2022_Stroke.pdf

Stroke/CVA and Exercise Callum Baker PhD AEP [email protected] Learning Outcomes By the end of this lecture, you should: • Have a basic understanding of the pathophysiology of stroke • Be familiar with the medical terms that describe motor and nonmotor impairments resulting from neurologica...

Stroke/CVA and Exercise Callum Baker PhD AEP [email protected] Learning Outcomes By the end of this lecture, you should: • Have a basic understanding of the pathophysiology of stroke • Be familiar with the medical terms that describe motor and nonmotor impairments resulting from neurological damage • Be aware of the types of functional scales used in stroke for competence when working in multidisciplinary teams • Be familiar with exercise prescription and considerations for exercise in stroke populations • Understand spasticity and weakness in stroke populations Case Susan's life after having a stroke • Think about how the CVA changed Susan’s life • Think about how the life of Susan’s family members have changes • What impairments do you see? • How do you see an AEP helping Susan? Readings ACSMs Resources for Clinical Exercise Physiology – Chapter 1 Prevalence • • • • • • ~1.3% of Australians have had a stroke = 387,000 people. Male > Female More common in older age groups Disproportionally impacts indigenous populations (1.7x greater risk than non-indigenous) Stroke events were decreasing but have since plateaued Deaths directly related to stroke has been steadily decreasing Stroke Types: Ischemic Vs Haemorrhagic • Strokes are classified as ischemic or hemorrhagic • Both types results in damage to CNS • Cell death and damage from lack of nutrients and build up of waste products • The site of the stroke will dictate the loss of function • Common disability from a stroke include limitations in communication, mobility and may last for a short amount of time or may be permanent Pathophysiology – Ischemic Stroke • Most strokes are ischemic (85%) • Subcategorised as • • Thrombotic Embolic • MCA is most common site of ischemic stroke Transient Ischemic Attack (aka mini stroke) Pathophysiology – Hemorrhagic - less common (15%) - Bleed into the brain tissue or extravascular space within the cranium - Subcategorised • Intracerbral • Subarachnoid Signs and Symptoms of a Stroke Associated Complications Post-Stroke Common conditions caused DIRECTLY by the stroke include • Spasticity • Weakness (hemi/quad-paresis) • Paralysis • Impaired balance • Memory loss • aphasia What are the exercise considerations for a patient who may have these disabilities? Secondary/Chronic Complications PostStroke Secondary and chronic post-stroke complications include: • Post stroke depression (↑ risk of second stroke/CV event) • CAD/Hypertension/dyslipidaemia • T2DM • Obesity • Injury from falls • Pain/fatigue/stress • Decreased CRF • Adaptive behaviours These may be directly related to the stroke or occur as a comorbid condition What are the exercise considerations for a patient who may have these conditions (asymptomatic/undiagnosed) Stroke Risk Factors Non-Modifiable • Age • Genders • Circadian and seasonal factors • Blood pathologies (sickle cell anaemia) Modifiable • Smoking • Obesity • Low PALs • Some medications (oral contraceptives) Primary Prevention of Stroke/Recurrent Stroke To reduce risk of a stroke, early interventions should target: • HTN • CVD • Smoking • Insulin Resistance • Hyperlipidaemia • Alcohol consumption Classification By Cause • Hemorrhagic (intracranial/subarachnoid) • Ischemic (thrombotic/Embolic) By Severity • Mild/moderate/severe (depending on symptom duration) By Duration • Acute/sub acute/chronic (by development/onset of spasticity) By Symptoms • Middle cerebral artery • Anterior cerebral artery • Posterior Cerebral Artery • Vetebro basilar artery • Lacunar Clinical Presentation Impairments: • Motor • Sensory • Language • Perception • Affective/mood • Cognitive Clinical Presentation • • • • • • • • Paresis – partial paralysis or weakness Hemiparesis – weakness or incomplete paralysis of one side Hemiplegia – weakness or paralysis of one side and loss of sensation Ataxia – loss of muscular coordination. Apraxia – impaired planning and sequencing of movement that is not due to weakness, incoordination (ataxia) or sensory loss. Neglect – the failure to attend or respond to or make movements towards one side of the environment Hypertonia – excessive tone of skeletal muscles; results in increased resistance to passive stretch. Hypotonia – diminution or loss of muscular tonicity; results in decreased resistance to passive stretch Clinical Presentation • • • • • Aphasia – impairment of language, affecting the production or comprehension of speech and the ability to read and write. Dysphasia – reduced ability to communicate using language (spoken, written or gesture). Dysarthria – impaired ability to produce clear speech due to the impaired function of the speech muscles. Dysphagia – a disorder of swallowing that may result from incoordination or weakness of the oral, pharyngeal, laryngeal or oesophageal muscles. Agnosia – the inability to recognise sounds, smells, objects or body parts (other people’s or one’s own) despite having no primary sensory deficits. Psychosocial Complications Common lifestyle consequences • Unemployment and financial hardship • Lack of transportation alternatives • Difficulties in maintaining interpersonal relationships, marital breakdown • Loss of pre-injury roles; loss of independence Factors Affecting Participation Physical • Severity of stroke/impairments • Comorbidities • Previous level of function Mental • Intrinsic motivation • Mood • Coping skills • Cognition Social • Support access • family context • accomodation Changes in Exercise Capacity/Kinematic Following Stroke Acute changes to Ex response following CVA • ↓VO2peak • ↓↔HRMax • ↓ Muscular strength • ↓ Muscular endurance Reduction in exercise capacity result from • primary injury (vascular disease) • Secondary impairments/associated conditions/medications Aerobic Exercise Testing Pre-screening • High-risk of CVD: resting ECG/Bloods/BP/resting HR Aerobic Exercise Testing • Safe and valid post stroke (<1SAE/5000ex tests) • Symptom limited > submaximal/field tests • Gradual increase of intensity throughout test • Treadmill (TM) preferable • • Stationary bike if balance is of concern Upper limb ergometer if LL impairment limit bike capacity (UL ergo results in lower VO2max results) Testing Protocol • Ramp TM/Cycling test • • Cycling • • 5-10W steps every 1 min Cadence 50RPM TM • • • short TM familiarisation bout prior to GXT If pt can complete 3 mins of familiarisation test complete TM GXT test, if not go to bike GXT test Harness/close support Aerobic Exercise Testing • Test termination criteria • • • • • • • Peak HR achieved (within 10bpm of predicted max) RER >1.1 Abnormal BP/ECG/HR response unable to maintain cadence (~50RPM) SBP>210mm Hg or DBP110mm Hg (non-affected side) Pt wishes to stop Fatigue/discomfort Strength Testing • Resistance training is contraindicated if pt is clinically unstable or <6weeks post stroke • 1RM or 10RM strength testing is reliable in stroke pops • Technique limited • Machines Vs Free weights • Velcro/wraps • Hemiparetic vs non-hemiparetic side testing In both Aex and Strength testing, consider cognitive impairments and mobility limitations and adapt tests as necessary. Aex Training Great need for aerobic exercise training following stroke given high CVD related morbidity/morality and VO2peak is often significantly reduced following stroke. • Freq and Time: 30-60min most days of the week Small bouts over or in one bout. BP/HR regularly tested throughout training Focus on long term adherence via education • Intensity: 40%–70% of peak VO2peak or HRR Duration > intensity in early stages of training • Type: use patient goals to guide type Strength and Aex training are critical components of stroke rehab but may be overlooked in place of functional training. Key role for AEPs in stroke rehab is Aer Training Strength Training Low muscular strength is a major contributor to functional limitations following stroke and is associated with increased falls risk. Limited current evidence to guide strength training. Current recommendations are similar to post-MI pts. • Freq: 2-3 days per week • Intensity: 30-80%1-RM*** Ramp into higher intensity over 2-4weeks • Time: minimum 1 set of 10-15 repetitions, 810 • Type: focus on large muscle groups. Consider pt factors when selecting machine or free weights. Bands/weight cuffs/body weight may also be appropriate. Active-assistive exercise may be necessary for pts with MRC MMT < 3 Summary of ExRx Recommendations Exercise Considerations • High risk population, need appropriate supervision and monitoring during exercise. • • • • • BP HR Note taking Glucose? Defib on site Pharmacotherapy Post-stroke Common medications • Diuretics (decrease resting/exercising BP) • ACE inhibitors (“pril” - decrease resting/exercising BP) • Beta-blockers (“lol” – decrease resting/exercising HR) • Statins (rare: rhabdomyolosis) • Calcium Channel blockers (“pine” – lower resting BP) • Angiotensin II receptor blockers (“sartan” – lower resting BP) • Anti-coagulants (heparin/warfarin – risk of bleeding) • Anti-platelet therapy (aspirin) • Anti-hyperglycmeics (lower BGLs at rest/during/after exercise) • Ant-depressants • Pain medications Clinical Scales/Outcome measures • • • • • • • NIH Stroke Scale: initial ax usually conducted in hospital Motor Assessment Scale (MAS): tasks from lying to sitting, sitting balance, walking Barthel Index: ADLs, feeding, bathing, grooming etc Fugl-Meyer Assessment of Physical Performance: Ax of UL & LL function Wolf Motor Function Test: arm function Modified Ashworth Scale: Spasticity MRC (Medical Research Council) Scale: for Muscle Strength, neuro MMT Spasticity/Clonus/Contracture Spasticity –“is a motor disorder characterised by a velocity-dependent increase in tonic stretch reflexes (“muscle tone”) with exaggerated tendon jerks, resulting from hyperexcitability of the stretch reflex, as one component of the upper motor neurone syndrome” Lance, 1980 • Back to Utah Neuro Rehab Other Rehab Approaches in Stroke Populations • Hands-on therapy (stretching, passive exercises and mobilisation) • Task-specific training (repetition of a functional task or part of the task) • Occupational therapy interventions • Constraint-induced movement therapy • Functional electrical stimulation • Augmented feedback systems Learning Outcomes By the end of this lecture, you should: • Have a basic understanding of the pathophysiology of stroke • Be familiar with the medical terms that describe motor and nonmotor impairments resulting from neurological damage • Be aware of the types of functional scales used in stroke for competence when working in multidisciplinary teams • Be familiar with exercise prescription and considerations for exercise in stroke populations • Have a basic understanding of spasticity presentation in stroke populations