Stroke Management And

Rehabilitation
Prepared
Mr. Maher Yassen AL
Madhoon
?What is a stroke

cute loss of circulation to area ofStroke is an a -

the brain with resultant ischaemia and loss of
.neuronal function
It is a type of cardiovascular disease.as -
.it affects arteries leading to and within the brain
A stroke occurs when a blood vessel that -
carries oxygen and nutrients to the brain is
.either blocked by a clot or bursts
When that happens, affected region in the brain
cannot get the blood,O2, nutirients it needs, and
cannot be cleared of waste products it has. so it
.starts to die
 Introduction

Stroke is Classified as Haemorrhagic or -

Ischemic
Deficits include: Weakness, sensory deficit, -
.language difficulties
Recent advances in treatment have -
significantly improved outcome (eg.
.(thrombolysis, 1995
Time is important factor in patient outcome, -
and current understanding of treatment
.options is poor
 Clinical categories of stroke

:Strokes can be clinically classified Into

ischemic stroke : accounts for more*
than 80% of all strokes
Hemorrhagic stroke : represents 10-15*
% of all strokes
ischemic strokes*
)Transient ischemic attack )TIA*
)Thrombotic CVA )Cerebral thrombosis*
)Embolic CVA )Cerebral embolism*
 Controllable or treatable stroke risk factors
High blood pressure — High blood pressure)140/90 mm Hg or higher) is
the most important risk factor for stroke. It usually has no specific
symptoms and no early warning signs. That’s why everybody should have
.their blood pressure checked regularly
Tobacco use — Cigarette smoking is a major, preventable risk factor for
stroke. The nicotine and carbon monoxide in tobacco smoke reduce the
amount of oxygen in your blood. They also damage the walls of blood
vessels, making clots more likely to form. Using some kinds of birth control
pills combined with smoking cigarettes greatly increases stroke risk. If you
!smoke, get help to quit NOW
Diabetes mellitus — Diabetes is defined as a fasting plasma glucose
(blood sugar) of 126 mg/dL or more measured on two occasions. While
.diabetes is treatable, having it still increases a person's risk of stroke
Many people with diabetes also have high blood pressure, high blood
cholesterol and are overweight. This increases their risk even more. If you
.have diabetes, work closely with your doctor to manage it
Carotid or other artery disease : A carotid artery narrowed from
atherosclerosis (plaque buildups in artery walls) & may become blocked by
.a blood clot. called carotid artery stenosis
peripheral artery disease : Entails a higher risk of carotid artery disease,
which raises their risk of stroke. Peripheral artery disease is the narrowing of
blood vessels carrying blood to leg and arm muscles. It's caused by fatty
.buildups of plaque in artery walls
Atrial fibrillation: This heart rhythm disorder raises the risk for stroke. The
heart's upper chambers quiver instead of beating effectively, which can let
the blood pool and clot. If a clot breaks off, enters the bloodstream and
.lodges in an artery leading to the brain, a stroke results
Other heart disease — People with coronary heart disease or heart failure
have a higher risk of stroke than those with hearts that work normally.
Dilated cardiomyopathy (an enlarged heart), heart valve disease and some
.types of congenital heart defects also raise the risk of stroke
Transient ischemic attacks )TIAs) :Are "warning strokes" that produce
stroke-like symptoms but no lasting damage. Recognizing and treating
TIAs can reduce the risk of a major stroke. It's very important to recognize
.the warning signs of a TIA or stroke
Certain blood disorders — A high red blood cell count thickens the blood
and makes clots more likely. This raises the risk of stroke. Doctors may
".treat this problem by removing blood cells or prescribing "blood thinners

Sickle cell disease (also called sickle cell anemia) is a genetic disorder
that mainly affects African Americans. "Sickled" red blood cells are less
able to carry oxygen to the body's tissues and organs. They also tend to
stick to blood vessel walls, which can block arteries to the brain and cause
.a stroke
High blood cholesterol — A high level of total cholesterol in the blood (240
mg/dL or higher) is a major risk factor for heart disease, which raises your risk of
.stroke
Recent studies show that high levels of LDL ("bad") cholesterol (greater than 100
mg/dL) and triglycerides (blood fats, 150 mg/dL or higher) increase the risk of
stroke in people with previous coronary heart disease, ischemic stroke or transient
.(ischemic attack (TIA
Low levels (less than 40 mg/dL) of HDL ("good") cholesterol also may raise stroke
risk. Clotting factors
Drinking alcohol : Drinking alcoholic beverages can raise blood pressure and
.may increase risk for stroke
Some illegal drugs : Intravenous drug abuse carries a high risk of stroke.
Cocaine use has been linked to strokes and heart attacks. Some have been fatal
.even in first-time users
Physical inactivity and obesity:Being inactive, obese or both can increase your
risk of high blood pressure, high blood cholesterol, diabetes, heart disease and
stroke. So go on a brisk walk, take the stairs, and do whatever you can to make
your life more active. Try to get a total of at least 30 minutes of activity on most or
all days
Uncontrollable or Non-treatable stroke risk factors
Increasing age: People of all ages, including children, have
.strokes. But the older you are, the greater your risk for stroke
Sex )gender): Stroke is more common in men than in women. In
most age groups, more men than women will have a stroke in a
given year. However, women account for more than half of all
.stroke deaths
Women who are pregnant have a higher stroke risk. (WHY ?) Also
women taking birth control pills or smoke or have high blood
.pressure or other risk factors
Heredity )family history) and race: Your stroke risk is greater if a
parent, grandparent, sister or brother has had a stroke. African
Americans have a much higher risk of death from a stroke than
Caucasians do. This is partly because blacks have higher risks of
.high blood pressure, diabetes and obesity
Prior stroke or heart attack: Someone who has had a stroke is at
much higher risk of having another one. If you've had a heart
.attack, you're at higher risk of having a stroke, too
 ACUTE Stage
..The goals of the treatment in acute stage are
a.Prevent ignorance or unawareness of the hemiplegic
side
b.Decrease the tendency to develop synergy in the
chronic stage
c.Prevention of any joint restriction or stiffness
d.Prevention of complications due to immobilizattion like
chest complication ,deconditioning of the bone and
.muscles,etc
.e.Early weight bearing
. f.Psychological counselling
.g.Education to the family
These goals can be achieved through the following
.treatment
 General Goals of Rehabilitation

Improving function by promoting natural recovery *

Equipping clients with new compensatory skills *

Substituting lost functions with orthotic and aides *

Prevention of complications *

Modifying clients environment to maximize *

independence

Educating and training client and Family *

Modifying risk factors to prevent future strokes *

 ?When and Where can a stroke patient get rehabilitation

Rehabilitation should begin as soon as a stroke

patient is stable, often within 24 to 48 hours after
.a stroke
This first stage of rehabilitation usually occurs
.inside the acute-care hospital
At the time of discharge from the hospital, the
stroke patient and family coordinate with hospital
social workers to locate a suitable rehabilitation
arrangement. Many stroke survivors return
home, but some move into some type of medical
.facility
 Benefits of Early mobilization and
rehabilitation therapy
Direct Benefits of Early mobilization and rehabilitation *
therapy
Prevent DVT, skin breakdown, contracture formation, constipation,
.and pneumonia
It has positive psychological effects on both the patient and the
.family
Direct evidence from controlled studies have shown better
.orthostatic tolerance and earlier improvement of ADL performance
.Enhance earlier return of mental, motor, and ADL performance
Indirect Benefits of Early mobilization and rehabilitation *
therapy is suggested by
the superiority of acute care stroke units in reducing mortality and
.improving functional outcomes
Early mobilization and early implementation of therapy are intrinsic
components of care on stroke units and may have contributed to
.improved outcomes
)Active Rehabilitation Phase)
During this phase Clients receives His out of bed sessions
Range from 20-40 days in duration
Patient master all BADL and IADL
.Receives all strengthening and therapeutic exercises
Receives counseling and education from case manger, psychologist,
.nursing staff and other team members
During this phase, the treatment program includes functional mobility
.training and appropriate therapeutic techniques
.Treatment takes place in individual as well as group sessions
PT emphasize on increasing the patient's functional mobility, areas of
sensory-motor dysfunction, which include range of motion,
strength/motor control, endurance, balance, and coordination, may need
.to be addressed at the same time
Bed mobility: training to increase the patient's ability to move in bed;
.includes rolling, moving from sit to supine, and scooting
Transfers: training to enhance the patient's ability to get from one
surface to another; includes to and from wheelchair, bed, floor, car, and
.sit to stand
Stairs: training to help the patient relearn the safest pattern
or technique for ascending and descending stairs; may
include using railings, bumping up or down, or using a
.wheelchair
Ambulation: training to increase the patient's ability to walk
with or without an assistive device as independently and
safely as possible in normal movement patterns with
.decreased deviations in gait
Wheelchair mobility: training to improve the patient's ability to
self-propel or direct propulsion in hospital, home, and
community environments; includes wheelchair parts
management and breakdown, and propulsion on level and
.unlevel surfaces and around community barriers
During this phase the patient's cognition and level of safety
awareness can affect his or her ability to meet the long- and
short- term goals therefore they should be thoroughly
.addressed as well
 Arrangement of the patient's room
))Fig2.3
Due to the lesion the patient suffers from
sensory deprivation that leads to neglect
of the hemiplegic side which can be
greatly influenced by the patient's head
position . Hence all the forms of the
stimulus like the entrance to the room
. ,the relatives ,television ,etc
Should be present on the hemiplegic side
so that the patient is forced to turn to
that side which will stimulate awareness
.of the hemiplegic side
 )Positioning )Figs2.4 to 2.6
Positioning of the patient in an
appropriate way is essential to control
the development of spasticity and to
help in faster improvement in the
later stages . Preferably the patient is
positioned sidelying and supine
.generally avoided
On the affected side : the shoulder should
be protracted and flexed . The elbow and
the wrist should be extended . The forearm
should be supinated .The pelvis should be
in protracted position .The hip and knee
should be in slight flexion and the ankle
. should be in neutral position
On the sound side :The arm should
be rested on the pillow kept in front
of the patient. The shoulder girdle
should be kept in protraction and
slight elevation .The shoulder is kept
in slight abduction and flexion with
the elbow and wrist in extension
position .The forearm should be in
supine position .The pelvis should
be kept in protraction the hip
should be slightly abducted and
flexed.the knee should be slightly
flexed and the ankls should be in
neutral position
It should be noted that the finger should be kept in
extension and the web space maintained on both the
. above occasion
Supine position is avoided as the primitive reflexes are
active and also change of pressure sores are increased .
In case supine position is given then the head should
.be kept in midline on pillow
Pillow should be kept under the shoulder girdle to keep it
protracted the shoulder is kept in abducation and
external rotation ,the forearm in supination ,the elbow is
extended ,wrist and finger extended
A pillow is kept under the pelvis ,leg kept in neutral
rotation the ankle maintained in neutral position ,I e
.90degree of dorsiflexion by a pillow and the hip is kept in
. slight abduction
Correct positioning is necessary to control the
development of spasticity and also to mininmize the
. influence of synergy in spasticity stage
 Mobilization and Stretching
During flaccid stage mobilization in the from of gentle
passive exercises and stretching of various biarticular
muscles should be given as they are very prone to develop
tightness.Thus muscles like tendon achilles ,hamstring
,quadriceps ,adductors ,tensor fascia lata,biceps ,wrist
flexors ,etc ,should be stretched .Passive exercises should
be given of all the movements to all the joints for at least
10 repetitions three to four times in a day
Some forms of splints may be given to maintain the body
. parts in the desired position
Commonly dorsiflexion splint or L splint may be given to
. prevent the foot from going into plantar flexion attitude
Similarly wrist extension splint is given to maintain the
. wrist and the fingers in extension position
.Care should be taken to maintain the first web space
 )Weight- bearing activities )Fig 2.7

Weight bearing exercises are necessary to promote

development of tone in the muscles and also to maintain
the absorption of calcium into the bones . Thus the patient
should be given activities like bridging supine on elbows
sitting with weight bearing on the affected arm and standing
should be given as soon as possible with in the limitation lf
. the patients general medical status
Subluxtion of the glenohumeral joint is a very common
complication in stroke patient which canbe be prevented by
proper positioning andhandling .some form of support may
be given to prevent distraction
 Fig.2.7..weight-bearing through affected upper
limb

Positioning and handling .some from of support may be given to

prevent distraction of the joint when the patient assumes an erect
position…generally a shoulder sling or bobath splint is given to
prevent this complication .skillful taping also helps in preventing the
subluxation vary effectively and in addition also gives room for free
movement .it also gives tactile feed back which helps in faster
development of tone in the shoulder muscles. Wight bearing
exercises for the involved upper limb has also been found to be
beneficial in preventing this .shoulder sling is usually avoided as it
facilitated the hemiplegic attittude.which the patient may develop in
later stages
 Blood supply to the Brain
Supply to Brain , Face and Scalp is via Rt & Lt Common Carotid
and Vertebral arteries
Int. Carotid supplies Anterior 3/5 of Cerebrum except parts of
.Temp/ Occip lobes
(Decreased flow = frontal lobe symps. (opp body side
Vertebro-basilar supplies post 2/5 of cerebrum, cerebellum and
.brainstem
.Decreased flow = blindness , paralysis, etc
 )Transient ischemic attack )TIA
A short-term stroke that lasts for less than 24 hours
(Mini-stroke). The oxygen supply to the brain is
restored quickly, and classical symptoms of the
.stroke disappear completely
A transient stroke needs prompt medical attention as
it is a warning of serious risk of a major stroke
 )Thrombotic CVA )Cerebral thrombosis
:60%of all ischaemic strokes
.large vessel, 30% small or lacunar vessel 70%
In situ occlusions on atherosclerotic lesions. Typically proximal to major
.branches
Thrombogenic factors :Injured endothelial cells
Platelet activation by sub endothelium
Activated clotting cascade
Inhibition of fibrinolysis and blood stasis
Frequently originate from ruptured atherosclerotic plaques but in younger
patients always consider : Coag disorders, SC disease, arterial dissection
.and vasoconstriction secondary to substance abuse
occurs when a blood clot (thrombus) forms in an artery (blood vessel)
.supplying blood to the brain
Furred-up blood vessels with fatty patches of atheroma(arteriosclerosis)
may make a thrombosis more likely. The clot interrupts the blood supply
.and brain cells are starved of oxygen
 .Embolic Strokes
of all Ischaemic strokes 20%
Cardiac: AF, recent MI, prosthetic valves, valve
disease, endocarditis, mural thrombus, dilated
.cardiomyopathy
Arterial: atherothrombolic or cholesterol emboli from
.extra cranial arterial tree
Very sudden onset
Neuro imaging may show previous infarcts in several
.vascular territories
 Intra-cerbebral and subarachnoid hemorrhage
Subarachnoid hemorrhages: occurs when a blood vessel on the surface
of the brain ruptures and bleeds into the space between the brain and the
.(skull (but not into the brain itself
.Subarachnoid hemorrhages account for about 7% of all strokes
Intracerebral hemorrhage : is another type of stroke occurs when a
defective artery or aneurysmin the brain bursts, flooding the surrounding
.tissue with blood
. Account for about 10-15 % of all strokes
Higher mortality rate
Similar presentation : headache
lowered GCS
seizures, nausea and vomiting
raised blood pressure
Bleed into parenchyma: leakage from small arteries
anticoagulation
bleeding diatheses
cerebral amyloidosis
cocaine abuse
Common sites = thalamus, putamen, cerebellum and brainstem
.Raised ICP and pressure effects
 Intra-cerbebral and subarachnoid hemorrhage
Subarachnoid hemorrhages: occurs when a blood vessel on the
surface of the brain ruptures and bleeds into the space between the brain
.(and the skull (but not into the brain itself
.Subarachnoid hemorrhages account for about 7% of all strokes
Intracerebral hemorrhage : is another type of stroke occurs when a
defective artery or aneurysmin the brain bursts, flooding the surrounding
.tissue with blood
. Account for about 10-15 % of all strokes
Higher mortality rate
Similar presentation : headache
lowered GCS
seizures, nausea and vomiting
raised blood pressure
Bleed into parenchyma: leakage from small arteries
anticoagulation
bleeding diatheses
cerebral amyloidosis
cocaine abuse
Common sites = thalamus, putamen, cerebellum and brainstem
.Raised ICP and pressure effects
Intraventricular Hemorrhage
 General Stroke Warning Signs
Sudden weakness or numbness of face/arm & leg on one side of body
Sudden dimness or loss of vision in only one eye
Sudden loss of speech or trouble understanding speech
Sudden, severe headaches w/o cause
Unexplained dizziness, unsteadiness or falls
Signs of a Stroke

Acute Hemiparesis, Monoparesis or Quadriparesis

Complete or Partial Hemianopia, Monocular or Binocular visual loss, or
.Diplopia
Dysarthria or Aphasia
Ataxia, Vertigo or Nystagmus
.Sudden decrease in consciousness
Establishing time of onset is critical , especially if considering
thrombolytic therapies
Cincinnati Prehospital Stroke Scale
:Components 3
(Facial droop (ask patient to show teeth and smile
(Arm drift (ask patient to extend arms, palms down, with eyes closed
(Speech (ask patient to repeat long sentence and observe slurring
Cincinnati Prehospital Stroke Scale
:Components 3
(Facial droop (ask patient to show teeth and smile
Arm drift (ask patient to extend arms, palms down, with eyes
(closed
(Speech (ask patient to repeat long sentence and observe slurring

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