stroke (cerebrovascular accident)
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STROKE (CEREBROVASCULAR ACCIDENT)
NAME: GOPI SUBRAMANIAMCOLLEGE: VICTORIA INTERNATIONAL COLLEGEPROGRAM: DIPLOMA IN PHYSIOTHERAPYTOPIC: STROKE
INTRODUCTION
A stroke occurs when the blood supply to part of your brain is interrupted or severely reduced, depriving brain tissue of oxygen and food. Within minutes, brain cells begin to die.
Stroke is caused by the blockage of blood flow or rupture of an artery to or in the brain.
AETIOLOGY
Ischaemic strokeDue to blockage of a brain artery
by an embolus or by thrombosis. If it lasts for less than 24 hours it is a transient ischaemic attack (TIA).
About 85 percent of strokes are ischemic strokes.
Haemorrhagic strokeHemorrhagic stroke occurs when a
blood vessel in your brain leaks or ruptures. Brain hemorrhages can result from many conditions that affect your blood vessels, including uncontrolled high blood pressure (hypertension) and weak spots in your blood vessel walls (aneurysms).
Intracerebral hemorrhageIn an intracerebral hemorrhage, a
blood vessel in the brain bursts and spills into the surrounding brain tissue, damaging brain cells. High blood pressure, trauma, vascular malformations, use of blood-thinning medications and other conditions may cause intracerebral hemorrhage.
Subarachnoid hemorrhageIn a subarachnoid hemorrhage, an
artery on or near the surface of your brain bursts and spills into the space between the surface of your brain and your skull.
This bleeding is often signaled by a sudden, severe headache. A subarachnoid hemorrhage is commonly caused by the rupture of an aneurysm,.
SIGN AND SYMPTOMS
Anterior cerebral artery
Paralysis or weakness of the contralateral foot and leg due to involvement of Motor leg area
Cortical Sensory loss in the contralateral foot and leg
Gait apraxia, Impairtment of gait and stanceAbulia akinetic mutism, slowness and lack of
spontaneityUrinary incontinence which usually occurs with
bilateral damage in the acute phase
Anterior communicating arteryvisual field defects
Internal carotid arteryparalysis of the entire opposite half to the
face and bodytemporary blindness in one eyeSensation may be lost on the other side of
the bodyMemory may be impaired. Urinary
Incontinence is another possible symptom
Posterior cerebral artery Contralateral loss of pain and
temperature sensations.Visual field defectsIpsilateral deficit of oculomotor
nerveContralateral deficits of facial
nerve
Posterior communicating arteryNystagmas
Basilar arteryPupillary and oculomotor
abnormalities, dysarthria, and dysphagia
Middle cerebral arteryParalysis or weakness of the
contralateral face and arm Sensory loss of the contralateral face
and arm.Aphasiacontralateral neglect syndrome
DIAGNOSIS
Computerized tomography (CT) scan A CT scan can show a brain
hemorrhage, tumors, strokes and other conditions.
Magnetic resonance imaging (MRI)An MRI can detect brain tissue
damaged by an ischemic stroke and brain hemorrhages.
CT SCAN
MEDICAL MANAGEMENT
Aspirin Aspirin prevents blood clots from
formingHeparin
Surgical endarterectomy A surgeon removes fatty deposits
(plaques) from your carotid arteries that run along each side of your neck to your brain.
Surgical blood vessel repair. Surgery may be used to repair certain blood vessel abnormalities associated with hemorrhagic strokes.
PHYSIOTHERAPY MANAGEMENT
Bed mobility : increase ability to roll / move in bed / sit / stand
Active exercise, active assisted exercise, active resisted exercise, resisted exercise
improve balance and coordination retrain normal patterns of movement increase affected arm and leg functionGait training and posture correctionincrease independence and quality of life reduce the risk of falls
CASE STUDY
SUBJECTIVE ASSESSMENT
Demographic date
Name: Miss. KAge: 54 years oldSex: FemaleRace: IndianR/N: 00****Date of assessment: 19/04/2013Doctor’s diagnosis: Right CVA with left hemiparesisDoctor’s management : conservative management
Chief complains Unable to lift left arm and legc/o muscle weakness on left side
Current hx : On 05/04/2013 Pt fainted during marriage function at her brother house, then was brought to ED of HSDG at 4 PM, she wasn’t conscious until she was admitted to ward 6 B for 3 days and was discharged on 08/04/2013, until 19/04/2013 Pt was cared by her sister in law.Type of stroke: infarctionSite of lesion: corticalMotor deficit: Left
Past Hx: No previous stoke and TIA, previous mobility was normal
PMHx/Surgery: HPT for past 4 years ( under medication ), DM type II for past 6 months, hyperlipidemia for past 1 month.
Social Hx: Pt married with 2 kids and staying in terrace house, pt doesn’t involve in any outdoor activites
Medication Hx: amlodipine 5 mg (HPT)
SPECIAL QUESTION
General health : WellInvestigation: Home /Social Situation (pre current
episode) - Home Care independentHome /Social Situation (Current Status)
- Home Care DependentBladder and bowel incontinence: NoOccupation: house wife
OBJECTIVE ASSESSMENTGeneral ObservationBody built: A medium size indian lady
came to physio department by wheelchair with her son
Dominant hand: RightMental/cognitive impairment: noneVisual field deficit: noHearing deficit: noPerceptual status: NAD Posture: normalGait pattern : unable to analyse gait d/t
pt on wheelchair
Palpation
Sensation -Light touch: impaired -Pain: impaired -Temperature: impairedComment: light touch and pain is impaired d/t interruption of sensory receptors in the skin
Muscle tone: Left : UL: 1+ LL: 1+
Proprioception UL: ImpairedLL: Impaired
Range of motion:UL: LL:
Muscle power:UL: 0LL: 0
P F(ROM)
Complication/ OthersPainful shoulder: Subluxed shoulder:Chest complication:Oro-facial function:
Movement And FunctionShoulder:Elbow: Forearm: Wrist:Hand:
No
Poor
ReflexesBiceps: briskTriceps: normalQuadriceps: normalTA: normal
BalanceStatic balance: FairDynamic balance: Fair
Motor Assessment Scale
Supine to side lying: 1Supine to sitting over side of bed:
2Balanced sitting: 3Sitting to standing: 1Walking: 0Upper arm function: 0Hand movements: 0Advanced hand activities: 0
Functional Activities A: dependent B: dependentC: Independent D: dependentE: Independent T: dependent
PHYSIOTHERAPY IMPRESSIONUnable to lift arm and legs d/t
muscle weaknessMuscle weakness is d/t
hypotrophy
SHORT TERM GOALS
To improve bed mobilityTo improve functional activitiesTo improve balanceTo normalize muscle toneTo teach transfer techniques To educate patient
LONG TERM GOALS
To improve ADL activities To regain balance in sitting and
standing
PLAN OF TREATMENT
Bed mobilityJoint approximationActive assisted exercise Balance exercise HEP/ Patient education
INTERVENTION
Bed mobilitySupine to side lying with unaffected
knee bend 90 degree with moderate assistance
Side lying to sitting with moderate assistance
Sitting to standing with maximal assistance
Standing to transfer wheelchair with maximal assistance
Joint approximationKnee joint approximation,
shoulder joint approximation To improve joint sense by applying
compression to the joint
Active Assisted exerciseUse right hand to carry left hand
for X10 Use right leg to carry left leg X 10In supine lying
Balance exerciseWobble board in sitting positionWeight shifting more on affected
side in sitting positionShifting forward and backward
HEP/ PATIENT EDUCATION Educate pt to perform all the
exercise that have been taught Educate pt to avoid sleeping on
affected sideIn sitting position educate pt to
shift more weight on affected side
Educate pt to support shoulder with triangular sling
Teach pt proper way of waking up from bed
EVALUATION
Pt is very cooperative and able to perform all the exercise
REVIEW
Review for next visit to improve functional activities and bed mobility, balance,
REFERENCES
Lennon S, Ashburn, A. The Bobath concept in stroke rehabilitation: a focus group study of the experienced physiotherapists' perspective. Disability and Rehabilitation. 2000; 22(15): 665-674.
Dickinson, John (1976). Proprioceptive control of human movement. Princeton Book Co. p. 4. Retrieved 8 April 2011.
O'Sullivan, Susan (2007). "Physical Rehabilitation", p.60, 512, 720. F.A. Davis, Philadelphia.
O'Sullivan, Susan B; Schmitz, Thomas J (2007). Physical Rehabilitation, Fifth Edition. Philadelphia, PA: F.A. Davis Company. p. 512.
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