CVA評估與æ2"ç™"2006.ppt
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CVA評估與æ2"ç™"2006.ppt

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  • Group of disorders that cause ischemia and disruption in the blood supply to the brain- can result in neurological deficits, damage Neurological deficits can present as TIA (deficits < 24 hrs) or CVA (deficits > 24 hours) TIA and CVA are symptoms of various cerebrovascular disease Cva=stroke= brain attack Leading cause of disability 3 rd leading cause of death Rate of death by stroke has decreased by 50% over last 20 years, from better dx and tx of HTN, early diagnosis and tx of TIA, improved tx during acute phase of CVA Rate of CVA’s in young increasing secondary to drug use (cocaine)
  • Atherosclerosis-plaque formation in arteries CVA classified as either ischemic (thrombus, embolism, or decreased blood flow) or hemorrhagic(ICH or SAH) Embolism- usually cardiac in origin A-fib, recent MI, bacterial endocarditis, valvular heart disease, cardioversion from a-fib- NSR
  • Require prompt dx and follow up Often sx of atherosclerosis of carotid or vertebral arteries, and can result in embolization of thrombus to branches of cerebral circulation Symptoms depend on area of brain that becomes ischemic
  • Most pts are asymptomatic before rupture Rupture occurs where vessel wall of aneurysm is weakest
  • Complications-vasospasm, rebleeding, hydrocephalus, seizures Vasospasm- spasms of cerebral vasculature that results in decreased blood flow to area- neuro sx wax and wane- less alert, decreased motor movement, subtle changes, combative Tx- Nimodipine (Ca channel blocker- ca being increased into vessels from breakdown of SAH blood causing vasospasm)- start with in 96 hrs to 21 days p bleed. Usually occurs between day 4-12, also with triple H therapy- hypertension (don’t want acute increase in bp- causing rebleed), hypervolemia (do not let these pt’s get dry), hyperosmolality Tx of hydrocephalus- ventriculostomy drain or permanent VP shunt Seizures-anticonvulsants 6mo-1 year p rupture Neurological deficits if permanent = CVA (cell death)
  • Shunt is formed Cerebral steal- results in ischemia to area of brain blood is shunted from
  • Rt hemisphere - responsible for sensory-perceptual and visual spatial processing and body space awareness *** more perceptual deficits Lt hemisphere - dominant for language *** more communication problems
  • 7 Arm length discrepancy Thermoplastic jig measurements Palpation is reported to be very reliable
  • HH- visual field deficit occurs posterior to optic chiasm resulting in blindness in right or left field of vision, temporal field on one side and nasal field on another side. Bitemporal hemianopia- pituitary gland tumor
  • Dysarthria- language comprehension and appropriate speaking intact Expressive speech is slow, hesitant and labored- short phrases or single words
  • Receptive speech may be of normal rate and grammar intact, however unaware of and unable to correct mistakes, may substitute a group of sounds, word or syllable ex/ dork instead of fork Global- few if any language skills

CVA評估與æ2"ç™"2006.ppt CVA評估與æ2"ç™"2006.ppt Presentation Transcript

  • Cerebrovascular Disease
  • STROKES
    • # 1 Cause of long-term disability in adults
    • 3 RD Leading cause of Adult Death in U.S.
      • About 730,000 people will have a Stroke
      • 150,000 will die.
    • Taiwan : 15,000/ yr
  • Cerebrovascular Disease
    • CVD: disease states which cause interruptions to cerebral blood supply
    • Examples:
      • Atherosclerosis
      • Thrombus
      • Embolism
      • Hemorrhage- secondary to trauma, hypertension, ruptured or leaking cerebral aneurysm, leaking arteriovenous malformation (AVM)
  • Cerebral Vascular Accident (CVA)
    • Definition of Stroke - sudden loss of neurological function, caused by vascular injury to the brain
    • Etiology - loss of brain tissue perfusion regardless of whether the triggering event is ischemic or hemmorhagic
    • Strokes Divided Into Two Major Categories Nonhemorrhagic (85%) and Hemorrhagic (15%)
    • Diagnosis based on symptoms, CT, MRI
      • Initial CT, MRI of ischemic stroke may be “normal”
      • LP performed (if no s/s increased ICP)
  • Risk Factors Associated With CVA
    • Reversible:
      • Smoking
      • Obesity
      • Use of OBC’s
    • Partially reversible:
      • HTN
      • Arteriosclerotic heart dz
      • Diabetes mellitus
      • Increased blood viscosity
      • COPD
    • Non-reversible:
      • + Family history of vascular disease
      • History of TIA’s
      • Previous CVA
      • Advancing age
      • Race, sex
      • Cardiac disorders
        • Atrial fibrillation
        • Recent MI
  • Types of CVA
    • Ischemic: (lack of blood supply)
      • Thrombosis
      • Embolism
      • Greatly reduced blood flow (following hypovolemic shock, cardiac arrest)
    • Hemorrhagic: (rupture of cerebral vessel)
      • Intracerebral hemorrhage
      • Subarachnoid hemorrhage
        • Ruptured cerebral aneurysm
  • Ischemic CVA (70~85%)
    • Pathophysiology:
      • Blood flow occluded  blood flow stops
      • Brain cells in immediate area die within 4 minutes  set off metabolic and electrical changes  cells within larger surrounding area damaged  edema  further compromised blood flow
      • Amount of damage dependent on
        • Extent of tissue destruction
        • Area affected
        • Collateral blood flow to area
        • Underlying health of brain tissue
  • Embolic Stroke
    • Sources of emboli:
      • Cardiac (most common), carotid arteries, systemic circulation, fat (long bone fractures)
    • At risk:
      • Patients diagnosed with recent MI, heart disease, carotid occlusion
  • Transient Ischemic Attack (TIA)
    • Warning sign!!
    • Ischemic event that occurs in the brain that causes temporary neurological deficit
      • (sudden onset, last minutes to 24 hours)
    • Symptoms last no longer than 24 hours and return to neurological baseline
    • Assess for carotid bruit
      • TIA often associated with atherosclerosis of carotid or vertebral vessels
    • Treatment-
      • anticoagulants, platelet inhibitor (Persantine,ASA)
      • correct risk factors (HTN, obesity)
  • Reversible Ischemic Neurologic Deficit (RIND)
    • Neurological symptoms last 24-48 hours
    • Ischemia without infarction or mild infarction that results in complete recovery
    • Risk of infarction following RIND higher than with TIA
  • Lacunar Infarction
    • Small, deep penetrators
    • Old age
    • Long-term hypertension
    • Not in cortex
    • No symptom or mild
  • Stroke in Evolution
    • Increasing neurologic deficit occurring over hours to days
    • Clinical worsening occurs in 20-35% of patients in first 7 days after initial symptoms
    • Frightening for family and patient
    • Patient must be assessed carefully during this time for increasing impairment, s/s increased ICP
  • Hemorrhagic Stroke
    • Causes: rupture of blood vessel causing sudden and severe neurologic symptoms
    • Types:
      • Intracerebral hemorrhage:
        • Elderly with poorly controlled HT
        • Anticoagulant therapy (coumadin, heparin)
        • Brain tumors, trauma, COCAINE ABUSE
        • Ischemic stroke  bleeding into necrotic tissue
      • Subarachnoid Hemorrhage:
        • MOST COMMON CAUSE : ruptured or leaking intracerebral aneurysm
        • Trauma, intracerebral hemorrhage, cocaine abuse
  • Ruptured Cerebral Aneurysm
    • Causes of leakage/rupture of aneurysm
      • Physical exertion
        • exercise/ sports, sexual intercourse
        • Valsalva maneuver
      • Hypertension
    • Signs and symptoms
      • Severe H/A- “ worst H/A of life”
      • Loss of consciousness
      • Decreased LOC
      • Vomiting
      • Meningeal irritation
      • Neurological deficits
      • Photophobia
  • Meningeal Irritation (Meningitis)
    • Due to blood in subarachnoid space irritating meninges
    • Symptoms:
      • Nuchal rigidity:
        • Neck stiffness with pain on flexion
      • + Brudzinski’s sign:
        • Patient’s head is lifted  both hips, knees flex upward
      • + Kernig’s sign:
        • Patient unable to completely extend legs at the knees without pain
  • Cerebral Aneurysms
    • Rupture or leakage:
      • Usually results in subarachnoid hemorrhage
      • Rarely results in a intracerebral hemorrhage or subdural hematoma
    • Diagnosis made by CT of head, cerebral arteriogram
  • Arteriovenous Malformation (AVM)
    • Congenital tangled collection of blood vessels in the brain
      • blood is shunted from arterial system to venous system resulting in “cerebral steal”
      • hemorrhage results from blood in high arterial pressure system moving to weaker venous system
    • Can result in SAH or ICH
  • CVA: Clinical presentation Right Vs. Left
    • Right sided CVA
    • (Lesion on right side of brain)
    • Left sided weakness
    • Impatient, impulsive, lack of insight, distractible
    • Left neglect
    • Difficulty with spatial-perceptual relationships
    • Left visual field deficit
    • Not aware of deficits
    • Head, eyes, deviate RIGHT
    • Left sided CVA
    • (Lesion on left side of brain)
    • Right sided weakness
    • Cautious, plodding, careful behavior
    • Aphasia (receptive, expressive, global)
    • Right visual field deficit (HH)
    • Head, eyes deviate to LEFT
  • Recovery from stroke
    • Intrinsic & adaptive recovery(Hewer, 1990)
      • Intrinsic (neurological ): remediation of neurological impairments
      • Adaptive (functional): regaining the ability to perform meaningful activities, tasks, and roles without full restoration of neurological function
  • Theories of Recovery
    • Resolution of harmful factors
      • Reduced edema, resorption of toxins, increased circulation
    • Neuroplasticity
      • Collateral sprouting - From intact cells to denervated region after some or all input has been destroyed
      • Unmasking of neural pathways and synapses not normally used
        • Can be altered by drugs, environmental conditions, electrical stimulation
  • Figure 5.25  Collateral sprouting A surviving axon grows a new branch to replace the synapses left vacant by a damaged axon.
  • Neurological recovery
    • 69% mild to severe U/E dysfunction
      • 14~16% regain complete or nearly complete motor function
    • Motor recovery
      • Tradition : proximal  distal, mass, patterned, undifferentiated  selective  coordinated movement
      • Recent
      • # Most typical manifestation: hemiparesis or hemiplegia
  • Functional recovery
    • Amount of assistance required to carry out daily living tasks
      • Mahoney & Barthel, 1965: 47% indep, 9% dep, 44% partially indep
      • Other reports
      • Few studies have addressed the recovery of IADL
    • Factors of recovery(Con’t)
    • Time frame for recovery
      • Wade, 1992: First 1~3 mons
      • Ferruci et al, 1993: continued improvement in neuromuscular function, mobility, and ADL
  • Initial Presentation and Recovery
    • At onset, UE involved more than LE
    • UE usually recovers less fully
    • Initial severity of UE weakness and rate of return are predictive of overall recovery
      • Poor prognosis if complete flaccidity at onset or grip strength immeasurable at 4 weeks
    • Almost all spontaneous recovery occurs within 6 months
  • Factors of recovery
    • Extent and course of recovery
      • Type
      • Size
      • Site of lesion
    • Impede optimal functional recovery
      • Coexisting disease: DM, heart disease, peripheral vascular disease
    • Advancing age (difficult to isolate as a predictor)
    • Poor functional outcome
      • Severe initial motor deficits
      • BADL dep
      • Prior CVA
      • Severe visuospatial deficits
      • Severe cognitive impairments
      • Depression
      • Severe aphasia
      • Altered consciousness level
      • Poor social support
      • Poor sitting balance
  • Consequences of Stroke/CVA
    • hemiplegia /hemiparesis (complete/partial paralysis, 1 side)
    • receptive and/or expressive aphasia
    • sensory disturbances
    • hemianopsia (vision loss in one eye)
    • cognitive impairments
    • behavior changes
  • Stroke rehabilitation
    • Interdisciplinary team
      • Team members
    • Assessment
      • Post-stroke Rehabilitation Clinical practice Guideline
    • Treatment
      • acute, rehabilitation, transition to the community
  • Assessment
    • Occupational performance
      • BADL (self-care), IADL
    • Component abilities and capacities
      • Postural adaptation
      • U/E function
      • Motor learning ability
  • Postural adaptation -postural control
    • Def-- remain upright against gravity for stability and during changes in body position
      • trunk control  , poor bilateral integration1/2, impaired automatic postural control
      • Postural strategy: more effort, low-level compensatory
    • Evaluation
      • Static & dynamicSitting & standing
        • # Berg Balance Scale
  • Sitting
  • Walking
  • Upper function
  • (1) Passive movement
    • secondary stroke complication
      • sudden / prolonged immobilization, persistent stereotyped position, edema
        • Shoulder/ hand
  • (2) Shoulder subluxation
    • weakness or spasticity of scapulohumeral or scapular m.
        • Spine/ glenoid fossa
      • Abnormal muscle tone
    • Evaluation
      • Anterior/ Superior subluxation
      • Inferior subluxation --finger widths
  • Measuring Subluxation
    • Palpation
      • Seated
      • Trunk alignment stability provided if needed
      • UE is unsupported at the side with neutral rotation
      • Palpate between acromion and superior aspect of humeral head
      • finger widths scale
    • X-Ray
  •  
  • Shoulder subluxation 1
  • Shoulder subluxation 2
  • (3) Voluntary movement
    • Motor control
      • Isolated or synergistic pattern
        • adaptive., selective motions
        • Limited, stereotyped movement patterns
      • Reciprocal movement (agonist-antagonist motion in succession in an individual joint)
      • # Fugl-Meyer Assessment of Motor Function / Motor Assessment Scale
  • Initial Presentation
    • Initially see flexion posture in UE and extension posture in LE as result of spasticity
    • UE flexion
      • Shoulder add and IR, elbow flex, wrist/fingers flexed
    • LE extension
      • Hip add and ext, knee ext, ankle PF, foot inv
  • Synergy pattern in U/E
  • (4) Strength and endurance
    • Slightly less normal strength~ total inability
      • Manual muscle testing – traditional view
    • Endurance: physical or mental fatigue/ cardiac, or respiratory conditions
  • U/E functional evaluation
    • Functional performance
      • Not accurately reflex patient’s deficits in ADL and IADL
        • Compensatory use of unaffected arm
        • Dominant / nondominant arms
      • Action Research Arm Test / Frenchay Arm Test/ Functional Test for the Hemiplegic/ paretic Upper Extremity
  • Clinical assessment
    • Somatosensory assessment
      • aphasia, confusion, cognitive deficits (attention, recognition, response)
        • expressive aphasia
        • Comprehension level
      • standard procedures/ observation
      • gross protective / discriminative sensation
  • Motor learning ability
    • 1. Visual function
      • Homonymous hemianopsia: visual field defect
      • Unilateral neglect: visual attention deficit
        • Right hemisphere damage & parietal lobe
    • 2. Speech and language
      • Fluent, Nonfluent, global aphasia
      • Dysarthria: slurred speech, drooling, decrease facial expression
      • Speech-language pathologist
  • Visual Field Defects
    • Homonymous hemianopia-
      • most common type of defect in CVA, right or left
    • Bitemporal hemianopia
    • Total blindness- right or left
  • Parietal Neglect Syndrome Clinical Illustration
    • Failure to recognize side of body contralateral to injury
    • May not bathe contralateral side of body or shave contralateral side of face
    • Deny own limbs
    • Objects in contralateral visual field ignored
  • Unilateral Neglect Syndrome
    • Hemi-inattention : 無法對環境一邊的刺激定向或反應
    • Hemispatial visual neglect : 無法去定向對側的視覺刺激
    • Extinction : 無法報告對側缺損的刺激
    • Allesthesia: 刺激在身體的一邊,另一邊卻感受到一致同屬性的刺激
    • Hemiakinethesia: 動作忽略
  • unilateral neglect vs visual field deficit
    • Visual Field Deficit
    • 1. 視覺掃瞄視野縮短
    • 2. 掃瞄形式是有組織的再掃瞄時可觀 察到
    • 3. 在任務中使用的時間長短與效率是 適當的
    • Unilateral Neglect
    • 1. 無組織且任意的掃瞄形式
    • 2. 在半側空間非對稱性的搜尋模式
    • 3. 掃瞄形式是無效率的,且不會再掃視一次
    • 4.task 迅速完成,或是病人若知道自己的不足, 會企圖去做補償而耗費很多時間
  • Aphasia and Dysarthria
    • Aphasia-impairment in ability to formulate or interpret language symbols
      • Can be grouped as expressive vs. receptive
      • Can be grouped as fluent vs. non-fluent
    • Dysarthria
      • Muscles used in speech are weak, paralyzed or uncoordinated
      • Language comprehension intact
      • Appropriate speaking intact
    • Can occur separately or together
  • Language Areas
  • Aphasia
    • Expressive aphasia (motor or Broca’s)
      • difficulty in selecting, organizing and initiating speech
      • speech is slow, hesitant and labored- short phrases or single words
    • Receptive aphasia (sensory or Wernicke’s)
      • impaired auditory comprehension and feedback, unable to monitor and correct speech
      • Speech may be of normal rate and grammar intact, however unaware of and unable to correct mistakes; may substitute a group of sounds, word or syllable
    • Global aphasia
      • nonfluent speech with poor comprehension and limited ability to name objects or repeat words
  • Motor learning ability (con’t)
    • 3. Motor planning
      • Apraxia: deficits of skilled, organized, purposeful movement sequences
        • Failure to orient head or body correctly to task
        • Failure to orient the hand properly to objects and/ or poor tool use
        • Difficulty initiating or carrying out a sequence of movement
        • Hesitation and perseveration
        • Only in context or in presence of a familiar object or situation
  • Motor learning ability (con’t)
    • 4. Cognition
      • Learning, rehabilitation goal
      • Safety concerns in mobility, meal preparation, self- medication
      • Evaluation: focus on adaptive abilities of planning, judgment, problem solving, and initiation
        • Differentiate between cognitive deficits and communication difficulties
  • Motor learning ability (con’t)
    • 5. Psychosocial aspects
      • Natural emotional reactions: denial, anxiety, anger, depression
      • Depression: 33~50% stroke
        • Physiological result of biochemical changes in the brain
        • Reaction to personal losses
      • Emotional lability (18%) : laughing, crying…
  • Occupational performance
    • Self-care
      • Barthel Index
      • Functional Independence Measure
      • Katz Index of Adl
      • Kenny Self-Care Evaluation
    • IADL
      • Frenchay Activities Index
      • Philadelphia Geriatric Center Instrunmental Activities of Daily living Scale
  • Functional Assessment
    • Fugl-Meyer (motor function)
    • NIH Stroke Scale (general deficits)
    • Barthel, FIM, SIS (ADL’s, disability)
    • Berg (balance)
    • Glasgow Coma Scale (LOC)
    • MMSE (mental status)
    • Modified Ashworth
    • Tinetti
  • Functional Assessment Scales
    • Fugl-Meyer
      • Measures impairment on a 3-point ordinal scale. Measures pain, ROM, sensation, volitional movement, and balance
      • Comprehensively evaluated for validity
      • Adequately evaluated for reliability
      • 30-40 minutes to complete
  • Functional Assessment Scales
    • NIH Stroke Scale
      • 3-4 point scales measuring consciousness, vision, eye movements, facial palsy, limb strength, ataxia, sensation, speech and language
      • Comprehensively evaluated for validity
      • Adequately evaluated for reliability
  • Functional Assessment Scales
    • Barthel Index
      • Measures primarily ADL’s, some measurement of transfers, gait, stair ability
    • Stroke Impact Scale
      • 5 point scale measures strength, memory, affect, mobility, daily activities
      • Not an objective test; questionnaire administered to patient, subjective answers
  • Functional Assessment Scales
    • Berg Balance Scale
      • 4 point scale assesses sitting, standing, transfers, mobility
    • Mini-Mental State Examination
      • Point scale assesses orientation, mental ability, language ability
    • Katz Index of Activities of Daily Living
      • 6 item scale measures ADL’s as I, A, D
  • Functional Assessment Scales
    • Modified Ashworth Scale
      • 5 point scale measures spasticity
    • Tinetti Assessment Tool
      • 2 sections, gait and balance to measure fall risk
      • Good interrater reliability
      • Validity?
  • Lab
    • NIH Stroke Scale
    • Berg Balance Scale
    • Mini-Mental State Exam
    • Barthel Index
    • Stroke Impact Scale
    • Tinetti Scale
    • Fugl-Meyer
  • Treatment
  • Acute phase
    • Early mobilization and return to self-care
      • Basic ADL: rolling, sitting, transfer, feeding, grooming, dressings
    • Lowering risk for secondary complications
      • Skin care
        • Transfer, mobility techniques, positioning for bed & sitting (scheduled position), W/C & seating selection, inspection to special area
  • Treatment (con’t)
          • Maintaining soft tissue length
          • Positioning: sitting (especially U/E), bed
          • Joint mobilization
          • Hand splinting
          • Controlled movements: proper scapulohumeral rhythm (relax / mobilize scapula)
            • External rotation
            • Prevent impingement
  • Treatment (con’t)
        • Fall preventation
          • Advanced age, confusion, impulsive behavior, mobility deficits, poor balance or coordination, visual impairments, communication deficits
          • Environmental hazards, motor control, adaptive devices
      • Patient and family education
  • Rehabilitation phase
    • Medically stable, at least one functional disability, sufficient endurance
      • A. To improve performance of occupational task
        • Compensatory methods
        • simple  difficulty
        • Hierarchy of achievement
          • Motor , cognitive , perceptual abilities
            • Dressing: U/E and L/E
            • Homemaking, home management skills
  • Treatment (con’t)
      • B. To improve component abilities and capacities
        • I. postural adaptation
          • Safest, effective, efficient position
          • Mature postural adaptation
            •  full range of movement in trunk & extremities
            •  differentiate body parts from one another
            •  stop and hold movement
            •  body segments automatically and appropriately to support movement and/or stability
            •  symmetrically move both sides
  • Treatment (con’t)
        • II. upper extremity function
          • Mechanical and physiological components of movement
            • Shoulder subluxation: Sling , Alternative positioning methods, functional electrical stimulation
            • Movement reeducation: clasp hand
            • Hand edema
  • Sling
    • Controversial
        • Reduction of subluxation (Carr & Shepherd, 1987)
        • Correct malalignment (Gillen, 1998)
        • Pain control
        • Reinforced U/E spasticity (Bobath, 1990)
      • Indication
        • Pain or edema increase
        • Proper balance during using a sling
        • Inability to protect arm during movement
  • Sling (con’t)
      • Contraindication
        • Prevent or hinder active movement or function
        • Impair circulation
        • Excessive pressure on the neck
        • At risk for contracture
        • Decrease sensory input
        • Promote unilateral disregard
  • Alternative positioning methods
      • Wheelchair lapboards
      • Armrest troughs
      • Use of a table while seated or standing
      • Put hand in a pocket or under a belt
      • Use an over-the-shoulder bag
  •  
  •  
  • Treatment (con’t)
        • c. Voluntary movement and function
        • Forced use / Constraint-induced movement therapy ( Taub, 1993)
            • Minimal voluntary movement requirement: 20°  wrist extension and 10 °  finger extension
        • Coordinated movement
            • Unilateral activity  bilateral simultaneous activity  bilateral alternating activity
            • Gross fine motor task  precise manipulation task (different patterns of grasp and pinch)
            • writing
  • Treatment (con’t)
      • III. Motor learning ability
        • Active approach:
            • Visual scanning ability: generalization limited
            • Toglia, 1991: multicontext approach of practicing strategies in muliple environments with varied tasks and demands
            • Compensatory skill training: turning the head to the left
        • Passive approach:
            • Alter environment