S T R O K E F A C T S : : A D U M M Y ' ' S G U I D E F O R D U M M I E S
Sources: (Delisa and Gans, 1993; Dewald, 1987; Rowland, 1995)
 Cerebrovascular accident (CVA) or Stroke is the most common serious neurological problem
 Second only to head trauma for neurological disability
 Half of neurological patients hospitalized have stroke
 3 rd most common cause of death in the US
 Half million strokes per year, 40% are fatal
 $ 7 Billion per year in costs
 Risk factors: Age, hypertension, cardiac impairment, thrombogenic diseases (e.g., clotting disorders), previous strokes, and diabetes.
 AGE as a factor:
 45 or younger: 66
 45-65: per 100,000
998 per 100,000
 65 or older: 5063 per 100,000
 Incidence has decreased about 1% per year since 1940's, mostly due to hypertensive medications.
 Types of CVA:
 40% Thrombotic:
 Stenosis or occlusion of carotid or middle cerebral artery.
 Usually a big impairment.
 Cortical and possibly other areas
 Typically slow onset
 Typically happens at night
 30% Embolic:
 Stuff floating in blood (usually clots from heart problems) loges and blocks the flow to the brain.
 Potentially big impairment.
 Cortical and possibly other areas.
 20% Lacunar:
 Area effected is small (<1 cm3).
 Internal capsule, basal ganglia, or brain stem -- subcortical.
 Caused usually by hypertension.
 Usually brief (resolve in 24 hours) -- This is why they are often called Transient Ischemic
Attacks (TIA).
 Usually an indication that bigger problems are coming.
 85% recovery.
 Focused effects: either pure motor or pure sensory deficit.
 10% Hemhoragic:
 Usually same areas as lacunar.
 Anatomy of a stroke:
 80% carotid (anterior) group.
 Most emboli fly to the carotid or the middle cerebral artery (see figure).
 Result: Hemiparesis (limbs, trunk and face), aphasia (no speech), Disarthria (slurred or problems with speech), headache, visual field loss
 20% Posterior circulation
 Effects brainstem, which is a compact center so there many areas affected.
 Bilateral problems
 Cerebellum, brain stem, midbrain, and other more central areas can be affected.
 Problems following stroke:
 Deep vein thrombosis (from paralysis and sitting still)  pulmonary embolus  heart arrhythmia
 Increase in blood pressure
 Edema in brain
J I M P A T T O N , , 1 2 / 1 / 9 9
 Pneumonia due to sitting still and poor swallowing mechanism
 More strokes
 Acute Treatments (Not much!):
 Thrombolitic agents (clot busters) if possible in the first couple of hours. Aspirin is a good initial treatment.
 endarterectomy (roto-root the vessel) in really serious, high-risk cases.
 Bypass and vasodilators are not effective
 Post acute phase:
 71% patients have impaired vocational capacity,
16% must be institutionalized, 31% need assistance in self-care, 20% need ambulatory assistance (e.g., a walker).
 Cognitive impairments are common and used as exclusion criteria fro rehabilitation.
 Geriatric population tends to have poor motivation
 Depression is common and believed to be not just caused by the impairments themselves.
 Shoulder sublexation (Palpable gap between the acromion and humeral head). More common when sitting.
 Shoulder-Hand Syndrome (SHS) can develop in 2 nd and 4 th month: pain when moving -- treated by moving.
 Left vs. right:
 Left hemiparetic:

 Left-sided neglect (sensory ignorance of the left side of the body) can often attribute the limb to not belong to them.
 Appears to be OK -- often perfect verbal skills
 Poor awareness of their deficits (falls, burns, etc result).
 Learning is impaired -- the patient does not learn from mistakes
 Typically argumentative and impulsive.
 Right hemiparetic:
 Poor communication
 Better learning -- learning by imitation has been shown to be successful.
 Rehabilitation:
 Begins about 48 hours after stroke.
 Typically 1-2 week trial period to determine if rehabilitation will be of benefit.
 Many studies supporting the efficacy of rehabilitation, but some remain skeptical that rehabilitation works. (Steinberg, 1986) reports 10% will spontaneously recover without rehabilitation, 10% cannot recover (predictors help determine which ones), and 80% may benefit from rehabilitation.
 Typical deficits and their recovery:
 Tone goes from flaccidity progresses to spasticity to normal during recovery.
 Synergy patterns (see below) progress to voluntary segmental control during recovery.
 Proximal function returns first.
 Poor prognosis for people with late recovery of motion (2-4 weeks).
 Typically progress is observed for up to 5
months.
 The key determinants of success are: age, perceptual impairment, depression and comprehension.
 Techniques:
 Conventional: range-of-motion stretching, strengthening exercises, and mobilization activities
(ADL).
 Neuromuscular re-education
(Neurofacilitation): see: (Dewald, 1987)
(This is pretty speculative stuff....)
 Kabat's PNF: (Proprioceptive Neuromuscular
Facilitation)
 Resist stronger components along the path of synergistic movement, in the hopes that other adjacent nerves will be activated in the process, restoring their function.
 Brunstromm:
 Cause the synergies to appear as early as possible
 Capitalize on "associated" and
"primitive postural" reactions: resist motion on unaffected side turn head to unaffected side to assist flexion on affected side.
 Use stretch reflex: rapid stretching to inhibit the antagonist.
 Works best for in flaccid subjects.
 Bobath NDT: (Neurodevelopmental
Technique)
 Recommended as the mainstream technique
 Normalization of muscle tone and inhibition of primitive postural reactions
 Reflex inhibitory patterns (RIP): Move to a position that excites spasticity very slowly and hold it there for a while. Repeat. This causes a reduction in tone by slow, prolonged lengthening of spastic muscles, which eventually accommodate to the stretch. It also increases stretch reflex activity in antagonists.
 Example: Shoulder protraction & abduction, with elbow, wrist and finger extension.
 Do not use resistance -- it excites spasticity. Assist only when necessary.
 Tapping on muscles that are antagonists to spastic ones to cause reciprocal inhibition.
 Rood:
 Use non-proprioceptors to inhibit/facilitate movement.
 The CNS has 2 components: Mobility
(withdrawal) and stability (stretch reflex)
 Developmental stages (levels):
1.
Development of mobility:
Stroking or stimulating using ice causes withdrawal.
2.
Development of stability.
3.
Development of mobility & stability in weight bearing : weight shifting and movement of proximal joints while the hands or feet remain stationary.
4.
Development of skilled movement
 Biofeedback: auditory, visual, and other sensory cues. (Not a lot of evidence it works)
 Functional Electrical Stimulation (FES):
Mildly successful
 Drugs:
 Amphetamines (1 successful study)
 Anti-spasticity medications
 Nerve blocks with phenol
 Surgery: Tendon transfers and releases (not that successful on upper extremity deficits).
References:
 Delisa, JA and Gans, BM (1993) Rehabilitation
Medicine. J. B. Lippincott Company, Philadelphia.
 Dewald, JPA (1987) Sensorimotor neurophysiology and the basis for neurofacilitation theraputic techniques. Stroke Rehabilitation, (M. E. Brandstater and J. V. Basmajian). 109-182. Williams and Wilkins,
Baltimore.
 Rowland, LP (1995) Merritt's textbook of neurology.
Williams & Wilkins, Baltimore.
 Steinberg, FU (1986) Rehabilitating the older stroke patient: what's possible? Geriatrics 41: 85-7.

R
ECENT
L
ITERATURE
S
URVEYS
(1996-1999)
ON
S
TROKE AND
.....
Neglect
 Bowen, A, McKenna, K and Tallis, RC (1999) Reasons for variability in the reported rate of occurrence of unilateral spatial neglect after stroke. Stroke 30: 1196-202.
 Carey, LM, Oke, LE and Matyas, TA (1996) Impaired limb position sense after stroke: a quantitative test for clinical use. Archives of Physical Medicine &
Rehabilitation 77: 1271-8.
 Lin, KC (1996) Right-hemispheric activation approaches to neglect rehabilitation poststroke. American Journal of
Occupational Therapy 50: 504-15.
 McGlone, J, Losier, BJ and Black, SE (1997) Are there sex differences in hemispatial visual neglect after unilateral stroke? Neuropsychiatry, Neuropsychology, &
Behavioral Neurology 10: 125-34.
Posture
 Brown, DA, Kautz, SA and Dairaghi, CA (1997) Muscle activity adapts to anti-gravity posture during pedalling in persons with post-stroke hemiplegia. Brain 120: 825-
37.
 Lee, MY, Wong, MK, Tang, FT, Cheng, PT, Chiou, WK and Lin, PS (1998) New quantitative and qualitative measures on functional mobility prediction for stroke patients. Journal of Medical Engineering & Technology
22: 14-24.
 Levin, MF and Dimov, M (1997) Spatial zones for muscle coactivation and the control of postural stability. Brain
Research 757: 43-59.
 Petersen, H, Magnusson, M, Johansson, R and Fransson,
PA (1996) Auditory feedback regulation of perturbed stance in stroke patients. Scandinavian Journal of
Rehabilitation Medicine 28: 217-23.
 Wong, AM, Lee, MY, Kuo, JK and Tang, FT (1997) The development and clinical evaluation of a standing biofeedback trainer. Journal of Rehabilitation Research
& Development 34: 322-7.
Reaching movments
 Dean, CM and Shepherd, RB (1997) Task-related training improves performance of seated reaching tasks after stroke. A randomized controlled trial. Stroke 28:
722-8.
 Fishman, MN, Colby, LA, Sachs, LA and Nichols, DS
(1997) Comparison of upper-extremity balance tasks and force platform testing in persons with hemiparesis.
Physical Therapy 77: 1052-62.
 Levin, MF (1996) Interjoint coordination during pointing movements is disrupted in spastic hemiparesis. Brain
119: 281-93.
 Lin, KC, Wu, CY and Trombly, CA (1998) Effects of task goal on movement kinematics and line bisection performance in adults without disabilities. American
Journal of Occupational Therapy 52: 179-87.
 Nierich, AP, Diephuis, J, Jansen, EW, van Dijk, D,
Lahpor, JR, Borst, C and Knape, JT (1999) Embracing the heart: perioperative management of patients undergoing off-pump coronary artery bypass grafting using the octopus tissue stabilizer [see comments].
Journal of Cardiothoracic & Vascular Anesthesia 13: 123-
9.
 Trombly, CA and Wu, CY (1999) Effect of rehabilitation tasks on organization of movement after stroke [see comments]. American Journal of Occupational Therapy
53: 333-44.
Adaptation
 Gibson, JW and Schkade, JK (1997) Occupational adaptation intervention with patients with cerebrovascular accident: a clinical study. American
Journal of Occupational Therapy 51: 523-9.
 Kim, P, Warren, S, Madill, H and Hadley, M (1999)
Quality of life of stroke survivors. Quality of Life
Research 8: 293-301.
 Rossetti, Y, Rode, G, Pisella, L, Farne, A, Li, L, Boisson,
D and Perenin, MT (1998) Prism adaptation to a rightward optical deviation rehabilitates left hemispatial neglect. Nature 395: 166-9.
 Stineman, MG, Maislin, G, Fiedler, RC and Granger, CV
(1997) A prediction model for functional recovery in stroke. Stroke 28: 550-6.
 Widen Holmqvist, L, de Pedro Cuesta, J, Moller, G,
Holm, M and Siden, A (1996) A pilot study of rehabilitation at home after stroke: a health-economic appraisal. Scandinavian Journal of Rehabilitation
Medicine 28: 9-18.
 Wilkinson, PR, Wolfe, CD, Warburton, FG, Rudd, AG,
Howard, RS, Ross-Russell, RW and Beech, RR (1997) A long-term follow-up of stroke patients. Stroke 28: 507-
12.
 Yelnik, A, Bonan, I, Debray, M, Lo, E, Gelbert, F and
Bussel, B (1996) Changes in the execution of a complex manual task after ipsilateral ischemic cerebral hemispheric stroke. Archives of Physical Medicine &
Rehabilitation 77: 806-10.