps in in thinning the blood and prevent blood clothing. ANTIPLATELET THERAPY acetylsalicylic acid [aspirin]. ANTISPASMODICS/SPASMOLYTICS (e.g., carisoprodol [Soma], chlorzoaxazone [ Parafon Forte], cyclobenzaprin [ Flexeril ], diazepam ANTI SPASTICS (e.g., baclofen [ Lioresal ], dantrolene sodium [ Dantrium ], diazepam [Valium], tizanidine [ Zanaflex ]) . ANTI CONVULSANTS (e.g., carbamazepine [ Tegretol ], clonazepam [ Klonopin ], diazepam , phenobarbital . ANTIHYPERTENSIVE: (e.g., ACE inhibitors, alpha-blockers, beta-blockers, calcium channel blockers, diuretics. ANTICHOLESTEROL AGENTS:(atorvastatin calcium [Lipitor], rosuvastatin calcium. ANTI DEPRESSANTSs (e.g., fluoxetine [Prozac], monoamine oxidase inhibitors, sertraline.

12. PT ASSESSMENT HISTORY: Detailed history of the patient should be taken. Abrupt onset with rapid coma is suggestive of cerebral hemorrhage. Severe headache typically precedes loss of consciousness. Embolus also occurs rapidly, with no warning, & is frequently associated with heart disease or heart complications. Uneven onset is typical with thrombosis Past history include TIAs or head trauma, presence of major or minor risk factors, medications, positive family history, & recent alterations in patient function.

13. •Level of consciousness: Arousal , attention, and cognition: Mental status, insight, motivation. Impaired alertness and attention, perseveration, confabulation, confusion, disorientation, distractibility, memory deficits, impaired judgment etc. • Emotional status: D epression , pseudobulbar affect; apathy, euphoria . Attention disorders Memory deficits, including declarative and procedural memory. • Behavioral style :Impulsive or cautious behavioral styles. Frustration , irritability • Communication and language: coordinate efforts with the speech-language pathologist

14. OBSERVATION May have abnormal posturing of limbs Synergistic patterns in the UL & LL . Facial asymmetry May use a walking aid such cane Abnormal gait pattern may also be observed Circumductory gait pattern may be observed.

15. VITALS May present with hypertension PAIN : Shoulder pain, secondary to subluxation, is a common issue. Shoulder-hand syndrome involves swelling & tenderness in hand and pain in entire limb Complex Regional Pain Syndrome involves pain & swelling of hand.

16. CRANIAL NERVE INTEGRITY Visual field deficits Weakness & sensory loss in facial musculature Deficits in laryngeal & pharyngeal function Hypoactive gag reflex Diminished , but perceived, superficial sensation etc.

17. SENSORY INTEGRITY Hemi sensory loss ( dysesthesia , or hyperesthesia, joint position & movement sense) May be able to identify sensations but difficulty in localizing it. Cortical sensations : such as 2 point discrimination, stereognosis & graphaesthesia are affected secondary to loss of grip function. Agnosia Perceptual problems Unilateral spatial neglect Pusher syndrome.

18. JOINT INTEGRITY AND MOBILITY Glenohumeral subluxation Shoulder impingement syndrome Adhesive capsulitis Complex Regional Pain Syndrome and Shoulder-Hand Syndrome.

19. RANGE OF MOTION May be decreased due to : Soft tissue shortening and contractures Increased muscle stiffness Joint immobility and muscle weakness. Disuse-provoked soft tissue changes Over extensibility of capsular structures of Glenohumeral .

20. MOTOR FUNCTION Synergistic patterns of movement Hypertonicity Weakness Associated movements or synkinesis Apraxia including motor & verbal apraxia.

21. REFLEX INTEGRITY Exaggerated deep tendon reflexes Diminished superficial reflexes Positive Babinski’s reflex Impaired Righting, equilibrium, and protective reactions Abnormal primitive reflex (ATNR) may be present .

22. ASSISTIVE DEVICES A sling for Glenohumeral support AFO Cane etc.

23. AEROBIC CAPACITY AND ENDURANCE BP , RR, & HR at rest & during exercise may have a sudden rise. Review pulse oximetry , blood gas, tidal volume, & vital capacity Administer a 2 or 6-minute walk test Administer Borg RPE after walk test or other physical activity.

24. ARTERIAL,VENOUS , LYMPHATIC SYSTEM Edema may occur in affected limbs May be associated with shoulder hand syndrome.

25. VENTILATION AND RESPIRATION Decrease Tidal volume & vital capacity • Decrease Respiratory muscle strength • Ability to cough & strength of cough is decreases • Dyspnea during exercise.

26. GAIT AND LOCOMOTION Decreased extension of hip & hyperextension of knee . Decreased flexion of knee & hip during swing phase Decreased ankle DF at initial contact & during stance resulting in hip circumduction

27. BALANCE Compromised static as well as dynamic balance Pusher’s syndrome may be present resulting in fall on the affected side.

28. POSTURE Spastic patterns can involve flexion & abduction of arm flexion of elbow , supination of forearm with finger flexion. Hip & knee extension , ankle plantar flexion & inversion. Protracted & depressed shoulder scoliosis hip hiking

29. FUNCTIONAL ASSESSMENT Using FIM Barthel index FMA There is compromised basic as well as instrumental ADL Ambulatory capacity is compromised.

30. BOWEL AND BLADDER Flaccid bowel & bladder during the acute stage Bowel & bladder function gradually improve. Uninhibited bladder if frontal lobe is involved Constipation is frequently seen.

31. PROBLEM LIST Tonal abnormalities Muscular weakness Synergistic pattern Tightness & contracture Imbalance I ncoordination Gait abnormalities Postural abnormalities Functional disability

32. GOALS OF TREATMENT Long term goals Improve muscle performance Improve muscle strenght Improve balance andcoordination Improve muscle endurance Improve postural control Functional indepence in ADL. Short term goals Decrease pain Improve sensation Prevent secondary complications Patient and family education Improve joint mobility and integrity. Improve muscle tone

33. NEUROFACILITATORY APPROACHES IN USE NDT PNF GMI BRUNNSTROM CIMT BIOFEED BACK ROOD’S APPROACH FES NMES ROBOTIC THERAPY MRP ETC.

34. PHYSIOTHERAPY MANAGEMENT OF STROKE ACUTE STAGE: Positioning strategies include placing patient : In supine In side lying on normal side In side lying on affected side Improve respiratory & circulatory function Prevent pressure sores Prevent from deconditioning

35. position should be changed frequently

36. IMPROVE RESPIRATION AND CIRCULATION To improve respiratory & circulatory function: • Breathing exercise • Chest expansion exercise • Postural drainage • Huffing & Coughing techniques • Passive & active ankle & toe exercise (after careful & thorough examination of cardiopulmonary system)

37. PREVENT BED SORES Proper positioning • Relieve pressure points by padding & cushion • Frequent turning & changing position • Prevent from moisture • Use cotton clothing • Tight fitting cloth is prevented • Use of water bed, air bed & foam mattress

38. PREVENT DECONDITIONING Early mobilization in the bed (active turning, supine to sit, sit to supine, sitting, sit to stand ) Pelvic bridging exercise Early propped up positionin sitting & then later to standing Moving around the bed Facilitate movement of functioning limbs .

39. POST ACUTE STAGE 5 days a week of active rehabilitation per day Intensive rehabilitation if vitals are stable

40. IMPROVE SENSORY FUNCTION Positioning hemiplegic side towards door or main part of room Presentation of repeated sensory stimuli auch as Stretching, stroking, superficial & deep pressure, iceing , vibration etc. Wt bearing ex & Joint approximation tech Stroking with different texture fabrics Pressure application Improve other senses like use of visual & auditory PNF tech., use of bilateral UE

41. 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 over head activities in supine , sitting & reaching to the floor .

42. IMPROVE STRENGHT Strengthening of agonist & antagonistic muscle Graded ex program using free weights, therabands , sand bags & isokinetic devices . For weak patients (<3/5), gravity eliminated exercises using powder boards, sling suspension, or aquatic ex is indicated Gravity-resisted active movements are indicated (>3/5 strength)

43. REDUC E SPASTICITY Sustained stretch & slow iceing 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

44. IMPROVE MOTOR ONTROL Dissociation & selection of desired movt 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 .

45. IMPROVE UPPER LIMB FUNCTION • Early mobilization, ROM, & positioning strategies • Relearning of movt 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.

46. REDUCE SHOULDER PAIN Proper handling & positioning of shoulder joint Reducing subluxation, NMES, gentle mobilization (grade 1 & 2) Use of supportive devices & slings Use of overhead pulley is contraindicated TENS & heat therapy

47. IMPROVE POSTURAL CONTROL & FUNCTIONAL MOBILITY Suggested exercise • Rolling • Supine to sit & sit to supine • Sitting • Bridging • Sit to stand & Sit down • Modified plantigrade • Standing • Transfer In pusher syndrome; • Passive correction often fails • Use visual stimuli to correct • Sit on the normal side & ask patient to lean on you • Sitting on swiss ball • Environmental boundary can be used e.g. corner or doorway

48. IMPROVE LOWER LIMB FUCTION 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

49. IMPROVE BALANCE Facilitate symmetrical wt 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

50. IMPROVE LOCOMOTION Initial gait training between parallel bars Proceed outside bars with aids & then without aids Walking forward, backward, sideways & in cross patterns Proper use of orthotics & wheelchair

51. IMPROVE AEROBIC FUNCTION 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 continous program • Regular ex reduces risk of recurrent stroke

52. 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 straws. 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

53. 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

54. PATIENT AND FAMILY EDUCATION Give factual information, counsel family members about patient’s capabilities & limitations Give information as much as Pt or family can assimilate Provide open discussion & communication Be supportive, sensitive & maintain a positive supporting nature Give psychological support Refer to help groups

55. 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

56. REFERENCES O’ Sullivan SB, Schmitz TJ. Stroke. Physical rehabilitation. 5th ed., New Delhi: Jaypee Brothers, 2007. Darcy A. Umphred . Neurological Rehabilitation, 5th ed., Mosby Elsevier, Missouri, 2007.

57. THANK YOU