2. Topics
• EPIDEMIOLOGY AND ETIOLOGY
• RISK FACTORS AND STROKE PREVENTION
• PATHOPHYSIOLOGY
• CLINICAL MANIFESTATIONS OF STROKE.
• NEUROLOGICAL COMPLICATIONS AND
ASSOCIATED CONDITIONS
• PHYSICAL THERAPY INTERVENTIONS
3. • Stroke (cerebrovascular accident [CVA]) is the sudden loss of
neurological function caused by an interruption of the blood
flow to the brain. Ischemic stroke is the most common type,
affecting about 80% of individuals with stroke, and results
when a clot blocks or impairs blood flow, depriving the brain
of essential oxygen and nutrients. Hemorrhagic stroke occurs
when blood vessels rupture, causing leakage of blood in or
around the brain.
4. EPIDEMIOLOGY AND ETIOLOGY
• Stroke is the fourth leading cause of death and the leading
cause of long-term disability among adults in the United
States. The incidence of stroke increases dramatically with
age, doubling in the decade after 65 years of age. Twenty-
eight percent of strokes occur in individuals younger than 65
years of age. hemorrhagic stroke accounts for the largest
number of deaths, with mortality rates of 37% to 38% at
1month ischemic strokes have a mortality rate of only 8% to
12% at 1 month.
6. RISK FACTORS AND STROKE
PREVENTION
• Cardiovascular diseases
• hypertension,
• heart disease (HD),
• disorders of heart rhythm,
• diabetes mellitus (DM).
• (hypercholesterolemia) low-density lipoprotein (LDL [“bad”])
• Cardiac disorders such as rheumatic heart valvular disease,
endocarditis, or cardiac surgery (e.g., coronary artery bypass
graft [CABG]) increase the risk of embolic stroke.
7. RISK FACTORS AND STROKE
PREVENTION (con’t)
• Modifiable risk factors include cigarette smoking, physical
inactivity, obesity, and diet.
• Lifestyle changes can greatly reduce the risk of stroke
• Recommendations include controlling BP, diet (cholesterol
and lipids), weight loss, quitting smoking, and
• increasing physical activity, as well as effective disease
management
8. PATHOPHYSIOLOGY
• Sudden cessation of cerebral blood flow and oxygen glucose
deprivation sets in motion a series of pathological events.
Within minutes neurons die within the ischemic core tissue,
while the majority of neurons in the surrounding penumbra
survive for a slightly longer time. Cell survival depends
largely on the severity and the duration of the ischemic
episode. The release of excess neurotransmitters (e.g.,
glutamate and aspartate) produces a progressive
disturbance of energy metabolism and anoxic depolarization
9. PATHOPHYSIOLOGY (con’t)
• This results in an inability of brain cells to produce energy,
particularly adenosine triphosphate (ATP). This results in an
inability of brain cells to produce energy, particularly
adenosine triphosphate (ATP). This is followed by excess
influx of calcium ions and pump failure of the neuronal
membrane
10. PATHOPHYSIOLOGY (con’t)
• Ischemic strokes produce cerebral edema, an accumulation
of fluids within the brain that begins within minutes of the
insult and reaches a maximum by 3 to 4 days. It is the result
of tissue necrosis and widespread rupture of cell membranes
with movement of fluid from the blood into brain tissues.
The swelling gradually subsides and generally disappears by
2 to 3 weeks
11. PATHOPHYSIOLOGY (con’t)
• Significant edema can elevate intracranial pressures, leading
to intracranial hypertension and neurological deterioration
associated with contralateral and caudal shifts of brain
structures (brainstem herniation). Clinical signs of elevating
intracranial pressure (ICP) include decreasing level of
consciousness (stupor and coma), widened pulse pressure,
increased heart rate, irregular respirations (Cheyne-Stokes
respirations), vomiting, unreacting pupils (cranial nerve [CN]
III signs), and papilledema.
12. Clinical Manifestations of Anterior
Cerebral Artery Syndrome
Contralateral hemiparesis involving mainly the LE (UE is
more spared)
Contralateral hemisensory loss involving mainly the LE (UE is
more spared)
Urinary incontinence
Problems with imitation and bimanual tasks, apraxia
Abulia (akinetic mutism), slowness, delay, lack of
spontaneity, motor inaction
Contralateral grasp reflex, sucking reflex Can be
asymptomatic if circle of Willis is competent
13. Clinical Manifestations of Middle
Cerebral Artery Syndrome
Contralateral hemiparesis involving mainly the UE and face (LE is more
spared)
Contralateral hemisensory loss involving mainly the UE and face (LE is
more spared)
Motor speech impairment: Broca’s or nonfluent aphasia with limited
vocabulary and slow, hesitant speech
Receptive speech impairment: Wernicke’s or fluent aphasia with
impaired auditory comprehension and fluent speech with normal rate
and melody Global aphasia: nonfluent speech with poor comprehension
Perceptual deficits: unilateral neglect, depth perception, spatial
relations, agnosia Limb-kinetic apraxia
Contralateral homonymous hemianopsia Loss of conjugate gaze to the
opposite side
Ataxia of contralateral limb(s) (sensory ataxia) Pure motor hemiplegia
(lacunar stroke)
14. Clinical Manifestations of Posterior
Cerebral Artery Syndrome
• Contralateral homonymous Hemianopsia
Visual agnosia
Prosopagnosia (difficulty naming people on sight) Dyslexia
(difficulty reading) without agraphia (difficulty writing),
color naming (anomia), and color discrimination problems
Memory defect
Contralateral hemiplegia
Oculomotor nerve palsy
15. Clinical Manifestations of
Vertebrobasilar Artery Syndrome
• Medial medullary syndrome :
Ipsilateral to lesion Paralysis with atrophy of half the tongue
with deviation to the paralyzed side when tongue is
protrudeddrome .
Contralateral to lesion :Paralysis of UE and LE
Impaired tactile and proprioceptive sense
16. Complete basilar artery syndrome (locked-in syndrome) :
Tetraplegia (quadriplegia)
Bilateral cranial nerve palsy: upward gaze is spared
Coma
Cognition is spared
17. Neurological complications and associations
conditions
• Altered Consciousness(coma, decreased arousal levels)
• Disorders of Speech and Language
• Dysphagia
• Cognitive Dysfunction
• Multi-infarct dementia
• Delirium
• Altered Emotional Status
18. • Hemispheric Behavioral Differences
• Perceptual Dysfunction
• Bladder and Bowel Dysfunction
• Cardiovascular and Pulmonary Dysfunction
• Seizures
• Deep Venous hrombosis and
• Pulmonary Embolus
19. Physical therapy interventions
• Strategies to improve motor learning
Mental practice or mental rehearsal is the systematic
application of imagery techniques for improving
performance and learning.( During early motor learning the
therapist provides extrinsic feedback (e.g., verbal cueing,
manual cueing), and manual guidance to shape
performance)
Mirror therapy (MT) is a therapeutic intervention that
focuses on moving the less impaired limb while watching its
mirror reflection
20. • Interventions to improve sensory
Mirror therapy for improving detection of light touch,
pressure, and temperature pain
Thermal stimulation intervention for improving rate of
recovery of sensation
Intermittent pneumatic compression for improving tactile
and kinesthetic sensation
21. • Interventions to improve hemianopsia and
unilateral neglect
visual, verbal, or motor cues
Imagine you are a lighthouse beam; use your beam to sweep
and scan the floor from one side to the other reaching
activities or PNF chop or lift patterns
22. • Interventions to improve flexibility and joint
integrity:
Soft tissue/joint mobilization and ROM exercises
Positioning strategies are also important in maintaining soft
tissue length
23. • Interventions to improve strength:
• Progressive resistive strength training
• Combining resistance training
24. • Interventions to manage spasticity:
early mobilization and daily stretching to maintain the
length of spastic muscles and soft tissues and promote
optimal positioning
Modalities can be used to treat spasticity. These include the
application of cold, massage, and electrical stimulation.
Orthotic devices
25. • Interventions to improve movement control:
voluntary movement control
postural control,
26. • Interventions to improve functional status:
Bed Mobility
Sitting
Sit-to-Stand and Sit-Down
Transfers
Standing Transfers
Ischemic
stroke is the most common type, affecting about 80% of
individuals with stroke, and results when a clot blocks or
impairs blood flow, depriving the brain of essential oxygen
and nutrients. Hemorrhagic stroke occurs when blood
vessels rupture, causing leakage of blood in or around
the brain.
A number of stroke risk factors are specific to women.
Women with early menopause (before 42 years of age)
have twice the risk of ischemic stroke as women with the use of estrogen alone or estrogen
plus progestin increases the risk of ischemic stroke (up
to 44% to 55% or higher).
later menopause.
Cerebral edema is the most frequent cause of death in acute stroke
and is characteristic of large infarcts involving the middle
cerebral artery and the internal carotid artery.
Mental practice can be facilitated through the use of audiotapes and has been
successfully combined with physical practice to enhance UE recovery121 and LE recovery and walking ability (gait speed) in patients with stroke
FunctionSensory retraining programs include use of
mirror therapy (previously discussed), repetitive sensory
discrimination activities, bilateral simultaneous movements,
and repetitive task practice (e.g., sensorimotor
integrative treatment with its focus on normalizing tone,
practice of functional activity, and use of augmented
sensory cues).
Sensory stimulation intervention includes
compression techniques (weight-bearing, manual compression,
inflatable pressure splints, intermittent pneumatic
compression), mobilizations, electrical stimulation,
thermal stimulation, or magnetic stimulation