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.