Physical Therapy After Stroke

A CVA (cerebral vascular accident) or more commonly known as a stroke is an acute neurologic injury that occurs as a result of:

1. Lack of oxygen to the brain due to blood clot or decreased blood flow
2. Brain bleed due to rupture of intracerebral blood vessels

Signs and Symptoms:

• FAST -Face drooping, Arm Weakness, Speech difficulties, Time to call 911
• Weakness of the face, arm and leg on one side of the body with decreased sensation, changes in vision, decreased cognitive function
• Decreased coordination, double vision, dizziness, deafness
• Sudden severe headache, loss of consciousness, nausea, vomiting
• Symptoms can vary depending on which part of the brain has decreased blood supply and type of stroke.

Risk Factors:

1. High blood pressure
2. High cholesterol
3. Smoking,
4. Physical inactivity
5. Atrial fibrillation

Types of Strokes:

1. Thrombotic stroke – blood clot that originates in a cerebral artery causes reduced blood flow.

2. Embolic stroke – particles of blood clot travel to brain and cause reduced blood flow.

Causes: blood clot in systemic arteries, AFIB, recent heart attack, heart valve disease, mechanical heart valve, endocarditis, congestive heart failure.

3. Intracerebral hemorrhage – bleeding caused by small arteries directly into the brain. The accumulation of blood occurs over minutes to hours and can slowly expand.

Causes include: hypertension, trauma, drug use (amphetamines and cocaine), and blood vessel malformations.

4. Subarachnoid hemorrhage – rupture of arterial aneurysms which releases blood directly into the cerebral fluid in the brain. This rapidly increases pressure in the brain; death or coma can happen quickly as bleeding only lasts a few seconds.

Causes include: ruptured aneurysm, blood vessel malformations, trauma, and drug use.

Who gets it?

Stroke is the second most common cause of mortality and third most common cause of disability in the world. Stroke risk increases with age. Men have a higher chance of having a stroke than women.  Blacks and Hispanics have an increased risk of stroke compared with whites in the US.

Diagnosis

History and Physical can be diagnostic for a stroke. A scale used for diagnosis is called the National Institutes of Health Stroke Scale (NIHSS) which is used to assess stroke severity. The three most predictive examination findings are facial paresis, arm drift/weakness, and abnormal speech.

Brain imagining with noncontract brain CT or brain MRI can be definitive to assess the degree of brain injury, identify the vascular lesion, and rule out hemorrhage as a cause. Other tests commonly done are finger stick blood glucose, oxygen saturation, EKG, CBC, Cardiac enzymes, PT/INR, PTT, CMP.

Treatment – Ischemic Stroke

• IV-tPa, tissue plasminogen activator (clot busting agent), is first line therapy if treatment is started within 4.5 hours of symptom onset. However, this agent cannot be used in those who have hemorrhage, internal bleeding, blood glucose <50, or BP >185/110.
• Endovascular procedures (mechanical thrombectomy), removed a large blood clot by sending a wire caged device to the site of blocked blood vessel in the brain.
• Antithrombotic therapy is continued with aspirin, usually within 48 hours, which reduces the risk of recurrent strokes.
• Lipid lowering agents like statins are used as long term therapy
• Blood pressure reduction
• Behavioral and lifestyle changes including smoking cessation, exercise, weight reduction, and diet modifications.
• Physiotherapy

Treatment – Hemorrhagic Stroke

1. Endovascular procedures use a catheter to deposit a mechanical agent in a blood vessel to prevent rupture.
2. Surgical treatment – a metal clip may be placed on the vessel or aneurysm to secure it and stop bleeding.

Prognosis

There are many factors that influence stroke prognosis including age, stroke severity, stroke mechanism, infarct location, co-morbid conditions, clinical findings, and complications.  Thrombolytic therapy, stroke unit care, and rehabilitation services can influence the outcome of a stroke.

The strongest predictors are severity and patient age. Severity can be judged on neurologic impairment (altered cognition, language, behavior, visual changes, loss of motor skills) and the size of damage on imaging.

In the time from 12 hours – 7 days after ischemic stroke, many patients experience improvement in neurologic deficits.  The greatest improvement occurs in first 3-6 months after stroke.

The return of arm and hand function is very important to recovery. Active finger extension, grasping, shoulder shrugging, and active range of motion exercises have a favorable prognosis and can be achieved through physical therapy rehabilitation.

However, 16-23% of patients die during the first 30 days after a stroke. Any deficit existing after six months is usually permanent. Disability including depression, inability to walk and social impairment often leads patients to nursing facilities.