Stroke

A stroke aka cerebrovascular accident is a condition in which impeded blood flow to the brain results in cell death.There are two main types of stroke:
(a) ischemic, due to lack of blood flow

(b) hemorrhagic, due to bleeding

There is another type when their is partial disruption of blood flow its called Transient Ischemic Attack.

EPIDEMIOLOGY

Stroke is one of the prominent cause of death and disability in India. The estimated prevalence rate of stroke ranges from 84-262/100,000 in rural population and 334-424/100,000 in urban population. The incidence rate is 119-145/100,000 based on the recent population based study.

CAUSES

(a) Ischaemic strokes – The most common type of stroke, occur when a blood clot blocks the flow of the blood in the arteries to the brain. Blood clots form in the part where the arteries have been narrowed or blocked by fatty cholesterol deposits (hypercholesterolemia) known as ‘plaques’. This narrowing of the arteries is caused by atherosclerosis

(b) Hemorrhagic stroke – Also known as cerebral hemorrhage or intracranial hemorrhage primarily caused due to hypertension

Other risk factors include

*Smoking

*Obesity

*Excessive alcohol consumption

PATHOPHYSIOLOGY

Due to thrombosis or embolism in case of ischemic stroke results in infarction which triggers tissue damage or tissue injury, cell or tissue injury disrupts metabolism leading to ionic disturbance and free radicals formation, calcium and other metabolites accumulate in injured tissue and release excitatory neurotransmitters, continued cell damage eventually results in brain cell death.

Due to impaired cerebral tissue perfusion in case of hemorrhagic stroke results in large blood accumulation in brain tissues which put further pressure in tissues and the regulatory mechanism tries to maintain BP and ICP but eventually cerebral blood vessels gets ruptured and then these vessels constrict in order to limit blood loss and vasospasm occurs, further constriction often leads to tissue necrosis and results in brain cell death

CLINICAL FEATURES

Signs and symptoms

Numbness or weakness of face, arm, or leg (especially one sided)

Confusion or change in mental status

Trouble speaking or understanding speech

Visual disturbances

Loss of balance

Dizziness

Difficulty walking

Abrupt severe headache.

Motor Loss

Hemiplegia

Flaccid paralysis

loss or decrease in the deep tendon reflexes
initially and after 48 hours reappearance of deep reflexes and spasticity

Communication Loss

Dysarthria

Dysphasia or aphasia

Apraxia

Perceptual Disturbances and Sensory Loss

Visualperceptual dysfunctions homonymous hemianopia (loss of half of visual field)

Disturbances in visualspatial relations (perceiving the relation of two or more objects in spatial areas), frequently seen in patients with right hemispheric damage

Sensory losses ( impairment of touch or more severe with loss of proprioception, difficulty in interpretation of visual, tactile, and auditory stimulus

Impaired Cognitive and Psychological Effects

Frontal lobe damage Learning capacity, memory, or other higher cortical intellectual functions may be impaired.

Difficulties in comprehension, forgetfulness, and lack of motivation.

Depression, other psychological problems emotional lability,frustration, and lack of cooperation.

PHYSICAL EXAMINATION AND DIAGNOSIS

The National Institutes of Health Stroke Scale (NIHSS) is a tool used by healthcare providers to objectively quantify the impairment caused by a Stroke

(1) PRE-HOSPITAL STROKE ASSESSMENT SCALE INCLUDES

Cincinati Stroke Scale
Los Angeles Pre hospital stroke scale
ABCD score

(2) ACUTE ASSESSMENT SCALES

Canadian Neurological Scale
European Stroke Scale
Hunt&Hess Scale
Hemispheric Stroke Scale
Glasgow Coma Scale
Mathew Stroke Scale
NIH Stroke Scale

(3) FUNCTIONAL ASSESSMENT SCALE

Berg Balance Scale
Lawton IADL Scale
Modified Rankin Scale

(4) Outcomes Assessment Scale

Barthel Index
Glasgow Coma Scale
Functional Independence Measurement

PHYSIOTHERAPY MANAGEMENT

(1) Improving Motor Control

Stroke Physical Therapy these therapeutic interventions use sensory Stimulation (e.g. quick stretch, brushing, reflex stimulation and associated reactions) to facilitate movement in patients following stroke (Duncan,1997). The following are the different approaches: –

i.Bobath

ii.Brunnstrom

iii.Rood

iv. Proprioceptive neuromuscular facilitation (PNF)

Developed by Knott and Voss, they advocated the use of peripheral inputs as stretch and resisted movement to reinforce existing motor response. Total patterns of movement are used in treatment and are followed in a developmental sequence.

b. Learning theory approach

i. Conductive education

In Stroke Physical Therapy, Conductive education is one of the methods in treating neurological conditions including hemiplegic patients. Cotton and Kinsman (1984) demonstrated a neuropsychological approach using the concept of CE for adult hemiplegia. The patient is taught how to guide his movements towards each task-part of the task by using his own speech – rhythmical intention.

ii. Motor relearning theory

It emphasises the practice of functional tasks and importance of relearning real-life activities for patients. Principles of learning and biomechanical analysis of movements and tasks are important. (Carr and Shepherd, 1987)

c. Functional electrical stimulation (FES)

FES is a modality that applied a short burst of electrical current to the hemiplegic muscle or nerve. In Stroke Physical Therapy, FES has been demonstrated to be beneficial to restore motor control, spasticity, and reduction of hemiplegic shoulder pain and subluxation.

d. Biofeedback

Biofeedback is a modality that facilitates the electromyographic activity in selected muscle or awareness of joint position sense via visual or auditory cues.

(2) Hemiplegia Shoulder Management

Shoulder subluxation and pain of the affected arm is not uncommon in at least 30% of all patient after stroke ,whereas subluxation is found in 80% of stroke patients

Suggested interventions are as follows

a) 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. In Stroke Physical Therapy, Upper extremity weight bearing can be used to lengthen or inhibit tight or spastic muscles.

b) 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, spasticity and functionally, for the restoring function in the upper and lower limb. In Stroke Physical Therapy, Electrical stimulation is effective in reducing pain and severity of subluxation, and possibly in facilitating restoration of arm function

c) Positioning & proper handling

d) Neuro-facilitation

e) Passive limb physiotherapy

Maintenance of full pain-free range of movement without traumatizing the joint and the structures can be carried out.

f) Pain relief physiotherapy

Passive mobilisation as described by Maitland, can be useful in gaining relief of pain and range of movement (Davies, 1991).

g) Sling

In Stroke Physical Therapy the use of sling is controversial.

(3) Limb physiotherapy

Stroke Physiotherapy includes passive, assisted active and active ranges of motion exercise for the hemiplegic limbs. This can be an effective management for prevention of limb contractures and spasticity

(4) Chest physiotherapy

In Stroke Physical Therapy, evidence shows that both cough and forced expiratory technique are proven effective. Directed coughing and FET can be used as a technique for bronchial hygiene clearance in stroke patient.

(5) Positioning

 In Stroke Physical Therapy consistent reflex inhibitory patterns of posture in resting is encouraged to overcome physical complications of stroke and to aid recovery, therapeutic positioning is a renowned strategy to discourage the development of abnormal tone, contracture, pain and respiratory complications.

(6) Muscle Tone management

A goal of Stroke Physical Therapy interventions has been to “normalize tone to normalize movement.” Therapy modalities for reducing tone include stretching, prolonged stretching, passive manipulation by therapists, weight bearing, ice, contraction of muscles antagonistic to spastic muscles, splinting, and casting. TENS stimulation showed improvement for chronic spasticity of lower extremities

(7) Sensory facilitation and education

Bobath and roods approaches recommend the use of sensory stimulation to promote sensory recovery of stroke patients.

(8) Balance Training

(9) Gait Training

Bobath assumed abnormal postural reflex activity is the cause of dysfunction and disability, so gait training involved tone normalisation and preparatory training for gait activity. In contrast Carr and Shepherd suggests task-related training with methods to increase strength, coordination and flexible musculoskeletal system to develop skill in walking along with treadmill training combined with use of suspension tube

(10) Functional Mobility Training

To handle the functional obstruction of stroke patients, specific functional tasks are explained to them based on movement analysis , these tasks include bridging, rolling to sit to stand, transfer skills, walking and stairing etc

(11) Upper limb conditioning

Many approaches to the physical rehabilitation of adults post-stroke exist that attempt to maximize motor skill recovery. However the literature does not support the efficacy of any single approach. The followings are the current approaches to motor rehabilitation of the UE.

a) Facilitation techniques

They are the most common methods of intervention for the deficits in UE motor skills including Bobath, proprioceptive neuromuscular facilitation, Brunnstrom’s approach and Rood’s approach.

b) Functional electric stimulation

In Stroke Physical Therapy, Functional electric stimulation can be effective in increasing the electric activity of muscles or increased active range of motion in individuals with stroke.

c) Constraint-induced therapy

(13) Mobility aid