The document discusses stroke assessment and management, outlining the definition, risk factors, classification, and symptoms of stroke, along with the pathophysiology and stages of recovery. It details primary and indirect impairments caused by stroke, emphasizing the importance of rehabilitation strategies for effective recovery. The management sections highlight acute rehabilitation processes and goals aimed at restoring function and preventing complications.

1. STROKE ASSESSMENT AND MANAGEMENT
Dr. Madiha Anees (PT)
Asst. Prof/VP RCRS
MS-PT , T-DPT, BS-PT

2. INTRODUCTION
• Stroke is an acute onset of neurological
dysfunction due to an abnormality in cerebral
circulation with resultant signs & symptoms which
corresponds to involvement of focal areas of the
brain.

3. ACC. TO WHO
• It is defined as the sudden onset of
neurological deficits due to an
abnormality in cerebral circulation with
the signs and symptoms lasting for more
than 24 hours or longer.

4. Transient ischemic attack
• It is defined as the sudden onset of
neurological deficits due to an
abnormality in cerebral circulation with
the signs and symptoms lasting for less
than 24 hours.

5. Epidemiology
• Third leading cause of death.
• The incidence of stroke is about 1.25 times greater for males than females.
• Most common cause of disability among adults.

6. Risk factors
MODIFIABLE
NON MODIFIABLE
• Ageing & gender
• Positive family history
• Heart disease
• Diabetes mellitus
• Hypertension
• Peripheral arterial disease
• Blood pathology
• Hyperlipidemia
• Smoking
• Obesity
• Lack of physical exercise or sedentary life style
• Diet & excess alcohol consumption
• Oral contraceptives
• Infection (meningeal infection)
• Psychological factors

7. Pathophysiology

8. Warning signs of stroke
• Sudden numbness or weakness of face, arm, or leg, on one side of body
• Sudden confusion, trouble speaking or understanding
• Sudden blurring of vision
• Sudden onset of dizziness, loss of balance or coordination
• Sudden, severe headaches with no known cause
• Sudden nausea, fever, & vomiting distinguished from a viral illness by speed of onset.
• Brief loss of consciousness or a period of decreased consciousness (fainting, confusion, convulsions, or
coma)

9. Stroke Classification
By specific vascular
territory or region:
• Artery: MCA, ACA,
PCA
• Lobe: Frontal,
temporal, occipital,
etc.
By management:
• Minor/major stroke
• Young stroke
• Deteriorating Stroke
By etiology:
• Thrombosis
(Ischemic)
• Embolus (Ischemic)
• Hemorrhage

10. CLASSIFICATION
Depending on the cause
Haemorrhagic stroke
• Intracranial haemorrhage
• Subarachnoid haemorrhage

11. CLASSIFICATION
Depending on the cause
ISCHEMIC STROKE
Thrombotic: more common. Usually occurs
in the sleeping hours. Characterised by
gradual onset of symptoms
Embolic: Occurs in the waking hours of the
day.
Emboli plug downstream arteries and
consist of pieces of thrombus or other
material that originate from proximal
arteries, the heart.

12. CLASSIFICATION
Depending on the severity:
• Mild stroke: symptoms subside with no deficit in a week period
• Moderate stroke: symptoms recover in a period of 3 - 6 months with
minimal neurological deficit
• Severe stroke: there is no complete recovery of the symptoms even
after 1 years. Always ends up with severe neurological deficit

13. CLASSIFICATION
Depending on the duration:
• Acute stroke: To a period of one week or until spasticity develops.
• Sub acute stroke: After the development of spasticity & last for a
period of 3-12 months
• Chronic stroke: More than 12 months

14. CLASSIFICATION
Depending on the symptoms:
• MCA Syndrome
• ACA Syndrome
• PCA syndrome

15. Circle of Willis

16. Territory of Circulation

17. Territory of Circulation

18. Territory of Circulation
Lateral View

19. MCA SYNDROME
RIGHT HEMI
• Contralateral hemiplegia (UL & face more affected
than LL)
• Contralateral hemisensory loss (UL & face more
affected than LL)
• Aphasia
• Ideomotor apraxia
• Ataxia of contralateral limb
• Contralateral Homonymous hemianopia
LEFT HEMI
• Autotopagnosia
• Anosgonosia
• Dysarthria
• Dressing & constructional dyspraxia
• Motor Impersistence
• Hemiparesis
• Topographic disorientation
• Anomia
• dysgraphia

20. Representation of body image over sensory &
motor cortex

21. ACA Syndrome
• Contralateral Hemiplegia of LL (LL more affected than UL)
• Contralateral sensory loss of LL
• Urinary incontinence
• Problems with imitation & bimanual task
• Apathy (Lethargic & lazy)
• Impulsive (lack of interest)
• Abulia (mental confusion)
• Akinetic mutism (mute)
• Gait Apraxia
• Personality disorders
• Problem in planning and execution

22. PCA Syndrome
• Coordination disorders such as tremor or ataxia
• Contralateral homonymous field deficit
• Cortical blindness
• Propagnosia (face blindness, unable to recognize faces)
• Cognitive impairment including memory impairment
• Thalamic syndrome (abnormal sensation of severe pain
from light touch or temperature changes)
• Weber’s syndrome (contralateral hemiplegia & third
nerve palsy)
• Physiological responses (vertigo, nausea, dizziness)

23. STAGES OF RECOVERY
Stage 1: Begins with a period of flaccidity immediately following
acute episode. No movement of limbs can be elicited.
Stage 2: Basic limb synergies. Minimal voluntary movement may be
present. Spasticity begins to develop.
Stage 3: Gains voluntary control of movement synergy although full
range is not developed. Spasticity has further increased.

24. STAGES OF RECOVERY
Stage 4: Some movement combination that do not follow
the synergy are mastered first with difficulty & later with more
ease. Spasticity begins to decline.
Stage 5: More difficult movement are learnt as the basic limb
synergy lose their dominance over motor roots. Spasticity
further declines.
Stage 6: Disappearance of spasticity, individual joint
movement become possible & coordination approaches normal.
Normal motor function is restored.

25. RED FLAG

26. Primary impairment
1. Altered sensation
2. Pain
3. Vision
4. Weakness
5. Alteration of tone
6. Abnormal synergy
7. Abnormal reflexes
8. Altered co ordination
9. Altered motor programing
10. Postural Control & Balance
11. Speech, Language, and Swallowing
12. Perception and Cognition
13. Emotional Status
14. Bladder and Bowel Function

27. PRIMARY IMPAIRMENT
1. ALTERED SENSATION
• Type and extent of deficit depends on location and
extent of the lesion.
• Profound hemisensory loss.
• Proprioceptive loss is common

28. PRIMARY IMPAIRMENT
2. PAIN:
• Pain is characterized by constant, severe burning pain with intermittent sharp pains.
• CVA can result in severe headache, neck or face pain.
• Thalamic pain syndrome.
• Pain due to secondary impairments.
• Hyperalgesia
• Loud sound, bright light etc. may trigger pain

29. Primary impairment
3. Vision
• Homonymous hemianopia, a visual field defect, in which there is
blindness on nasal half of one eye and temporal half of the other eye.
• Occurs with lesions involving the optic radiation (MCA) or to primary
visual cortex (PCA)

30. Primary impairment
4. Weakness
• Usually seen in the contralateral side of the lesion
• MCA stroke are more common so weakness is largely seen in the UL.
• Distal muscle are more affected than proximal muscles
• Mild weakness of ipsilateral side

31. Primary impairment
5. Alteration of tone
• Flaccidity (Hypotonicity) is present immediately after stroke and short lived.
• Spasticity (hypertonicity) emerges in about 90 percent of cases and occur
typically in predictable pattern.

32. ABNORMAL SYNERGY PATTRENS
• Stereotypical movement patterns associated with
spasticity.
• The patient is unable to move an isolated segment of a
limb without producing movements in the remainder of
the limb.
• 2 distinct abnormal synergy patterns have been
described for each extremity

33. Primary impairment
6. Abnormal synergy

35. Primary impairment
7. Abnormal reflexes
• Initially, hyporeflexia with flaccidity
• Middle stages of recovery (spasticity/synergy) hyperreflexia
• May demonstrate clonus, & +ve Babinski

36. Primary impairment
8. Altered co ordination
• Proprioceptive losses can result in sensory ataxia.
• Strokes affecting cerebellum typically produce cerebellar ataxia (e.g.
basilar artery syndrome, pontine syndromes) & motor weakness.
• Basal ganglia involvement (PCA syndrome) may lead to bradykinesia or
involuntary movements.

37. Primary impairment
9. Altered motor programing
• Motor praxis is ability to plan & execute coordinated
movement
• Lesions of premotor frontal cortex of either hemisphere, left
inferior parietal lobe, & corpus callosum can produce apraxia.
• Apraxia is more evident with left hemisphere damage than
right and is commonly seen with aphasia. It has 4 types.

38. Apraxia
Ideational
apraxia
Ideomotor
apraxia
Constructional
apraxia
Dressing apraxia
The patient has no
idea. They cant
perform complex
activity.
They are able to explain how to
perform movement, but cant
perform the movement.
Inability to draw or
construct simple
configuration.
Cant dress himself.

39. Primary impairment
10. Postural Control & Balance
• Impairments in steadiness, symmetry, & dynamic stability
• Problems may exist when reacting to a destabilizing external
force (reactive postural control) or during self-initiated
movements (anticipatory postural control).

40. Primary impairment
11. Speech, Language, and Swallowing
• Lesions involving cortex of dominant hemisphere
• Aphasia: Impairment of language comprehension, formulation, and use. It has 3
types.
Expressive aphasia Receptive aphasia Global aphasia
Broca’s aphasia
Motor aphasia
Problem in speaking words and
sentences
Wernicke’s aphasia
Sensory aphasia
Problem in understanding words
and sentences
Problem in both speaking and
understanding words and
sentences.

41. Primary impairment
Dysarthria:
Motor speech disorders caused by lesions of CNS or PNS that mediate speech
production.
Dysphagia:
• Swallowing difficulty – Usually delayed swallowing reflex – Aspiration occurs in 1/3 of patients
with dysphagia.
• Occurs with lesions affecting medullary brainstem (CN IX and X), large vessel pontine lesions, as
well as in acute MCA and PCA lesion.

42. Primary impairment
12. Perception and Cognition
• They are the result of lesions in right parietal cortex & seen more with left hemiplegia
than right.
• These may include disorders of body scheme/body image, spatial relations, and
agnosias.
• Visuospatial distortions: difficulty judging distance, size, position, rate of movement,
form.
• Unilateral neglect: patients are unaware of what happens on the hemiplegic side.

43. Primary impairment
13. Emotional Status
• Lesions of brain affecting frontal lobe, hypothalamus & limbic system
• May demonstrate pseudobulbar affect (PBA), also known as emotional lability or
emotional dysregulation syndrome.
• Emotional outbursts of uncontrolled or exaggerated laughing or crying that
are inconsistent with mood.
• Depression is extremely common
• Persistent feelings of sadness, feelings of hopelessness, worthlessness or
helplessness.

44. Primary impairment
14. Bladder and Bowel Function
• Disturbances of bladder function are common during acute phase
• Urinary incontinence can result from bladder hyperreflexia or
hyporeflexia, disturbances of sphincter control, or sensory loss.
• Disturbances of bowel function can include incontinence & diarrhea or
constipation

45. Hemispheric Behavioral Differences

46. Indirect Impairments
1.Musculoskeletal changes
2.Neurological signs
3.Thrombophlebitis & deep venous thrombosis (DVT)
4.Cardiac Function
5.Pulmonary Function
6.Integumentary

47. Indirect Impairments
1. Musculoskeletal changes
• Loss of voluntary movement and immobility can result in loss of ROM &
contractures.
• Contractures are apparent in spastic muscles of paretic limbs
• Disuse atrophy & muscle weakness results from inactivity and immobility
• Osteoporosis, results from decreased physical activity, changes in protein
nutrition, hormonal deficiency, & calcium deficiency.

48. Indirect Impairments
2. Neurological signs
• Seizures occur in a small % of patients - more common in occlusive carotid
disease than in MCA disease
• Hydrocephalus is rare but can occur with subarachnoid or intracerebral
hemorrhage.

49. Indirect Impairments
3. Thrombophlebitis & deep venous thrombosis (DVT)
• Complications for all immobilized patients.

50. Indirect Impairments
4. Cardiac Function
• Stroke as a result of underlying coronary artery disease (CAD) may demonstrate
impaired CO, cardiac decompensation, & rhythm disorders.
• If these problems persist, they can alter cerebral perfusion & produce additional
focal signs (e.g., mental confusion).
• Cardiac limitations in exercise tolerance

51. Indirect Impairments
5. Pulmonary Function
• Decreased lung volume, decreased pulmonary perfusion & vital capacity &
altered chest wall excursion
• Aspiration, occurs in about one third of patients with dysphagia.

52. Indirect Impairments
6. Integumentary
• The skin breaks down over bony prominences from pressure, friction and
shearing.

53. Imaging
CT Scan
• In acute phase, CT scans are used to rule out brain lesions such as tumor
or abscess & to identify hemorrhagic stroke
• In sub-acute phase, CT scans can identify development of cerebral
edema (within 3 days) & cerebral infarction (within 3 to 5 days) by
showing areas of decreased density.

54. Imaging
Magnetic Resonance Imaging (MRI)
• MRI is more sensitive in diagnosis of acute strokes, allowing detection
of cerebral infarction within 2 to 6 hours after stroke.
• It is also able to detail extent of infarction or hemorrhage & can detect
smaller lesions

55. Recovery and Prognosis
• Fastest in first weeks after onset.
• Measurable neurological & functional recovery occurring
in first month after stroke.
• Continue to make measurable functional gains for
months or years after insult.

56. Variation of recovery
• Recovery also depends on severity of stroke
• Depends on type of stroke – hemorrhagic or ischemic
• Varies from individual to individual
• Depends on intensity of therapy
• Depends on age of the patient

57. STROKE
ASSESSMENT

58. STROKE ASSESSMENT
• History
• Observation
• Vitals , Arousal, Attention & Cognition
• Functional mobility
• Cranial Nerve Integrity
• Sensory integrity
• Vision
• Joint Integrity
• Range of Motion
• Motor Function
• Reflex Integrity
• Gait & Locomotion
• Balance
• Coordination

59. Problem list
• Tonal abnormalities
• Muscular weakness
• Synergistic pattern
• Tightness & contracture
• Imbalance & incoordination
• Gait abnormalities
• Postural abnormalities
• Functional disability

60. STROKE MANAGEMENT

61. Recovery
• Fastest in the first few weeks after onset.
• Most measurable neurologic recovery (90%) occurs during the
first 3 months.
• Functional gains continue for up to 6 months or longer (at
reduced rate).
• Rates of improvement vary greatly depending on the
management category (minor vs. severe)

62. Acute Rehabilitation

63. Acute Rehabilitation
• Positioning
• Prevent pressure sores
• ROM and prevention of limb trauma
• Functional mobility activities
• Improve respiratory & circulatory function

64. Acute Rehabilitation
Begins as soon as the patient is stable.
General goals:
• Maintain ROM and prevent deformity.
• Promote awareness, active movement and use of the affected side.
• Improve functional mobility
• Improve trunk control, symmetry, and balance
• Initiate self-care activities
• Monitor changes associated with recovery

65. Acute Rehabilitation
Positioning:
• Want to stimulate the patient to turn toward and engage the affected side.
• Place bed so affected side faces main part of the room.
• Assume upright postures ASAP.
• Turning in bed to prevent pressure sores.

66. Acute Rehabilitation
AVOID these positions:
• Lateral flexion to the affected side.
• Scapular depression & retraction, IR & add of the UE, elbow flex, FA pronation,
wrist & finger flexion.
• Hip retraction & elevation, hip & knee extension with hip adduction; or hip &
knee flexion with hip abduction; ankle plantarflexion

67. Acute Rehabilitation
Supine positioning:
Promote these positions
• Small pillow under scapula (promotes protraction)
• Support UE on pillow (promotes extension)
• Pillow under pelvis (promotes anterior pelvic tilt)
• Pillow under knee (prevents hyperextension).

68. Acute Rehabilitation
Lying on the sound (uninvolved)
side:
• Trunk straight; pillow under rib cage (elongates
affected side);
• Pillow under the affected UE (promotes scap
protraction, elbow extension, forearm neutral or
supinated).
• Pillow under the affected leg (pelvis protracted, hip
extended, knee flexed, rotation)

69. Acute Rehabilitation
Lying on the affected side:
• Trunk straight
• Scapula protracted (with the UE well forward)
• Elbow extended
• Forearm supinated
• Hip extended with knee flexed.

70. Acute Rehabilitation
Sitting:
• Head/trunk in midline.
• Symmetrical WB on buttocks.
• Hips/knees flexed to 90 degrees.
• Feet flat.
• Use resting on pillows, arm/lap board with scapula
protracted and wrist/fingers in extended in a functional
open position.

71. Acute Rehabilitation
Prevent pressure sores
• Proper positioning
• Relieve pressure points by padding
& cushion
• Frequent turning & changing
position
• Prevent from moisture
• Use cotton clothing
• Tight fitting cloth is prevented
• Use of water bed, air bed & foam
mattress

72. Acute Rehabilitation
ROM and prevention of limb trauma:
UE: Can be supported in a sling during the
flaccid stage, preventing joint trauma;
contraindicated in the spastic stage.
LE: Stretch plantar flexors / activate weak
Dorsiflexors.

73. Acute Rehabilitation
Functional mobility activities:
Promote use of both sides rather than
just the sound side.
Focus on:
• Rolling (both directions)
• Sitting up (both directions)
• Bridging
• Sitting
• Standing
• Walking
• Transfers

74. Acute Rehabilitation
Improve respiratory & circulatory function
• Breathing exercise
• Chest expansion exercise
• Postural drainage
• Huffing & Coughing techniques
• Passive & active ankle & toe exercise.

75. Post acute Rehabilitation
• Continue and modify (if necessary) the treatment activities begun in the acute
phase.
• Important to monitor CV status as activities and challenges increase so as not to
over-exert the patient.
• 5 days a week for a minimum of 3 hours of active rehabilitation per day.
• Intensive rehabilitation if vitals are stable

76. Post acute Rehabilitation
Goals:
• Prevent/minimize secondary complications.
• Compensate for sensory and perceptual loss.
• Improve postural control and balance.
• Develop independent functional mobility skills.
• Develop independent ADLs.
• Endurance.
• Encourage socialization and motivation

77. STROKE
INTERVENTIONS

78. SHORT TERM GOALS
• To improve bed mobility
• To improve functional activities
• To improve balance
• To normalize muscle tone
• To teach transfer techniques
• To educate patient

79. LONG TERM GOALS
• To improve ADL activities
• To regain balance in sitting and standing

80. Improve sensory function
• Positioning hemiplegic side towards door or
main part of room.
• Presentation of repeated sensory stimuli.
• Stretching, stroking, superficial & deep
pressure, icing, vibration etc.
• Wt. bearing ex & Joint approximation tech
• Stoking with different texture fabrics
• Pressure application
• PNF tech., use of bilateral UE

81. Flexibility & joint integrity
• Soft tissue, joint mobilization & ROM
exercise
• AROM & PROM with end range stretch
• Effective positioning & edema reduction
• Stretching program & splinting
Suggested activities:
• Arm cradling
• Table top polishing
• Self overhead activities in supine &
sitting & reaching to the floor

82. Improve strength
• Strengthening of agonist & antagonistic
muscle.
• Graded ex program using free weights,
therabands, sand bags & isokinetic devices
• For weak patients (<3/5), gravity-eliminated ex
using powder boards, sling suspension, or
aquatic ex is indicated
• Gravity-resisted active movements are
indicated (>3/5 strength).

83. Manage spasticity
• Sustained stretch & slow icing of spastic muscle
• Rhythmic rotations
• Weight bearing exercise
• Prolonged & firm pressure application
• Slow rocking movement
• Positioning in anti synergistic pattern
• Rhythmic initiation
• Air splints
• Neural warmth
• Electrical stimulation

84. Improve movement control
• Dissociation & selection of desired movement patterns
• Select postures that assist desired movements through optimal
biomechanical stabilization & use of optimal point in range
• Start with assisted movement, followed by active & resisted movement
• Task oriented exercise

85. Postural control & functional mobility
• Suggested exercise:
• Rolling
• Supine to sit & sit to supine
• Sitting
• Bridging
• Sit to stand & Sit down
• Modified plantigrade
• Standing
• Transfer

86. IMPROVE UE FUNCTION
• Early mobilization, ROM, & positioning strategies
• Relearning of movt pattern & retraining of missing component
• UL weight bearing exercise
• Dynamic stabilization exercise
• Picking up objects, Reaching activities
• Lifting activities
• Manipulation of common objects
• Push up ex. in various position
• Kitchen sink exercise
• Functional movement like hand to mouth & hand to opposite
shoulder
• Advance training – CIMT, biofeedback etc.

87. Managing shoulder pain
• Proper handling & positioning of shoulder joint
• Reducing subluxation, gentle mobilization (grade 1 & 2)
• Use of supportive devices & slings
• Use of overhead pulley is contraindicated
• TENS & heat therapy

88. IMPROVE L/L FUNCTION
• Strengthening muscles in appropriate pattern
• Suggested activities:
• PNF pattern of LL
• Holding against elastic band resistance around upper thighs in supine or
standing positions
• Standing, lateral side-steps
• Exercise to improve pelvic control
• Facilitation of DF
• Cycling & treadmill training

89. Improve balance
• Facilitate symmetrical wt. bearing on both side.
• Postural perturbations can be induced in different positions.
• Sit or stand on movable surface to increase challenge
• Reaching activities
• Dual task training s/a kicking ball in standing, throwing activities, carrying an
object while walking
• Divert attention
• Single limb stance
• Exercise on trampoline

90. Improve locomotion
• Initial gait training between parallel bars
• Proceed outside bars with aids & then without aids
• Walking forward, backward, sideways & in cross
patterns
• BWSTT with higher speed improve overall locomotor
activity & overground speed
• Proper use of orthotics & wheelchair

91. Improve aerobic function
• Early mobilization & functional activity
• Treadmill training & cycle ergometer
• Symptom limited graded ex. training
• Ex 3 times a week for 20-60 minutes
• Proper rest should be given
• Gradually progressed to 30 minutes continuous
program
• Regular ex reduces risk of recurrent stroke

92. Improve feeding & swallowing
• Proper head position in chin down position.
• Movements of lips, tongue, cheeks, & jaw.
• Firm pressure to anterior 3rd of tongue with tongue depressor to stimulate
posterior elevation of tongue.
• Puffing, blowing bubbles & drinking thick liquids through straw.
• Tasty food should be given to facilitate swallowing reflex.
• Stroking the neck during swallowing.

93. Patient & family education
• Give factual information, counsel family members about patient’s capabilities &
limitations
• Give information as much as Pt or family can assimilate
• Provide open discussion & communication
• Be supportive, sensitive & maintain a positive supporting nature
• Give psychological support
• Refer to help groups

94. Discharge planning
• Family member should participate daily in the therapy session & learn
exercises
• Home visits should be made prior to discharge
• Architectural modifications, assistive devices or orthotics should be ready
before discharge
• Identify community service & provide information to the patient

95. References
• O’ Sullivan SB, Schmitz TJ. Stroke. Physical rehabilitation. 5th
ed., New Delhi: Jaypee Brothers, 2007.
• Darcy A. Umphred. Neurological Rehabilitation, 5th ed., Mosby
Elsevier, Missouri, 2007.

96. Thank You