Understanding Stroke and Transient Ischemic Attacks

• Stroke is a leading cause of neurological disability and the 3rd leading cause of death in Canada.
• 6% of all deaths are due to stroke, which equates to about 14,000 deaths per year in Canada.
• Approximately 50,000 strokes occur each year in Canada.
• Stroke happens with reduced or absent blood flow to a brain region, leading to brain cell death.
• Blood clot stops blood flow to an area of the brain during an ischemic stroke.
• A Hemorrhagic stroke occurs when a vessel bubble explodes, causing bleeding around the brain.
• Both strokes and TIAs are cerebrovascular events.
• Transient Ischemic Attack (TIA) is a temporary blockage, usually caused by a blood clot and it's a ministroke or warning sign.
• TIAs do not damage brain cells, generally allow complete recovery and may persist for several minutes up to 24 hours.
• Signs and symptoms for TIAs and Strokes are the same.
• The extent of impairment after a stroke depends on the affected brain region and the size of the ischemic area.
• Act F.A.S.T! can help recognize stroke symptoms.

Signs and Symptoms of Stroke

• FACE: Look for face drooping, ask the person to smile.
• ARMS: Check for arm weakness or numbness by asking the person to raise their arms, and seeing if one arm drifts downward.
• SPEECH: Determine slurred speech by asking the person to repeat a simple sentence.
• TIME: If any symptoms are apparent, call 911 or get to a hospital immediately.
• Aphasia is the inability to comprehend or formulate language after a stroke.
• Mobility issues that can result from strokes include: wheelchair dependence, walker use, cane use or braces.
• Stroke patients are susceptible to falls.
• Coordination and strength are negatively affected by stroke.
• Stroke patients may feel fatigued or may only be active for 1-2 hours and still perform remaining daily activities.
• Sensation loss may affect kinesthetic awareness of limb in space, making it difficult to feel exercise equipment.
• Other issues that can arise are vision or hearing loss.
• Behavior changes include episodes of anger/crying, impulsivity, emotional expression.
• Cognitive status may be affected, with deficits in following instructions and monitoring exertion, pain, fatigue, or safety.
• Self-care abilities can be compromised, making it difficult to dress, undress, and use the bathroom independently.
• Symptoms worsen as the person becomes more fatigued.

Terms Related to Stroke

• Ataxia: loss of control of muscle function.
• Dysarthria: difficulty communicating due to weakness of speaking muscles.
• Dyspraxia: difficulty in coordinating movement or speech.
• Hemiparesis: weakness or partial paralysis on one side of the body.
• Dysphagia: difficulty swallowing.
• Incontinence: involuntary urination.
• Clonus: muscular spasms involving rhythmic contractions.
• Slow, prolonged stretching can help with clonus.

Aerobic Exercise Post-Stroke (FITT)

• Speak slowly and make sure your lips are moving clearly to the patient.
• Include 5-10 minutes of warm-up and cool-down.
• Exercise most days of the week.
• Maintain 45-60% intensity, with an RPE of 4-6.
• Engage in 20-30 minutes of continuous activity, starting with 5 minutes if initial tolerance is low.
• Functional and task-specific activities should be included, such as activities of daily living.
• A later-stage aerobic exercise FITT consists of 5-10 minutes of warm-up and cool-down, 3x/week, maintain 45-60% intensity or RPE: 4-6.
• 20-30 min continuous activity, start with five min if initial tolerance is low.
• Examples of functional and task-specific exercises include treadmill walking, stationary biking, steppers, and walking circuits.
• Activities of daily living should still be practiced.
• Interval training combines cardio and stroke rehabilitation.
• Walking is the exercise.
• Walk for two minutes at a lower intensity or 11 RPE, and one minute at higher intensity or 13 RPE.
• It's important the difference between low and high intensity is reasonable.

Strengthening FITT

• 2-3x/week, 1-3 sets, 10-15 reps
• Begin with light weights.
• 15-30 minutes.
• Concentrate on muscles that are important for gait.
• Incorporate task related exercises.
• For stroke the arm movements should be kept at or below shoulder level, strengthen major muscle groups for functional tasks.
• If scapula can't rotate properly, you can impinge supraspinatus tendon.
• Utilize a 20 point RPE scale, don't go higher than 14, aim for 14 and below.

Stretching FITT

• 2-3x/day.
• Don't push the body beyond the point of pain.
• 10-30s, rest and repeat the stretch 3 times.
• Stretching is important and should be slow, gradual, and sustained.
• Stretching requires increased caution in patients with permanent contractures or joint limitations, with increased spasticity or flaccidity.
• Take a moment to stretch if muscle tone increases during exercise, then resume the exercise.
• Perform a slow, prolonged stretch during clonus.
• Monitor stroke patients, they will fatigue quicker and facial expression may be absent during exercise.
• Other signs of fatigue include loss of balance, leaning heavily on a cane or walker, and shortness of breath.
• Reduced movement quality and coordination can result from a stroke.

Muscular Deficiencies After Stroke

• Hip flexors can be weak on the affected side.
• If the hip flexors are weak, the patient will use abductors to swing the leg in gait.
• Knee extensor rigidity requires facilitating activation of hip and knee flexors together.
• Droopy hip (trendelenburg sign).
• Glut med underactivation.
• Inability to plantar or dorsi-flex foot through full ROM.