PT-PNS 301

Physiotherapy In Stroke

Dr. Sukumar Shanmugam, MPT, Ph.D.

Dr. Meruna Bose, MPT, PhD.
Assistant professor, College of Health Sciences
Gulf Medical University, Ajman, UAE

October 19, 2023

www.gmu.ac.ae COLLEGE OF ALLIED HEALTH SEIENCES

 OBJECTIVES
• End of the lecture, the students will be able to
• Define stroke
• Explain various causes for stroke
• Explain Pathophysiology of stroke
• Describe clinical features of various type of stroke
• Perform neuro-physiotherapeutics for stroke
 Stroke, Cerebrovascular Accident

• "rapidly developing clinical signs

of focal or global disturbance to
cerebral function, with
symptoms lasting 24 hours or
longer, or leading to death, with
no apparent cause other than of
vascular origin and includes
cerebral infarction, intracerebral
hemorrhage, and subarachnoid
hemorrhage"
 PREVALENCE
• Annually, 15 million people worldwide suffer a stroke.
• 5 million die and 5 million are left permanently disabled
• Uncommon in people under 40 years; main cause is high blood pressure.
• Also occurs in about 8% of children with sickle cell disease.
 COMMON RISK FACTORS

• Hypertension, diabetes mellitus, hypercholesterolemia, physical inactivity,

obesity, genetics, and smoking.

• Cerebral emboli commonly originate from the heart, especially in patients

with preexisting heart arrhythmias, valvular disease, structural defects and
chronic rheumatic heart disease.

• Emboli may lodge in areas of preexisting stenosis.

• Alcohol intake increases the risk of hemorrhagic stroke in a near-linear

relationship.
 ISCHAEMIC STROKES

• Ischaemic strokes are the most common, accounting for up to 80%

• Thrombotic - clot usually forms around atherosclerotic plaques.

• Embolic - A blood clot, air bubble or fat globule forms within a blood vessel elsewhere

in the body and is carried to the brain.

• Systemic Hypoperfusion - A general decrease in blood supply, Venous Thrombosis

 ISCHAEMIC STROKES

• Four main types of ischemic strokes.

• Large vessel atherosclerosis,

• Small vessel diseases (lacunar infarcts),

• Cardioembolic strokes

• Cryptogenic strokes
 Haemorrhagic Strokes

• Haemorrhagic Strokes occur when a blood vessel in the brain ruptures and
bleeds.

• Intracerebral Haemorrhagic Stroke — bleeding from a blood vessel within

the brain. High blood pressure is the main cause of intracerebral
haemorrhagic stroke.

• Subarachnoid Haemorrhagic Stroke —bleeding from a blood vessel

between the surface of the brain and the arachnoid tissues that cover the
brain.
Cerebral perfusion supply
 Location of Infarct & Deficits Produced
• Left MCA Superficial Division

• Right face and arm upper-motor weakness due to damage to motor

cortex, nonfluent (Broca’s) aphasia due to damage to Broca’s area.
• There may also be right face and arm cortical type sensory loss if the
infarct involves the sensory cortex.
• Other deficits include a fluent (Wernicke’s) aphasia due to damage to
Wernicke’s area.
 Right MCA Superficial Division

• Left face and arm upper-motor weakness due to damage to motor cortex.

• Left hemineglect (variable) due to damage to non-dominant association

areas.

• There may also be left face and arm cortical type sensory loss if the infarct
involves the sensory cortex.
 Left MCA Lenticulostriate Branches

• Right pure upper-motor hemiparesis due to damage to the basal ganglia

(globus pallidus and striatum) and the genu of the internal capsule on the

left side.

• Larger infarcts extending to the cortex may produce cortical deficits such

as aphasia.
 Right MCA Lenticulostriate Branches

• Left pure upper-motor hemiparesis due to damage to the basal ganglia

(globus pallidus and striatum) and the genu of the internal capsule on the

right side.

• Larger infarcts extending to the cortex may produce cortical deficits such

as aphasia.
Left PCA
• Right homonymous hemianopia due to
damage to left visual cortex in the
occipital lobe.
• Extension to the corpus collusom
interferes with communication between
the two visual association areas so it can
cause alexia without agraphia.
• Larger infarcts involving the internal
capsule and thalamus may cause right
hemi-sensory loss and right hemiparesis
due to the disruption of the ascending and
descending information passing through
these structures.
 Right PCA

• Left homonymous hemianopia due to damage to the right visual cortex in

the occipital lobe.

• Larger infarcts involving the internal capsule and thalamus may cause left

hemi-sensory loss and left hemiparesis due to the disruption of the

ascending and descending information passing through these structures.

 Left ACA

• Right leg upper-motor neuron weakness due to damage to the motor

cortex and right leg cortical sensory loss due to damage to the sensory

cortex.

• Grasp reflex, frontal lobe behavioral abnormalities, and transcortical

aphasia can also be seen if the prefrontal cortex and supplemental motor

areas are involved.

 Right ACA

• Left leg upper-motor neuron weakness due to damage to the motor cortex

and left leg cortical type sensory loss due to damage to the sensory cortex.

• Grasp reflex, frontal lobe behavioural abnormalities and left hemineglect

can also be seen if the prefrontal cortex and non-dominant association

cortex are involved.

 Outcome Measures

• NIH Stroke Scale

• Dynamic Gait Index,

• the 4-item Dynamic Gait Index,

• Functional Gait Assessment

• Chedoke-McMaster Stroke Assessment

• Chedoke Arm and Hand Activity Inventory

• CRS-R Coma Recovery Scale Revised

 Differential diagnosis

• TIA,

• Metabolic derangement such as hypoglycemia, hyponatremia,

• Hemiplegic migraine,

• Infection,

• Brain tumor,

• Syncope,

• Conversion disorder.
 Early Management of Acute Stroke
• Stabilize the patient and complete initial evaluation and assessment, including imaging
and laboratory studies, within a short time frame.
• Critical decisions need for intubation, blood pressure control, and determination of
risk/benefit for thrombolytic intervention.
• Glasgow Coma Scale scores of 8 or less or rapidly decreasing Glasgow Coma Scale
scores, require emergent airway control via intubation.
• Gait improvement with high-intensity interval training and moderate-intensity continuous
training in ambulatory chronic stroke patients.
• Moderate-intensity, continuous aerobic training (MCT) improves aerobic capacity and
mobility after stroke.
• High-intensity interval training (HIT) has been shown to be more effective than MCT
among healthy adults and people with heart disease.
 Goals of Rehabilitation

Primary Goals of Rehabilitation

• Prevent complications
• Minimise impairments
• Maximise function

Optimizing Post Stroke Rehabilitation

• Early assessment with standardized evaluations and validated assessment tools
• Early employment of evidence-based interventions relevant to individual patient
needs
• Patient access to an experienced multidisciplinary rehabilitation team
• ongoing medical management of risk factors and co-morbidities
 Upper Limb Impairments
• Subluxation
• Changes in Sensation
• Contracture
• Swelling
• Coordination Problems
• Weakness
• Altered Muscle Power
• Changes in Muscle Tone
• Hand Dysfunction
 Aims of Treatment

• Prevent shoulder pain and manage should pain effectively.

• Be selective when choosing compensatory versus remedial intervention

methods to treat clients who are predicted to have a low return of motor
function and poor functional use of their arm and hand.

• Provide remedially focused rehabilitation to clients who are predicted to

change in arm and hand function.

• Use measures of known reliability and evidence of validity for treatment

planning and outcome prediction.
 Upper extremity with severe impairment
• Focus on proper positioning to provide support at rest and careful handling
during functional activities
• Participate in classes supervised by professional rehabilitation clinicians in
institutional or community settings that teach the client and caregiver to
perform a self range of motion exercises.
• Avoid the use of overhead pulleys (risk of shoulder tissue injury)
• Use some means of external support for stage 1 or 2 upper limbs during
transfers and mobility
• Place arm and hand in a variety of positions that include placement within
the client’s visual field
• Use some means of external support to protect the upper limb during
wheelchair use
 Upper extremity with moderate
impairments
• Engage in repetitive and intense use of novel tasks that challenge the stroke survivor to
acquire necessary motor skills to use the involved upper limb during functional tasks and
activities

• Engage in motor-learning training including the use of imagery.

 Treatment Techniques
Strength Training
• improve upper-limb strength and function without increasing tone or pain in
individuals with stroke.
• Balance training with electromyogram-triggered functional electrical stimulation
(EMG-triggered FES) to improve static balance, dynamic balance, and ankle muscle
activation
• A improvement in strength and motor function in patients after subacute stroke with
high-intensity and low-intensity arm resistance training.
Modified Constraint-Induced Movement Therapy (mCIMT) and CIMT
• address learned non-use and decreased motor function in an upper extremity
affected by post stroke.
• Some studies suggest that performing aerobic exercise prior to m-CIMT enhances
the outcomes.
 Treatment Techniques
• Orthotics
• therapy incorporating a dynamic wrist-hand orthosis may be no better than manual
therapy
• Gaming
• goal-orientated computer gaming has proven to significantly reduce upper limb
impairment in stroke survivors.
• Virtual Reality
• effective in restoring upper limb motor impairments and motor-related functional
abilities.
• Mirror Therapy
• beneficial effect on motor control and function compared with conventional therapy.
• Robot-Assisted Therapy
• beneficial effect on motor recovery and function
 Enhancing Healthcare Team Outcomes
• The prevention and management of stroke are best done with an interprofessional team approach.
• Education of the public and Emergency Medical Services(EMS) are extremely important in
improving stroke outcomes.
• During the time-dependent early stroke phase and rehabilitation, stroke care involves an
interprofessional team to manage the disease. Evidence reveals that hospitals with stroke teams
with demonstrated knowledge in stroke and decreased door to needle times have decreased
mortality and improved outcomes.
• Once the diagnosis of stroke is made and acutely treated, the patient may need extensive physical
rehabilitation, speech therapy and/or a dietary consult.
• For those who recover function within 3 months, the prognosis is good, but for those with residual
neurological deficits, the outcome is guarded.
• Nurses and physical therapists at this point played a crucial role in providing family and patient
education as often activities of daily living may be a challenge.
• Secondary prevention after an acute stroke depends on the underlying stroke mechanism.
• Management of stroke is one of the single most difficult and challenging issues for health
professionals. Only through an interprofessional approach will the best outcomes be achieved.
DISCUSSION