CNS: Stroke Risk Factors and Symptoms

• Strokes occur when blood flow to the brain is blocked or there is sudden bleeding, causing a range of consequences from death to full recovery.

Hemiplegia

• Hemiplegia is a non-progressive paralysis on one side, often from a stroke, but can also stem from genetics, SCI, or other brain injuries.
• Paralysis occurs on the opposite side of the brain lesion, with temporary or permanent effects depending on the damage.
• Post-stroke, muscles initially weaken or become flaccid, transitioning to spastic paralysis, though some flaccidity may persist.
• Lesions disrupt the brain's control over spinal cord activity, leading to uninhibited alpha motor neuron firing.
• A common paralysis pattern is a flexor pattern in the upper limb paired with an extensor pattern in the lower limb.
• Altered posture due to spasticity, altered gait, hemiplegic shoulder, seizures, pain and sensory deficit are other symptoms
• Shoulder-hand syndrome causes decreased ROM, throbbing pain and edema
• Neglect of the affected side, behavioural and emotional changes, visual impairment, speech difficulties and cognitive impairment can occur

Observations

• Spasticity pattern occurs on the affected side, circumducted gait, impaired balance, differences in muscle bulk, postural symmetries and neglect of the affected side are some signs that could be observed.
• Impairment levels depend on the damage location and degree, needing intensive rehab for around 18 months.
• Stroke occurs when brain blood supply is interrupted, leading to brain cell impairment.
• There are three main stroke types: ischemic (blood clot), hemorrhagic (vessel bursts), and transient ischemic attack (TIA).
• Tumors, infections, or brain swelling can also cause strokes.

Risk Factors

• Warning signs of a stroke include sudden numbness or weakness, confusion, vision issues, difficulty walking, and severe headache
• Controllable factors: unhealthy weight, inactivity, alcohol/drug abuse, smoking, stress, and hormone therapy.
• Uncontrollable: sex, age, family history, ethnicity, personal circumstances, and prior stroke/TIA history.
• Modifiable risk factors are blood pressure (hypertension linked to hemorrhagic strokes) and atherosclerosis (linked to ischemic strokes).
• FAST: facial numbness/weakness, arm numbness/weakness, speech difficulty, time to call EMS/9-1-1.

Brunnstrom stages of stroke recovery

• Stage 1: Flaccidity with no voluntary movement.
• Stage 2: Spasticity appears, basic synergy patterns emerge, minimal voluntary movements are present.
• Stage 3: Voluntary control over synergies increases along with spasticity.
• Stage 4: Some movement patterns outside synergy are mastered, but synergy patterns still dominate, spasticity decreases.
• Stage 5: More complex movements are learned as synergies become less dominant, spasticity further decreases.
• Stage 6: Spasticity disappears, individual joint movements possible, coordination nears normal.
• Stage 7: Normal function is restored.

Massage in relation to Brunnstrom stages

• Stage 1: Focus on PROM, gentle passive stretches, and positioning to support the upper limb, especially the shoulder.
• Stage 2: PROM and sensory stimulation massage.
• Stage 3: Continue above techniques with increased emphasis on stress reduction and relaxing massage for spastic areas.
• Stage 4: Maintain above techniques, emphasizing the use of the recovering arm.
• Stage 5: Spasticity continues to decrease with minimal need to work in homecare & ADLs and PNF patterning (PROM, AROM) as well as strengthening routine
• Stage 6: Spasticity disappears and coordination reappears, focus on fine motor skills and continue with the routine above

Synergy

• Synergy describes the recruitment of a series of muscles, even when only a few are needed for the movement.
• Example - when trying to reach forward, the shoulder abducts and elevates, and the wrist flexes

Upper limb synergies

• Most Common - Flexor synergy
  • Shoulder: Internal rotation/adduction
  • Elbow: Flexion
  • Forearm: Supination
  • Wrist: Flexion
• Extensor synergy
  • Shoulder: Internal rotation/adduction
  • Elbow: Extension
  • Forearm: Pronation
  • Wrist: Flexion

Assessment

• Palpation
• ROM
• Sensory testing
• Brunnstrom stages of stroke recovery

Treatment Planning

• Goals: Promote relaxation, decrease pain, address postural changes and muscle imbalances, decrease edema, decrease spasticity, maintain joint health, encourage relaxation and stress management
• Stress worsens spasticity
• PROM and stretching
• Prevents neglect of affected limb
• Maintains sensory mapping
• Prevents contracture formation
• Lowers tone of spastic muscles.
• Decreasing edema is important for tissue health
• Trying to stimulate muscles outside of synergy or opposite to spasticity
• PROM and joint play maintain joint health
• ROODS, PNF, Stretching/strengthening and full body integration supports overall well-being

Explore stroke risk factors and transient ischemic attacks (TIAs). Understand modifiable and non-modifiable risks. Learn about the causes and prevention of strokes.