EHR523 Lecture 06a Stroke (1 Slide) PDF

WARNING This material has been reproduced and communicated to you by or on behalf of Charles Sturt University in accordance with section 113P of the Copyright Act 1968 (Act). The material in this communication may be subject to copyright under the Act. Any further reproduction or communication of th...

WARNING This material has been reproduced and communicated to you by or on behalf of Charles Sturt University in accordance with section 113P of the Copyright Act 1968 (Act). The material in this communication may be subject to copyright under the Act. Any further reproduction or communication of this material by you may be the subject of copyright protection under the Act. Do not remove this notice School of Allied Health, Exercise and Sports Sciences 1 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 1 EHR525 EXERCISE FOR NEUROLOGICAL & MENTAL HEALTH CONDITIONS Exercise Prescription for Stroke Presenter: Jack Cannon School of Allied Health, Exercise and Sports Sciences 2 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 2 What We Will Cover: ■ ■ ■ ■ ■ Stroke statistics in Australia. POathophysiology of stroke and risk factors for a stroke event. Role of surgery and medications in stoke treatment. Common neurological consequences following stroke. Cerebral circulation and vascular territories as they relate to stroke and neurological deficits. ■ Goals for exercise rehabilitation in stroke. ■ General exercise testing and prescription guidelines in stroke. School of Allied Health, Exercise and Sports Sciences 3 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 3 Introduction ■ Stroke: Heterogenous groups of disorders involving sudden, focal interruption of cerebral flow blood resulting in a neurological deficit/s lasting longer than 24-hrs. □ Aka: Cerebrovascular accident or “brain attack”. ■ Causes anoxic tissue damage downstream from the site of origin possibly causing permanent impairments in brain function. ■ Most stroke survivor have some form of persistent neurological deficit and physical/functional impairment. School of Allied Health, Exercise and Sports Sciences 4 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 4 Stroke Statistics ■ Stroke is Australia’s 2nd largest cause of death. ■ 65% of all stroke survivors suffer a disability that impedes their ability to carry out daily living activities unassisted. ■ In 2017 there will be almost 56,000 new and recurrent strokes (one stroke every 9 mins). ■ In 2017 there will be more than 475,000 people living with the effects of stroke (1 million by 2050). ■ Around 30% of stroke survivors are under 65 years of age. Aust. Stroke Foundation (2017). School of Allied Health, Exercise and Sports Sciences 5 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 5 Stroke Statistics School of Allied Health, Exercise and Sports Sciences 6 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 6 Stroke Statistics Males at increased risk for stroke School of Allied Health, Exercise and Sports Sciences 7 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 7 Pathophysiology ■ Cerebral tissue damage with stroke may be due to: □ O2 deprivation (hypoxia). □ Glutamate release (excitotoxicity). □ Pressure on tissues. ■ Both white and grey matter are affected. ■ Two types of stroke: Ischemic and Haemorrhagic. School of Allied Health, Exercise and Sports Sciences 8 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 8 Ischemic Stroke ■ Accounts for 90% of all strokes. ■ Thrombotic: Blood vessel is blocked by the formation of a clot within the brain. □ Responsible for 50% of all strokes. □ Large-vessel thrombosis: Involves one of the larger vessels (e.g. carotid or middle cerebral). □ Small-vessel thrombosis: Involves one (or more) of the smaller, but deeper, penetrating vessels (lacuner stroke). ■ Embolic: Blood vessel is blocked by a clot formed elsewhere in the body (e.g. heart) travelling in circulation. School of Allied Health, Exercise and Sports Sciences 9 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 9 Ischemic Stroke ■ Clot may form inside the brain or travel from other body region. School of Allied Health, Exercise and Sports Sciences 10 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 10 Ischemic Injury ■ Two zones of injury: □ Ischemic core (infarction). □ Ischemic penumbra. ■ Severe ischemia (75-90% reduction in normal flow) results in rapid depletion of energy stores and necrosis occur quickly. ■ Cells within the penumbra remain viable but will die if reperfusion is not established during the early hours. School of Allied Health, Exercise and Sports Sciences 11 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 11 Transient Ischemic Attack ■ A transient ischaemic attack (TIA) or ‘mini stroke’ occurs with temporary occlusion of blood flow (secs to mins). ■ Warning sign of stroke. ■ TIA is a medical emergency. School of Allied Health, Exercise and Sports Sciences 12 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 12 Haemorrhagic Stroke ■ Accounts for 10% of all strokes. ■ Occurs when a vessel ruptures allowing blood to leak inside the brain disrupting flow to downstream tissues and increasing pressure on tissues at rupture site. ■ Usually occurs in selected parts of the brain, including the basal ganglia, cerebellum, brain stem, or cortex. ■ Initial prognosis is poor but recovery may be surprisingly good. School of Allied Health, Exercise and Sports Sciences 13 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 13 Haemorrhagic Stroke School of Allied Health, Exercise and Sports Sciences 14 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 14 Major Stroke Risk Factors ■ Same modifiable and non-modifiable factors for the development and progression of CVD and PVD are associated with stroke: □ □ □ □ □ □ □ □ □ □ Age. Prior stroke/TIA. HTN AF Family history. Established cardiovascular disease. Diabetes. Cigarette smoking. Alcoholism. Obesity. School of Allied Health, Exercise and Sports Sciences 15 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 15 INTERSTROKE Study ■ INTERSTROKE study (n=2337, 78% ischaemic; n=663, 22% haemorrhagic; n= 3000 controls) found that 10 risk factors accounted for 90% of the worldwide population attributable risk for stroke: □ □ □ □ □ Hypertension (OR 2.6). Current smoking (OR 2.1). High WHR (not BMI) (OR 1.7). Poor diet (OR 1.4). Physical activity (OR 0.64) □ □ □ □ □ Diabetes (OR 1.4). Alcohol intake >30 /mth (OR 1.51) Stress/drepression (OR 1.3). Cardiac condition (OR 2.38). Apolipoproteins B/A1 ratio (OR 1.9) O’Donnell et al. (2010). The Lancet, 376; 112-123. School of Allied Health, Exercise and Sports Sciences 16 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 16 Models of Stroke Risk O’Donnell et al. (2010). The Lancet, 376; 112-123. School of Allied Health, Exercise and Sports Sciences 17 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 17 Australia Data ■ Audit of patient records from hospitals participating in the 2011 National Stroke Audit reported: □ □ □ □ □ □ □ □ □ 73% Hypertension. 50% High cholesterol. 40% Previous stroke or a TIA. 36% Atrial fibrillation. 33% Recent CVD or AMI. 31% were current or past smokers. 30% Diabetes. 14% high alcohol consumption. 9% rheumatic fever or other valvular heart disease. School of Allied Health, Exercise and Sports Sciences 18 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 18 Treatment For Stroke ■ Ischemic stroke: Involves removing blockage and restoring cerebral blood flow. □ Surgery (carotid endarterectomy). □ Medications. ■ Haemorrhagic stroke: Usually involves surgery to relieve intracranial pressure and insertion of stents to support weak vessels. School of Allied Health, Exercise and Sports Sciences 19 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 19 Carotid Endarterectomy ■ Reduced 5-year risk of stroke by 6-7% in persons with 50-70% stenosis. ■ 80% risk reduction in clients with >70% stenosis. School of Allied Health, Exercise and Sports Sciences 20 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 20 Medications ■ Many classes of medications used to management stroke: □ □ □ □ Antithrombotics Antihypertensives (ACE inhibitor, betablocker, diuretic). Antiplatelet agents (Clopidogrel): No effect on exercise. Anticoagulants (Warfarin). ■ Be aware of their effects on the exercise HR and BP responses. School of Allied Health, Exercise and Sports Sciences 21 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 21 Medications School of Allied Health, Exercise and Sports Sciences 22 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 22 Complications Following Stroke ■ Extent of neurological impairment depends on: □ Size and location of the blood flow disruption. □ Degree of cerebral collateral circulation. ■ Long-term consequences may effect: □ □ □ □ □ □ Sensorimotor function. Cognition. Visuospatial/perceptual. Communication. Behaviour. Reduced overall health. School of Allied Health, Exercise and Sports Sciences 23 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 23 Cerebral Circulation and Vascular Territory ■ Brain is suppled with blood via four (4) arteries: □ Two internal carotid arteries: Left and right branches of the common carotid arteries in the neck which enter the skull. □ Two vertebral arteries: Smaller arteries which branch from the subclavian arteries. ■ Vertebral arteries fuse into the basilar artery that supplies the brainstem. ■ Circle of Willis: Interconnection between the internal carotid arteries and basilar artery. School of Allied Health, Exercise and Sports Sciences 24 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 24 Cerebral Blood Vessels School of Allied Health, Exercise and Sports Sciences 25 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 25 Vascular Territories School of Allied Health, Exercise and Sports Sciences 26 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 26 Vascular Territories School of Allied Health, Exercise and Sports Sciences 27 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 27 Large Vessel Clinical Presentation School of Allied Health, Exercise and Sports Sciences 28 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 28 Sensorimotor Impairments ■ ■ ■ ■ ■ ■ ■ Contralateral Weakness/hemiplegia. Sensory impairment (temp, pain, touch). Spasticity. Contractures. Ataxia Balance impairment. Fatigue. School of Allied Health, Exercise and Sports Sciences 29 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 29 Cognitive Impairments ■ Decreased attention. ■ Loss of concentration. ■ Memory difficulties. ■ Impaired executive function (e.g. decision making, planning, responding). School of Allied Health, Exercise and Sports Sciences 30 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 30 Visuospatial/Perceptual Impairment ■ Decreased visual function (e.g. field deficits). ■ Hemispatial neglect: deficit in attention to and awareness of one side of the field of vision. ■ Agnosia: Inability to process sensory information. ■ Apraxia: Difficulty with motor planning/organisation. School of Allied Health, Exercise and Sports Sciences 31 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 31 Communication Impairment ■ Oral dyspraxia: Difficulty in making and coordinating the precise articulatory movements. ■ Dysarthria: slurred or slow speech that can be difficult to understand. ■ Dysphagia: Difficulty swallowing. School of Allied Health, Exercise and Sports Sciences 32 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 32 Behavioural/Emotional Impairments ■ Depression. ■ Anxiety. ■ Mood swings. ■ Impulse control. ■ Anger. School of Allied Health, Exercise and Sports Sciences 33 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 33 Reduced Overall Health ■ Reduced physical conditioning. ■ Low aerobic capacity. ■ Reduced BMD. ■ Increased fat mass. ■ Losses in lean mass. School of Allied Health, Exercise and Sports Sciences Lazoura, J. (2010). Clin Densitom, 13(2); 175-180. 34 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 34 Recovery From Stroke ■ Most recovery occurs in the first 6 months post-event. ■ Further recovery may occur after this time, which rate is recovery is reduced. ■ Studies show that recovery >6 mths is associated with exercise and physical conditioning training. School of Allied Health, Exercise and Sports Sciences 35 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 35 Long-Term Disability Resulting From Stroke School of Allied Health, Exercise and Sports Sciences 36 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 36 The Modified Rankin Scale (mRS) ■ Commonly used scale for measuring the degree of disability or dependence in the daily activities after stroke: □ 0 - No symptoms. □ 1 - No significant disability. Able to carry out all usual activities, despite some □ □ □ □ □ symptoms. 2 - Slight disability. Able to look after own affairs without assistance, but unable to carry out all previous activities. 3 - Moderate disability. Requires some help, but able to walk unassisted. 4 - Moderately severe disability. Unable to attend to own bodily needs without assistance, and unable to walk unassisted. 5 - Severe disability. Requires constant nursing care and attention, bedridden, incontinent. 6 - Dead. School of Allied Health, Exercise and Sports Sciences 37 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 37 Goals For Exercise Rehabilitation In Stroke ■ Three (3) for exercise rehabilitation in stroke survivors: ■ Goal 1: Commence physical conditioning exercise to support return to pre-stroke levels of physical activity as soon as possible. ■ Goal 2: Reduce the risk of recurrent stroke and CVD events. ■ Goal 3: Improve aerobic fitness within residual limits of capacity. Gordon et al. (2004) Circulation, 109; 2031-2041 School of Allied Health, Exercise and Sports Sciences 38 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 38 Key Points For Exercise Rehabilitation ■ Major goal is to aerobic functional capacity since the average for stroke clients is 14.4 ml/kg/min whereas 20 ml/kg/min is the minimum for independent living. ■ Aggressive rehab after 6mths can increase aerobic capacity and sensorimotor function. ■ Aerobic exercise improves multiple CVD risk factors. ■ Standard rehab therapy does not address aerobic capacity. School of Allied Health, Exercise and Sports Sciences 39 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 39 Other Considerations ■ Significant reductions in muscular strength and endurance are commonly observed in stroke patients and should also be addressed. ■ Spasticity and loss of flexibility are also common with stroke clients so these should be addressed. School of Allied Health, Exercise and Sports Sciences 40 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 40 Benefits of Exercise in Stroke ■ Research indicates that stroke clients obtain similar benefits from exercise as healthy persons: ■ Adaptations to exercise in stroke include: □ □ □ □ □ □ □ Increases in VO2 regardless of stage of recovery (Pang et al. (2006) Clin. Rehab.) Increases muscle strength (paretic and non-paretic). Improved functional performance. Improved balance. Increased gait recovery (Luft et.al. (2008) J Stroke) Increased max work capacity. Improved body composition. School of Allied Health, Exercise and Sports Sciences 41 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 41 Pre-Exercise Screening and Assessment ■ Normal ESSA Adult Pre-Exercise Screening procedures apply: □ Risk factors for CVD and diabetes frequently present. □ Resting ECG/stress test? ■ Thorough medical history: □ Date of diagnosis, medications, side-effects, post-stroke complications, comorbidities, lifestyle issues (exercise history, anthropmetry). ■ Many stroke clients develop depression so a psychological referral may be necessary. School of Allied Health, Exercise and Sports Sciences 42 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 42 Pre-Exercise Screening and Assessment ■ A brief upper body, lower body, and cerebellar neurological exam may be useful to determine extent of motor impairments and regions affected. ■ Special attention should be given to evidence of: □ □ □ □ Postural misalignment. Weakness/paresis. Restricted ROM. Spasticity (Modified Ashworth scale). School of Allied Health, Exercise and Sports Sciences 43 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 43 Stroke-Specific Contraindications For Exercise ■ Absolute: Due to the high incidence of CVD with ischemic stroke it is important to assess for unstable angina. ■ Relative: Because haemorrhagic stroke is frequently related to HTN it is important to assess pre-exercise resting systolic BP <200 mmHg and diastolic BP <110 mmHg. School of Allied Health, Exercise and Sports Sciences 44 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 44 Cardiorespiratory Response to Exercise ■ Stroke clients have lower maximal workloads that are associated with lower maximal HR and BP responses to exercise than controls. ■ VO2 at a given workload is higher in stroke than healthy persons. School of Allied Health, Exercise and Sports Sciences 45 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 45 General Exercise Testing Considerations School of Allied Health, Exercise and Sports Sciences 46 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 46 Functional Testing Mild Impairment Timed stair climb Moderate Impairment Timed up and go Shuttle walking test 6-min walk 6-10m walk Sit to stand Transfer (number per minute) School of Allied Health, Exercise and Sports Sciences Severe Impairment Transfers (number per minute) Sit to stand 47 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 47 Treadmill Walking and Aerobic Exercise Training ■ Suggested that treadmill walking is best for stroke clients because ■ It is used for everyday tasks, which should enhance transference and generalisability of training effects. ■ Handrail support and harness allow clients to walk who might not otherwise be able to. ■ Exercise intensity can be adjusted by either speed or gradient. Gordon et al. (2004) Circulation, 109; 2031-2041 School of Allied Health, Exercise and Sports Sciences 48 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 48 Aerobic Exercise Prescription (Ehrman) ■ Can consist of: □ □ □ □ Ground/treadmill walking. Cycle ergometer. Treadmill. Seated stepper. ■ Frequency: 3-5 days /wk ■ Intensity: 40-80 % HRR □ RPE 11-13 ■ Duration: 15-30 minutes ■ Progress from low to high intensity and to longer durations. ■ Because of biomechanical limitations, intensity by HR should be superseded by RPE. □ Interval training? School of Allied Health, Exercise and Sports Sciences 49 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 49 Resistance Exercise Prescription (Ehrman) ■ Should include all major muscle groups and functional exercises. ■ May include: □ □ □ □ Weight machines Free weights Body weight Therabands ■ Frequency: 3-5 days/wk. ■ Intensity: Up to 80% 1RM. ■ Progression as tolerated. School of Allied Health, Exercise and Sports Sciences 50 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 50 Flexibility Exercise Prescription (Ehrman) ■ Goal: To improve ROM of involved extremities and prevent contractures. ■ Frequency: 3-5 days/wk (before or after aerobic or strength activities). ■ Intensity: Below point of discomfort. ■ Progression as tolerated. ■ Emphasis on stretching muscles on the paretic side, particularly in muscle groups experiencing spasticity. School of Allied Health, Exercise and Sports Sciences 51 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 51 Special Considerations for Exercise ■ Knee/hip arthritis is common bas stroke clients are older. ■ Reduced motor control of legs may cause balance problems and necessitate greater use of uninvolved limb. ■ Closely monitor for CVD related adverse events. ■ Avoid isometrics and high-intensity exercise that will elevate SBP. School of Allied Health, Exercise and Sports Sciences 52 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 52 Summary ■ Stroke is a significant cause of neurological deficit in Australia. ■ Exercise testing and training are important in both the prevention and management of stroke. ■ General guidelines for exercise testing and prescription are similar to that of cardiovascular clients. ■ AEPs will likely be in increasing demand as an allied health professionals in the provision of treatment after stroke. School of Allied Health, Exercise and Sports Sciences 53 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 53