Cerebrovascular Accident

Types of Strokes

Physiotherapy and Stroke

Strokes and the Shoulder Positioning

Strokes
Strokes have symptoms which act as warning signs. Transient ischaemic attacks (TIAs) are an important warning sign that a stroke may occur in the future. Symptoms can include a numb or weak feeling in the face, arm or leg, trouble speaking or understanding, unexplained dizziness, blurred or poor vision in one or both eyes, loss of balance or an unexplained fall, difficulty swallowing, headache, confusion and unconsciousness.

Types of Strokes
Ischemic stroke occurs as a result of an obstruction within a blood vessel supplying blood to the brain. It accounts for 87 percent of all stroke cases. Ischemic strokes occur as a result of an obstruction within a blood vessel supplying blood to the brain. The underlying condition for this type of obstruction is the development of fatty deposits lining the vessel walls. This condition is called atherosclerosis. These fatty deposits can cause two types of obstruction:

Ischemic Strokes
Cerebral thrombosis refers to a thrombus (blood clot) that develops at the clogged part of the vessel. Cerebral embolism refers generally to a blood clot that forms at another location in the circulatory system, usually the heart and large arteries of the upper chest and neck. A portion of the blood clot breaks loose, enters the bloodstream and travels through the brain's blood vessels until it reaches vessels too small to let it pass. A second important cause of embolism is an irregular heartbeat, known as atrial fibrillation. It creates conditions where clots can form in the heart, dislodge and travel to the brain.

Ischemic Strokes

Hemorrhagic Strokes
Hemorrhagic stroke occurs when a weakened blood vessel ruptures. Two types of weakened blood vessels usually cause hemorrhagic stroke: aneurysms and arteriovenous malformations (AVMs) Hemorrhagic stroke accounts for about 13 percent of stroke cases. It results from a weakened vessel that ruptures and bleeds into the surrounding brain. The blood accumulates and compresses the surrounding brain tissue. The two types of hemorrhagic strokes are intracerebral hemorrhage or subarachnoid hemorrhage.

Hemorrhagic Strokes
An aneurysm is a ballooning of a weakened region of a blood vessel. If left untreated, the aneurysm continues to weaken until it ruptures and bleeds into the brain. An arteriovenous malformation (AVM) is a cluster of abnormally formed blood vessels. Any one of these vessels can rupture, also causing bleeding into the brain.

Hemorrhagic Strokes

Transient Ischemic Attack

Often called a mini stroke, these warning strokes should be taken very seriously. TIA (Transient Ischemic Attack) is caused by a temporary clot. While transient ischemic attack (TIA) is often labeled mini-stroke, it is more accurately characterized as a warning stroke, a warning you should take very seriously. TIA is caused by a clot; the only difference between a stroke and TIA is that with TIA the blockage is transient (temporary). TIA symptoms occur rapidly and last a relatively short time. Most TIAs last less than five minutes; the average is about a minute. Unlike a stroke, when a TIA is over, theres no permanent injury to the brain.

Transient Ischemic Attack

Transient Ischemic Attack

The warning signs of a TIA are exactly the same as for a stroke: Sudden numbness or weakness of the face, arm or leg, especially on one side of the body Sudden confusion, trouble speaking or understanding Sudden trouble seeing in one or both eyes Sudden trouble walking, dizziness, loss of balance or coordination Sudden, severe headache with no known cause

Physiotherapy and Strokes

Goal Management of stroke patients begins as the acute care during acute hospitalization and continues as rehabilitative care as soon as patients medical & neurological status has stabilized. Moreover, community reintegration of patients continues during the community care stage.

Physiotherapy and Strokes

1. Acute Care Aims : 1) Prevent recurrent stroke 2) Monitor vital signs, dysphasia adequate nutrition, bladder & bowel function. 3) Prevent complications 4) Mobilize the patient 5) Encourage resumption of self-care activities 6) Provide emotional support & education for patient & family 7)Screen for rehabilitation and choice of settings

Physiotherapy and Strokes

2. Rehabilitation care Aims : 1) Set rehabilitation goals; develop rehabilitation plan and monitor progress 2) Manage sensori-motor deficits 3) Improve functional mobility & independence 4) Prevent & treat complications 5) Monitor functional health conditions 6) Discharge planning (safe residence recommendation, patient & caregivers education & continuityof care) 7) Community reintegration

Physiotherapy and Strokes

3. Community care Aims : 1) Assist patient to reintegrate into community 2) Enhance family and caregivers functioning 3) Co-ordinate continuity of patient care 4) Promote health and safety and prevent further hospitalization 5) Give advice on community supports, valued activities and vocational reintegrate

Strokes and the Shoulder

Special consideration Shoulder assessment Shoulder subluxation and pain is a major and frequent complication in patients with hemiplegia. (Joynt, 1992; Grossen-Sils, and Schenkman, 1985). As many as 80% of patients with cerebrovascular accident has been reported to show shoulder subluxation. Clinical examination of shoulder should include thorough evaluation of pain , range of movement, motor control, and shoulder subluxation.

Strokes and the Shoulder

Hemiplegic shoulder management Shoulder subluxation and pain of the affected arm is not uncommon in at least 30% of all patient after stroke (RCP, 1998) ,whereas subluxation is found in 80% of stroke patients (Najenson et al., 1971). It is associated with severity of disability and is common in patients in rehabilitation setting.Suggested interventions are as follows:

Shoulder Subluxation
Shoulder subluxation is a common occurrence after stroke and can be due to muscle weakness or spasticity. It is characterized by the upper arm bone (humerus) dropping out of the shoulder socket.

The muscles may be too weak to hold the arm bone securely into the shoulder socket or spasticity can cause subluxation by pulling the bone into an abnormal position. Both muscle weakness and spasticity can cause the shoulder blade (scapula) to be abnormally positioned as well.

Strokes and the Shoulder

Exercise Active weight bearing exercise can be used as a means of improving motor control of the affected arm; introducing and grading tactile, proprioceptive, and kinesthetic stimulation; and preventing edema and pain. Upper extremity weight bearing can be used to lengthen or inhibit tight or spastic muscles while simultaneously facilitating muscles that are not active (Donatelli, 1991). According to Robert (1992), the amount of shoulder pain in hemipelgia was related most to loss of motion. He advocated that the provision of ROM exercise (caution to avoid imprigement) as treatment as early as possible. AHCPR (1995) recommended ROM exercise should not carry the shoulder beyond 90 of flexion and abduction unless there is upward rotation of scapular and external rotation of the humeral head.

Strokes and the Shoulder

Functional electrical stimulation Functional electrical stimulation (FES) is an increasingly popular treatment for the hemiplegic stroke patient. It has been applied in stroke physical therapy for the treatment of shoulder subluxation (Faghri et al.,1994), spasticity (Stefanovska et al., 1991) and functionally, for the restoration of function in the upper and lower limb (Kralji et al., 1993). Electrical stimulation is effective in reducing pain and severity of subluxation, and possibly in facilitating recovery of arm function (Faghri, et al., 1994; Linn, et al., 1999).

Strokes and the Shoulder

Positioning & Proper Handling Proper positioning and handling of hemiplegic shoulder, whenever in bed, sitting and standing or during lifting, can prevent shoulder injury is recommended in STROKE guidelines for stroke rehabilitation. Positioning can be therapeutic for tone control and neuro-facilitation of stroke patients (Davies, 1991). Braus et al 94 found shoulder hand syndrome reduced from 27% to 8% by instruction to every one including family on handling technique. MOST IMPORTANT.

Positioning
prevent musculo-skeletal deformities prevent pressure sores prevent circulatory problems (blood and lymphatic) send normal inputs to the brain, contrasting with the temporary lack of sensory inputs caused by the stroke promote recognition and awareness of the affected side

Positioning
Proper positioning can be useful to minimize or prevent pain and stiffness that are commonly present post-stroke. It can also help the patient to regain movement that was lost after there stroke, or limit future problems with movement. In addition, proper positioning has been shown to increase awareness and protection of the weaker side of the body.

Positioning
How Effective is Positioning after Stroke? Preventing shoulder pain: Arm positioning while lying and sitting was shown to be ineffective in preventing shoulder pain for all stages of stroke. However positioning of the weaker arm using slings and supports while standing and moving around was shown to be effective in preventing shoulder pain. There was no evidence as to whether positioning of the shoulder and arm during transfers was effective in preventing shoulder pain but it is definitely best practice to protect the weaker arm by supporting it (and never pulling on it) during transfers. Reducing shoulder pain: Positioning of the weaker shoulder and arm using slings and supports while standing and moving around was shown to be an effective way of reducing shoulder pain. There is evidence to show that upper limb positioning during transfers would reduce shoulder pain. Arm positioning while lying and sitting was also found to be ineffective in reducing shoulder pain. Again it is important to note that it is definitely best practice to support the weaker arm (and never pull on it) during standing and walking.

Positioning
Preventing and reducing shoulder subluxation (dislocation of the shoulder): There is conflicting scientific evidence concerning the effectiveness of arm positioning while sitting on the prevention of shoulder subluxation (dislocation). Upper limb positioning while standing and walking is effective in preventing and reducing shoulder dislocation. Improving range of motion: Proper arm positioning while lying and sitting has been shown to be ineffective for improving arm range of motion (how much it can move through space). Improving functional independence: Proper arm positioning while lying and sitting has been shown to be ineffective in improving ability to perform daily tasks after a stroke. Increasing awareness of the upper limb: No evidence was found concerning the effectiveness of arm positioning while sitting to increase awareness of the weaker arm. Generally, best practice is to have the arm placed in a position where the patient is able to see the arm - for example on a lap tray if the person is sitting in a wheelchair.

Positioning
Positioning devices exist for various purposes, including support and padding.

Slings: Various slings are available and can be used following a stroke to support your weaker arm while you are standing or during transfers. Slings can prevent pain that is caused by dislocation of the shoulder
Head Donut: this supports the back of your head when lying down. Pillows: Pillows are used for padding and protection of some pressure points of the arm and legs, such as elbows, knees, and heels. Wedges: Wedges are placed under your knees to prevent the patient from sliding in a chair while sitting down. Lap trays: Lap trays are attached to the armrest of a wheelchair and lay across there lap. This will allow them to rest your weaker arm on the tray. Arm trough: Arm troughs are placed on the armrest of the wheelchair to keep the weaker arm from hanging over the side. A strap can also be added to the trough to provide additional support. Harness: These can be used for the weaker shoulder. They are often adjustable and fastened with Velcro. A shoulder harness offers support by fitting over the weaker shoulder, and passing behind the neck to strap onto the stronger arm.