Types of Stroke, Risk Factors, and Acute Medical Management PDF

Types of Stroke, Risk Factors, and Acute Medical Faculty Name PT, PhD Management Gabriele Moriello PT, PhD Objectives 1. Define cerebrovascular accident (CVA) 2. Compare and contrast ischemic vs. hemorrhagic stroke vs. TIA 3. Identify stroke risk factors 4. Describe the acute managem...

Types of Stroke, Risk Factors, and Acute Medical Faculty Name PT, PhD Management Gabriele Moriello PT, PhD Objectives 1. Define cerebrovascular accident (CVA) 2. Compare and contrast ischemic vs. hemorrhagic stroke vs. TIA 3. Identify stroke risk factors 4. Describe the acute management of CVA What is a Cerebrovascular Accident (CVA)? 1. Sudden loss of neurological function caused by an interruption of blood flow to the brain a. Caused by a clot or a bleed b. Types i. Ischemic stroke (87%) Thrombotic or embolic ii. Hemorrhagic stroke (13%) Due to uncontrolled HTN, aneurysm or AVM Intracerebral or subarachnoid iii. Transient Ischemic Attack (TIA) Transient Ischemic Attack (TIA) 1. Also known as a “mini-stroke” 2. Temporary blockage of blood flow to the brain 3. Symptoms last from a few minutes to 24 hours 4. 1/3 of people who have a TIA go on to have a more severe stroke within 1 year Facts about Stroke Modifiable Risk Factors for Stroke Non-modifiable risk factors for stroke Prior Age Family history Race Gender diet CVA, TIA or heart attack drugs and COVID-19 Location Social Determinants of Health Acute Medical Management of Ischemic Stroke IV t-PA Transport to nearest Rapid identification and thrombectomy stroke center if a large clot Rapid Identification Ischemic vs Hemorrhagic Stroke? Rapid Identification (Dr M’s Addition) Transport to Nearest Stroke Center IV Tissue Plasminogen Activator (t-PA) t-PA Absolute Contraindications 1. Intracranial Eligibility; within 3 hours hemorrhage on CT 1. Age ≥ 18 2. Clinical presentation suggesting subarachnoid 2. CT scan: ischemic stroke hemorrhage 3. Known intracranial AVM, neoplasm or aneurysm Eligibility; within 4.5 hours 4. Neurosurgery, head trauma 1. < 80 years old or stroke in the past 3 months 2. No hx of diabetes or prior CVA 5. Uncontrolled hypertension; 3. No oral anticoagulants >185 mmHg SBP or >110 mmHg DBP 4. NIHSS ≤ 25 6. Suspected or confirmed endocarditis Thrombectomy Acute Management of Ischemic Stroke Maintain adequate Maintain sufficient Restore/maintain fluid blood pressure cardiac output and electrolyte balance Restore/maintain Control edema and Decrease risk of normal blood glucose intracranial pressure complications levels Acute Medical Management of Hemorrhagic Stroke Transport to nearest Rapid identification Medical Management stroke center Acute Management of Hemorrhagic Stroke 1. Blood pressure management 2. Stop medication that could cause increased bleeding (any blood thinner) 3. Management of raised intracranial pressure (ICP) 4. Hemostatic therapy to reduce progression of bleeding 5. Antiepileptic therapy 6. Surgery Craniotomy Craniectomy 7. General Care National Institutes of Health Stroke Scale (NIHSS) 11-item scale that categorizes the severity of the stroke and aids in discharge planning Level of consciousness, gaze, visual fields, facial weakness, ataxia, sensation, language, dysarthria, extinction, inattention and arm and leg movement Score Stroke severity 0 No stroke symptoms 1–4 Minor stroke 5–15 Moderate stroke 16–20 Moderate to severe stroke 21–42 Severe stroke © All rights reserved. Pathophysiology of Stroke and Mechanisms of Recovery Faculty Name PT, PhD Gabriele Moriello PT, PhD Objectives 1. Describe mechanisms of cellular dammage after stroek 2. Understand the mechanisms for recovery post-stroke 3. Define neuroplasticity 4. Recognize prognostic factors that affect recovery post stroke Ischemic Cascade Following Ischemic Stroke ↓ blood flow ↓ glucose and oxygen Anaerobic metabolism ATPase failure Excess intracellular calcium Excitotoxicity , ↑ cell membrane permeability, and free radical formation Cell death Also, cytotoxic edema and apoptosis Mechanism of Cerebral Damage after Hemorrhagic Stroke 1. Ischemic cascade 2. Blood irritates brain tissue 3. Possible increase in intracranial pressure (ICP) Spontaneous Neurological Recovery 1. Resolution of edema 2. Reperfusion of the penumbra Spontaneous Neurological Recovery Resolution of diaschisis Recovery of Function after Stroke 1. Spontaneous recovery 2. Forced or adaptive recovery Neuroplasticity 1. Synaptic changes after injury Post synaptic receptors increase 2. Functional reorganization of the cerebral cortex Areas of function move toother areas 3. Activity related changes in neurotransmitter release Neurons that fire together become stronger 4. Neurogenesis Stem cells can become new neurons  1. Older individuals 2. Women Minorities Poorer outcomes 3. 4. Being uninsured 5. Lower education levels 6. Lower income © All rights reserved. Common Impairments and Classic Stroke Symptoms Gabriele Moriello, PT, DPT Objectives 1. Describe common impairments in inidivuals who have had a stroke 2. Compare and contrast left versus right brain stroke 3. Describe the signs and symptoms of various stroke syndromes Common Impairments 1. Paresis/paralysis 6. Perceptual deficits 2. Sensory loss a. Body scheme/body image b. Spatial relations 3. Speech and language deficits c. Agnosia 1. Aphasia 2. Dysarthria 7. Visual field deficits 4. Dysphagia 5. Cognitive deficits Speech and Language Deficits 1. Aphasias a. Wernicke’s or receptive i. Impaired auditory comprehension b. Broca’s or expressive i. Impaired speech production a. Global i. Mixture of both 2. Dysarthria a. Slurred speech  Dysphagia 1. Difficulty with swallowing or inability to swallow Cognitive Deficits 1. Disorientation 2. Attention impairments 3. Memory impairments 4. Confusion 5. Perseveration a. Repetition of a behavior, thought, or speech pattern 6. Executive function deficits a. Impairments in working memory, cognitive flexibility, inhibitory control, etc Perceptual Deficits 1. Body scheme and body image a. Unilateral neglect 2. Spatial relations 3. Agnosia a. Visual b. Auditory c. Tactile Visual Field Deficits Homonymous hemianopsia  Cerebral strokes Right v. Left Stroke NO brainstem or cerebeller strokes Right hemispheric lesion Left hemispheric lesion 1. Left sided hemiparesis 1. Right sided hemiparesis 2. Left sided sensory impairments 2. Right sided sensory impairments wenicke’s unilateral neglect broca’s agnosias 3. Visual-perceptual impairments disturbances of body 3. Speech and language impairments global APHASIA’S image and body scheme impulsivity 4. Behavioral deficits poor judgement 4. Behavioral deficits slow and cautious behavior deny disability super aware of disability 5. Intellectual deficits abstract reasoning problem solving 5. Intellectual deficits problem solving highly distractable tend to perseverate perceiving emotion 6. Emotional deficits expression of 6. Emotional deficits difficulty with negative emotion expressing posisitve emotions Classical Stroke Syndromes 1. Middle cerebral artery stroke 2. Anterior cerebral artery stroke 3. Posterior cerebral artery stroke 4. Basilar artery stroke 5. Anterior inferior cerebellar artery (AICA) stroke 6. Posterior inferior cerebellar artery (PICA) stroke Name the Type of Stroke Case 1 Sarah Thompson was brought to the emergency department with sudden onset of right-sided weakness, difficulty speaking, and facial droop. Her husband reported that she had been fine until she suddenly became unable to move her right arm and leg while watching TV. MCA because UE>LE Neurological Examination a. Right-sided hemiplegial; paralysis of the right side of the body i. UE more involved than LE b. Aphasia; difficulty speaking and understanding language i. Right facial droop  PCA Name the Type of Stroke because vision Case 2 John Doe was brought to the emergency department with acute onset of cognitive impairment and right-sided hemianopia (loss of vision in the right half of the visual field). His family reported that he had been well until the morning of admission when he suddenly became confused and had difficulty speaking. Name the Type of Stroke PICA Case 3 because Jane Smith presented to the emergency department with sudden onset of vertigo, nausea, vomiting, and difficulty walking due to ataxia. Her family noted that she had been experiencing a severe posterior headache and dizziness for several hours before admission. Neurological Examination Ataxial lack of coordination, on the left side Dysarthria; slurred speech Nystagmus; involuntary eye movement Name the Type of Stroke Case 4 Robert Johnson presented to the emergency department with sudden onset of vertigo, nausea, vomiting, and hearing loss in his left ear. His family reported that he had been experiencing dizziness and imbalance for several hours before admission. Neurological Examination Ataxia; lack of coordination, on the left side AICA because facial weakness Dysarthria; slurred speech Nystagmus; involuntary eye movement Left-sided facial weakness Hearing loss in the left ear Horner syndrome; smaller pupil, drooping eyelid Name the Type of Stroke Case 5 Emily Davis was brought to the emergency department with sudden onset of weakness in her right leg, difficulty speaking, and confusion. Her husband reported that she had been fine until she suddenly became unable to move her right leg and had trouble forming words while preparing breakfast. ACA Neurological Examination because LE>UE Right leg weakness; hemiparesis Aphasia; difficulty speaking and understanding language Confusion and disorientation Urinary incontinence Name the Type of Stroke Case 6 Michael Brown was brought to the emergency department with sudden onset of severe dizziness, double vision, and difficulty speaking. His wife reported that he had also experienced weakness in his limbs and had collapsed at home. Basilar Artery Neurological Examination because all 4 limbs Dysarthria; slurred speech Diplopia; double vision Quadriparesis; weakness in all four limbs Decreased level of consciousness © All rights reserved. Neuro Clinical Reasoning Framework Part 1: Examination Jason E. Cook, DPT, PhD  Examination Evaluation Intervention Re-Evaluation Systems Test & PT Diagnosis Outcomes History Plan of Care Intervention Review Measures & Prognosis Assessment  Examination Evaluation Intervention Re-Evaluation Systems Test & PT Diagnosis Outcomes History Plan of Care Intervention Review Measures & Prognosis Assessment Evaluating for: Medical Diagnosis Impairments Functional Limitations Body Structure Activity and Participation and Function Function Participation Restrictions Impairments Limitations Restrictions Contextual Factors: Contextual Factors: Personal External  Examination History Systems Review Test & Measures PMH Patient Identified Problems Non-Patient Identified Problems Home environment Work, hobby, support (family/friends)  Examination History Systems Review Test & Measures Medical Diagnosis PMH Body Function and Activity Participation Structures (Functional Limitations) (Participation Restrictions) (Impairments) PIP’s PIP’s PIP’s NPIP’s NPIP’s NPIP’s Work/Hobby Work/Hobby Contextual Factors: Contextual Factors: Personal Environmental Personal Motivators Home environment Personal Barriers Family/Supports History will give you information about the different categories of the ICF  Examination History Systems Review Test & Measures Musculoskeletal AROM Cardiopulmonary/respiratory HR, RR, BP, SpO2 Neuromuscular Integumentary Additional systems based on patient medical history  Examination History Systems Review Test & Measures Medical Diagnosis PMH Body Function and Activity Participation Structures (Functional Limitations) (Participation Restrictions) (Impairments) PIP’s PIP’s PIP’s NPIP’s NPIP’s NPIP’s System’s Review Work/Hobby Work/Hobby Contextual Factors: Contextual Factors: Personal Environmental Personal Motivators Home environment Personal Barriers Family/Supports System’s Review will give you direction, for further testing impairments  Examination History Systems Review Test & Measures Purpose of Examination of Test and Measures: Determine what is causing the issues for this patient We will use a 3-step process to assist in your decision of which test and measures to test.  Examination History Systems Review Test & Measures 3 Step Process for Examination: 1) Observe Movement (movement analysis) 2) Hypothesize Impairments 3) Test Hypothesis (with Impairment Level Test and Measures)  Examination History Systems Review Test & Measures Medical Diagnosis Step 1: Observe Movement for Functional Limitations Perform Movement Analysis Body Structure Activity and 1) Movement Analysis of function and Function Function Participation tasks 1) (bed mobility, coming to sit, sit, sit to stand, stand, gait, steps) Impairments Limitations Restrictions 2) Movement Analysis during Functional Outcome Measures 1) Timed Up and Go, 5x Sit to Stand Contextual Factors: Contextual Factors: 2) Week 2: Edge Core Set - Personal External 10MeterWT, 6MinuteWT, Functional Gait Assessment, Berg Balance Test (Neuro 1, Week 2) 3) At lab: Mini-BESTest  Examination History Systems Review Test & Measures  Examination History Systems Review Test & Measures Impairments Impairment Testing Step 3: Test Hypothesized Impairments Hypertonia Muscle Tone Week 3: (all ICF impairment level testing) Dec. Strength Impaired Sensation MMT Sensation Testing Motor Dec. ROM/Dec. Flexibility AROM / PROM Sensation Impaired Joint Stability Joint Glides / Mobility Hypermobility “” Cranial Nerves Dec. Endurance SpO2, HR, BP, Distance Mental Status and Perception Dec. Pulmonary Function SpO2, HR Gait and Coordination Impaired Blood Flow BP Cuff Pressure Edema Circumference Measure Impaired Skin Integrity Capillary flow or return  Examination History Systems Review Test & Measures Step 1. Observe and Analyze Movement Step 3: Test Hypothesis Using impairment level testing or further movement analysis Step 2: Create a hypothesis Further Movement Analysis Based on what was seen during outcome measures Neuro Movement Systems Diagnosis Muscle Tone MMT Fractionated Movement Deficit Sensation Testing Force Production Deficit AROM / PROM Dysmetria Joint Glides / Mobility Postural Vertical Deficit “” Cognition SpO2, HR, BP, Distance Etc. SpO2, HR BP Cuff Pressure New and more academy specific Circumference Measure Not used by everyone (in it’s infancy) Capillary flow or return  Examination History Systems Review Test & Measures Data Collected Medical Diagnosis Place pertinent “results” of findings in the ICF Model Body Function and Activity Participation Structures Contextual Factors: Contextual Factors: Personal Environmental Medicine Doctor of Physical Therapy Program All rights reserved. © All rights reserved. Neuro Clinical Reasoning Framework Part 2: Prognosis, Interventions, Outcomes Jason E. Cook, DPT, PhD  Evaluation Medical Diagnosis PT Diagnosis Plan of Care & Prognosis Body Structure Activity and and Function Function Participation Impairments Limitations Restrictions Contextual Factors: Contextual Factors: Personal External PT Diagnosis: “The PT diagnosis of this patient includes impaired/decreased [insert Body Structure and Function Impairments], limiting their ability to perform [insert Activity Limitations], which lead to [insert Participation Restrictions]. Assessment: add before or after additional pertinent details that will influence the plan of care.  Examination 3 Step Process for Examination: PMH 1) Observe Movement (movement analysis) Patient Identified Problems 2) Hypothesize Impairments Non-Patient Identified Problems 3) Test Hypothesis (with Impairment Level Home environment Test and Measures) Work, hobby, support (family/friends) Evaluation Systems Review PT Diagnosis Plan of Care Musculoskeletal & Prognosis Cardiopulmonary/respiratory Neuromuscular Patient Prognosis Integumentary Patient Long Term Goals Additional Systems Patient Short Term Goals  Evaluation PT Diagnosis Plan of Care & Prognosis PT Prognosis: Based on multiple factors, including PMH, current medical status, and Contextual Factors (personal and external) PT Goals: i. Appprox. 95% of your neuro (and pediatrics) based goals should be written to measure an activity limitation or a participation restriction i. No impairment-based goals in this course ii. Any impairment based goals will cause deduction i. Example of a goal that would have a point deduction i. Patient will obtain an increase in 10 degrees of ankle dorsiflexion in order to be able to walk with heelstrike in 2 weeks ii. Example of the same goal written as a measurable activity: i. Patient will ambulate 50 feet with bilateral heelstrike independently with 80% accuracy in 2 weeks.  Examination Evaluation Intervention Re-Evaluation Systems Test & PT Diagnosis Outcomes History Plan of Care Intervention Review Measures & Prognosis Assessment Medical Diagnosis Body Structure Activity and and Function Function Participation Impairments Limitations Restrictions Compensatory Restorative Contextual Factors: Contextual Factors: Personal External Neuroplastic Principles Principles of Motor Learning  Examination Evaluation Intervention Re-Evaluation Systems Test & PT Diagnosis Outcomes History Plan of Care Intervention Review Measures & Prognosis Assessment Location of services: Inpatient ICU Acute Care Get the patient ready for their next stage of care (home health, rehab, skilled) Inpatient Rehab- Must tolerate combination of 3 hours/day of PT, OT, and,or SLP Skilled- cannot tolerated 3 hours of PT, OT, SLP or cannot go home Home Health- housebound except for medical appointments Outpatient Therapy  Examination Evaluation Intervention Re-Evaluation Systems Test & PT Diagnosis Outcomes History Plan of Care Intervention Review Measures & Prognosis Assessment Compensatory Restorative When to focus on restorative vs compensatory Compensatory- learn to move with help, assistance, or with alternative ways of causing the movement to occur. Restorative- relearn to move typically  Neuroplastic Principles Principles of Motor Learning  Examination Evaluation Intervention Re-Evaluation Systems Test & PT Diagnosis Outcomes History Plan of Care Intervention Review Measures & Prognosis Assessment When you combine Restorative - Compensatory Patient goals Location of Service Neuroplastic Principles Principles of Motor Learning = Strong foundation in management of the neuro patient  Examination Evaluation Intervention Re-Evaluation Systems Test & PT Diagnosis Outcomes History Plan of Care Intervention Review Measures & Prognosis Assessment Outcome measures Week 2 and at lab Repeat for outcomes Test- Retest  Examination Evaluation Intervention Re-Evaluation Systems Test & PT Diagnosis Outcomes History Plan of Care Intervention Review Measures & Prognosis Assessment Refer back to this presentation and the content often. Highlights: Identify PIP’s and NPIP’s. Systems Review 3 Step Exam Process Observe (Outcome measures and general movement analysis) Hypothesize ( know cheat sheet for movement systems diagnosis) Test and Measures PT diagnosis Goal Writing Aspects of Neuro Based interventions Medicine Doctor of Physical Therapy Program All rights reserved. © All rights reserved.  Neuromuscular Practice Movement System and Neuro-Based Diagnosis Jason E. Cook, DPT, PhD Certified Specialist in Pediatric Physical Therapy Objectives Understand how the movement system applies to neurologic physical therapy Apply the neuro-based movement system diagnoses to observable motor behaviors Movement Systems Diagnosis HOD 2013 and 2019 adopts language of the movement system A System of Systems to create movement Immune System A System of Systems Movement Systems Diagnosis HOD 2013 and 2019 adopts language of the movement system A System of Systems to create movement Diagnoses based around movement dysfunction or the movement impairment to create common/unified language In its infancy- just beginning Neuro-based Movement System Diagnoses Neuro Based Movement System Diagnoses Force Production Deficit Fractionated Movement Deficit Postural Vertical Deficit Dysmetria Cognitive Deficit Sensory Selection and Weighting Deficit Sensory Detection Deficit Hypokinesia Movement Pattern Coordination Deficit Movement Pattern: Force Production Deficit Examples of motor behavior Observed as generalized weakness, or weakness of a limb However, its not due to simply muscle weakness, but rather impaired CNS and muscle together May present in gait as crouching or buckling of the legs May present as flaccidity or difficulty moving an extremity against gravity May present in trunk as difficulty getting up from bed due to weakness How to test? Test muscle strength Test functional movement Movement Pattern: Fractionated Movement Deficit Examples of Motor Behavior Difficulty isolating movement between joints in the same extremity (leg and or arm) During active attempts at movement, see an increase in muscle tone During attempts at movement, see stereotypical mass movement patterns of flexion or extension How to test: Test: Tone, Spasticity Test: Complex isolated arm and leg movements Test: Functional movement Other: Fugyl Myer Movement Pattern: Postural Vertical Deficit Example or Motor Behaviors Shifts center of mass beyond limits of stability to side or backwards Attempts to move out of vertical alignment Resists correction How to test: Observe movement. Attempt to correct alignment, and watch for whether the patient can sustain the upright posture Movement Pattern Dysmetria Example seen Motor Behaviors: Difficulty with targeting during reaching Variable foot placement during gait, inconsistent foot placement Slow, small steps Ataxia Often associated with cerebellar dysfunction How to test: Test Coordination Test functional movement Movement Pattern: Cognitive Deficit Example seen Motor Behavior Lacks initiation of movement Difficulty understanding instructions of task May have greater difficulty with multi-step activities How to Test? Test via instructions Cognitive testing