1
Q
Transient Ischemic Attack (TIA)
A
Neurological dysfunction
Symptoms last from minutes up to 24 hours
TIA is a warning sign for potential stroke
2
Q
Is an stroke considered at ABI?
A
YES - injury after birth, not from genetic or congenitial disorder and included traumatic and non traumatic injures
3
Q
Cerebral Vascualr Accident: Overview
A
- 3rd leading cause of death in Canada, 1st in LT disability
- Risk factors: HTN, CVD, diabetes, elevated cholesterol, smoking, obesity, older age, M>F, family history, previous stroke/TIA
4
Q
CVA: Signs and Symptoms
A
- Sudden numbness or weakness of the face, arm or leg
- Sudden confusion
- Trouble speaking
- Sudden trouble seeing out of both eyes
- Dizziness, loss of balance, or coordination
- Sudden severe headache with no known cause
5
Q
CVA: Ischemic Stroke
A
- 80% (most common)
- Could be due to a thrombus or embolism
- BLOCKAGE
- Most common cause in older adults = thrombosis
6
Q
CVA: Ischemic Stroke - Lacunar strokes
A
- Subgroup of ischemic stroke
- Most common type of stroke
- Blockage of small deep generating arteries of the brain that feed the deep nuclei of the brain
- Associated with HTN and diabetes
- Correlation with decreased cognition
7
Q
CVA: Hemorrhagic Stroke
A
- 20% of strokes
- Due to aneurysms and arteriovenous malformation (AVM), HTN, head trauma, illicit drug use and bleeding disorders
- BURST
- AVM: a tangle of abnormal or poorly formed blood vessels that have a higher rate of bleeding than normal vessels
- Arterial factors: atherosclerotic plaques, aneurysms, pressure on artery walls
- Venous factors: tendency for blood to clot quickly, irritation or inflammation of the lining of a vein
8
Q
CVA: Penumbra
A
- Area of the brain at risk of dying
- Located between an area of perfusion and necrosis
- May be viable for several hours post stroke
- If ischemic, TPA can be used to save more brain tissue
9
Q
CVA: Prognosis for a Stroke - ABCD score
A
- Clinical prediction rule used to determine the risk for stroke on the days following a TIA
- Age, blood pressure, clinical features, duration
- Those who are older than 60, uncontrolled HTN, multiple clinical features and TIA symptoms lasting greater than an hour have increased prognosis for a CVA
10
Q
CVA: Positive prognosis post stroke
A
- Younger age
- Ability to mobilize within a couple days
- Ischemic type stroke
- Absence of visuospatial deficits, absence of aphasia, absence of severe cognitive deficits, absence of incontinence, absence of LOC, absence of co-morbidities
- Early PT on a daily basis to maximize recovery
11
Q
CVA: Medical Treatment
A
IF THROMBOTIC:
- Thrombolytic agents
- Tissue plasminogen activator (TPA): digests fibrin to break down clot, administered within 3 hours of initial symptoms
- Within 6 hours, can be mechanical thrombectomy
IF HEMORRHAGIC:
- Endovascular procedure: coil is inserted to prevent a rupture, aneurysm clip
PREVENTION of THROMBOTIC:
- Asprin
- Lipid lowering agents
- Lifesytles changes
- Angioplasty/stents to widen artery
12
Q
CVA: RIght CVA Characteristics
Non verbal artsitic brain
A
- Left sided weakness
- Visual agnosia: impairment of recognition of visually presented objects
- Prosopagnosia: inability to recognize faces or pictures of familiar people
- Anosognosia (denial): deny that they had a stroke, believe limbs belong to someone else
- Disorientated awareness and impression of self: NEGLECT - may ignore left side of body or environment
- Decreased/short attention span: difficulty following instructions or answering questions
- Decreased musical/artistic abilities
- Visual spacial problems: judging distance, size, position and rate of movement
- Difficult with emotional content of language (speaks monotone)
- Issues discriminating smells
13
Q
CVA: Left CVA Characterstics
Verbal analytical brain
A
- Right sided weakness
- Decreased numerical and scientific skills
- Diminished functional speech (aphasia)
14
Q
CVA: Types of Aphasia: Wernicke’s
- Types
- Location
- Characteristics
- Communication strategy used
A
- Type: Receptive/fluent
- Location: left temporal lobe
- Characteristics: Spontaneous speech is preserved, auditory comprehension is impaired
- Strategy: Use demonstrations, gesture, pictures (visual modalities) for communication
15
Q
CVA: Types of Aphasia: Broca’s
- Types
- Location
- Characteristics
- Communication strategy used
A
- Type: expressive/non fluent
- Location: left frontal lobe
- Characteristics: impairment motor production of speech, auditory comprehension is spared
- Communication strategy used: use verbal cues in communication
16
Q
CVA: General PT Treatment
A
- Maintain ROM and prevent deformities, PROM, mobilization
- General positioning in bed
- Functional mobility: transfer practice
- Promote awareness, active movement, strengthening of affected limbs
- Hemi shoulder: education, strengthening, positioning, bracing and PROM
- Gait re-training and gait aid prescription
- Pain management
- Spasticity management: bracing, stretching, splinting
- Promote independence in ADLs
- FES and NMES for muscle activation
- Cardiovascular endurance
17
Q
CVA: Treating Neglect
A
- Incorporate involved side into crossing midline activities
- Teach visual scanning strategies
- Stand and sit on neglect side
- Include neglected hand into tasks
- Stimulate affected side using sensory stimulation
18
Q
CVA: Transfers
A
- Initially done towards strong side because it is the safest
- Later in rehab, go towards affected side to re-train motor control, weight shift and weight bearing
19
Q
CVA: Shoulder Subluxation
A
- Initial position of the scapula is flaccid upper extremity = downward rotation and adduction of inferior angle
- Usually caused by traction and gravitational forces acting on depressed, downwardly rotated scapula
- Spasticity (especially at subscap and pec major) and loss of external rotation are the most likely causes of hemiplegic painful shoulder
20
Q
CVA: Treatment for Flaccid Shoulder
A
- Weight bearing into affected UE
- NMES
- Shoulder positioning: GH always supported, avoid IR, and educate patient, family and care givers
- Do not pull shoulder, support shoulder during transfers
- Safe PROM to avoid impingement/trauma to GH joint
- No shoulder flexion or abduction above 90
21
Q
CVA: Positioning
A
- If extensor spasticity… try laying in side lying or sitting) - avoid supine
- When in supine: slight bend of hips and knees to avoid mass extension in lower limb and shoulder is supported in slight abduction/ER, elbow extension, forearm supination (palm up)
- If side lying on good side: affected shoulder is protracted and elbow extended with pillow - avoid elbow flexion, shoulder adduction/IR (due to spasticity developing)
22
Q
CVA: Laying on Hemi side
A
- Helps decrease spasticity due to elongation of the affected side
- Increased physical awareness of the affected side
- Hemi side should be extended at the hip and slightly flexed at the knee
23
Q
CVA: Outcome Measures
A
- Fugl-Meyer
- CMSA
- Modified Ashworth Scale
- FIM
- 6MWT, TUG, 10 m walk
- Box and block test
- BBS
24
Q
CVA: Side lying positioning for strokes
A
Explain them - look up picture to check if right
25
CVA: Areas of the Brain - Frontal Lobe
Primary motor, Broca's area, cognition (judgement, awareness, attention, abstract thinking)
26
CVA: Areas of the Brain - Parietal Lobes
Primary sensory, short term memory
27
CVA: Areas of the Brain - Occipital Lobes
Primary visual
28
CVA: Areas of the Brain - Temporal Lobes
Primary auditory, Wernicke's area, olfactory area, long term memories
29
CVA: Homunculus
Physical representation of the human body. Map of anatomical divisions of the body!
30
CVA: Cerebral Blood Flow and Anatomy
- Major blood supply to the brain
- Common carotid arteries bifurcate into external carotid and internal carotid arteries
- Internal: supplies brain tissue
- External: supplies face, meninges, scalp, skull and parts of neck
31
CVA: Internal Carotid Artery
- Supplies anterior 3/5 of cerebrum, expect for temporal and occipital lobes
- Deficits: contralateral hemiplegia and hemisensory distrubances, global aphasia, mentally slow, homonymous hemianopia, partial Horner's syndrome, gaze palsy
32
CVA: Anterior Cerebral Artery
- Arises from internal carotid artery
- Supplies medial portion of the frontal and parietal lobes including the primary motor and sensory areas of the lower limbs
- Deficits: motor sensory --> weakness and sensory loss of contralateral lower extremity, frontal cortex --> emotional liability, changes to personality, deficits to logical thoughts, disinhibition, memory, seizures
33
CVA: Middle Cerebral Artery
- MOST COMMON for ischemic stroke
- Arises from internal carotid artery
- Supplies part of the frontal lobe and lateral surface of the temporal and patietal lobes including the primary motor and sensory areas of the face, throat, hand and arms and in the dominant hemisphere, the areas of speech
- Deficits:
--> Motor sensory coretx: weakness and sensory loss of contralateral upper extremity and face, difficulty with ADLs
--> Contralateral homonymous hemianopsia
--> Parietal lobe: perceptual deficits - contralateral neglect, apraxia, anosognosia (more common with right hemi stroke)
--> Language centers: aphasia
--> Temporal lobes: impaired hearing
34
CVA: Posterior Cerebral Artery
- Arises from basilar artery
- Supplies part of temporal and occipital lobes, thalamus, upper brainstem
- Deficits:
--> vision problems (contra homo hemi), visual agnosia, disorders of reading, disorders of color vision
--> thalamus injury: thalamic syndrome (oain syndrome)
--> brainstem: CNIII, contra hemi motor and sensory, chorea
--> memory impairments
35
CVA: Vertebrobasilar System
- Vertebral arteries merge to form the midline basilar artery
- Together the vertebral and basilar artery are called vertebrobasilar system
- Supply posterior 2/5 of cerebrum
36
CVA: Basilar Artery Stroke
- Locked in syndrome
- Patient is aware but cannot move or communicate verbally due to complete paralysis of nearly all voluntary muscles in body expect for eye movements and blinking
- Caused by damage to specific portions of the lower brain and brainstem with no damage to upper brain stem
37
CVA: Horners Syndrome
- Lesion of the nerves of the sympathetic trunk that supply the head and neck
- Can be congenital or acquired as a result of disease or trauma (tumour, stroke)
- Presents with IPSILATERAL droppy eyelids, contristed pupils, dry face and red face
38
CVA: Circle of Willis
- Carotid and vertebrobasilar systems form a circle of communicating arteries
- Allows for redirection of blood flow in case of ischemic stroke
- Preserves as much cerebral perfusion as possible and limit tissue damage
Physio
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