STROKE (Neurological Disorders in Elderly)
Definition
A
stroke is usually understood to be the sudden onset of neurological deficits
due to local
disturbances
in the blood supply to the brain, i.e. a vascular occlusion (ischemic infarct)
or a
vascular
disruption (hemorrhage).
Prevalence
Prevalence
of stroke rapidly increases with age. Two thirds of stroke patients are found
in the
over-65
age group.
Morbidity
and Mortality
Stroke
is the third most common cause of death and the leading cause of disability in
developed
countries.
In the United States, the rate of death due to stroke is 160,000 per year.2 Wagenaar
and
Kwakkel reported that about 30 percent of the stroke patients died within 21
days. Of those
who
survived the acute phase, 42 percent remained dependent upon other persons for
their
ADLs,
24 percent were hospitalized or sent to a nursing home, 11 percent were unable
to walk,
and
66 percent were unable to return to work.1 On the basis that elderly is the
fastest growing
segment
of world population, it may be expected that the proportion of disability will
continue
to
increase considerably.
Risk
Factors
• Age:
After age 55, the risk for stroke doubles every 10 years.
• Sex: Male > female for all age groups below 75
years.
• Race:
Afro-Caribbean > Asian > European.
• Diseases:
Heart diseases such as heart failure or atrial fibrillation, hypertension,
diabetes,
hyperlipidemia,
polycythemia.
• Lifestyles:
Smoking, excess alcohol consumption, obesity, diet, lack of physical activity
•
Oral contraceptives.
Clinical
Features
•
The neurological deficit reflects the size and site of the lesion.
•
At the time of onset, the level of consciousness is more depressed in patients
with cerebral
hemorrhage
than those with ischemic stroke.
•
Acute focal stroke presents with variable symptoms. Most common is a
haemiplegia with
or
without the signs of focal higher cerebral dysfunction, for example aphasia.
Other
symptoms
are related with sensory, visual, cognitive and language deficits.
•
Subarachnoid hemorrhages are not common in elderly individuals. Typically they
presents
with
a sudden, unusually severe headache that lasts for hours or even days, often
accompanied
by
vomiting.
• presents
clinical features of most common forms of stroke.
•
Following the onset of stroke with hemiplegia, a state of flaccidity exists
from hours to
weeks
or months. This is followed by the development of patterns of returning muscle
function
and spasticity.
Clinical features of most common forms of stroke
Ischemia
•
Middle cerebral artery Contralateral paralysis and sensory deficit
Aphasia
Homonomous
hemianopsia
Hemineglect
Numbness:
face, arm > leg
Apraxia
Impaired
ability to judge distance
Loss
of conjugate to opposite side
•
Anterior cerebral artery Weakness: leg > face, arm
Numbness:
leg > face, arm
Urinary
incontinence
Contralateral
grasp reflex, sucking reflex
Amnesia
•
Vertebrobasilar artery Ataxia
Dizziness,
nausea, vomiting, nystagmus
Dysmetria
Dysarthria
Dysphagia
Visual
field deficits
Quadriplegia in complete basilar syndrome
Hemorrhage
•
Intracerebral hemorrhage Headache
Lethargy
or coma
Focal
symptoms resembling ischemic stroke
•
Subarachnoid hemorrhage Severe, unusual headache, often during physical
exertion
There
may be loss of consciousness or vomiting at onset
Nuchal
rigidity takes about 6 hrs to develop
Cardiac
symptoms such as chest pain, syncope, arrhythmias
Focal
hemisphere signs at onset due to an associated intracerebral hematoma
Focal
hemisphere signs developing after some days due to arterial vasospasm
A
3rd nerve palsy due to local pressure from an aneurysm of the posterior communicating
artery
Investigations
•
CT/MRI: To confirm the vascular nature of the lesion
•
ECG, ultrasound scanning, Doppler ultrasound, contrast angiography: To
investigate the
underlying
vascular disease
•
Serum glucose, complete cell and platelet blood count, cholesterol, prothrombin
and partial
thromboplastin
time, electrolytes: To investigate the risk factors
Evaluation
and Assessment
• Level of consciousness: The
Glasgow Coma Scale records motor response to pain, verbal
responses
to auditory as well as visual clues, and eye opening.3
• Cranial nerves: Ocular
movements; strength of facial muscles; labyrinthine auditory, laryngeal
and
pharyngeal function, should be checked.
• Sensation: Light touch, deep
pressure, pain, temperature, kinesthesia, two-point
discrimination,
proprioception, appreciation of texture and size, and vibration should be
assessed.
• Musculoskeletal: Muscle strength
as well as range of motion especially ankle dorsiflexion
and
shoulder movements should be assessed thoroughly.
• Movement pattern: Physical
therapist should know whether the movement produced is in
normal
pattern or not. Initiation pattern, sequencing and control of firing patterns,
balanced
return
are the indicators of controlled smooth movement pattern.
• Hypertonicity: Physical
therapist dealing with stroke patients should understand the difference
between
‘true spasticity’ and ‘hypertonicity’. According to Burke5 and Sheean6, ‘true
spasticity’
depends upon afferent information from feedback following movement of the
stretched
muscle whereas hypertonicity which is a form of sustained efferent muscular
hyperactivity,
depends upon continuous supraspinal drive to the alpha motoneurones. This
results
into increased tonic muscle contraction which continues in the absence of
movement.
As
a consequence, hypertonicity in hemiplegia gives rise to abnormal postures such
as
flexion of upper limb and extension of lower limb.
• Pain: Shoulder pain is the most
common pain complaint after stroke.10 It can be assessed
by
using Visual Analogue Scale.
• Edema: The distal parts of
extremities should be observed for the presence of edema.
• Communication:
Physical therapist should be aware of aphasia or dysarthria as well as
alternate
modes of communication such as auditory or visual deficits.
• Behavior: Cognitive function and
behavior problems should be noted, • Balance: The Berg Balance
Assessment is easy to administer and has good reliability for
stroke
patients.
• Posture: Postural problems in
regard with alignment or rotation, midline orientation, and the
position
of extremities should be evaluated in detail.
• Gait: Gait pattern is an
important component of evaluation of a hemiplegic patient. Loss of
controlled
planterflexion and normal combinations of movement patterns in swing and stance
phases
of gait, are some of the common abnormalities. Wisconsin Gait Scale (WGS)58,59
provides
the qualitative evaluation of the gait of hemiplegic patients. (Appendix- VIII)
• Appliances: Use or a need to use
the assistive devices, splints for positioning, orthotic
devices
or wheelchair should be noted down.
• ADLs:
Management
• Medical
management:
–
The hospital stay for acute stroke is usually 2 to 4 days.
–
Management starts with assessment of the “ABCs” meaning Airway, Breathing and
Circulation.
–
A rapid reduction of blood pressure, especially in case of moderate elevation,
should be
avoided.
This is to prevent acute exacerbation of the neurological deficit.
–
No treatment is recommended unless the systolic pressure is > 220 mm Hg.
–
If needed, intravenous B-blockers should be administered to reduce blood
pressure.
–
Admission to neurointensive care unit is must in case of subarachnoid
hemorrhage.
–
Patients should not be allowed to take food or liquid by mouth until swallowing
function
becomes
normal.
–
Patients should lie flat in bed so as to avoid the worsening of ischemia.
–
Depending upon the stroke subtype, secondary prevention strategies should be
initiated
as
soon as possible. For example, aspirin and other antiplatelet drugs reduce the
risk of
recurrence
in noncardioembolic strokes.
• Physical therapy interventions:
A number of treatment approaches, ranging from neurological
exercise
therapies to cognitive remediation programs for perceptual deficits, have been
developed
in last four decades. The frequently applied neurological exercise therapies
are
Neurodevelopmental
Treatment (NDT) derived from Bobath method, Motor Relearning
Program
(MRP) by Janet Carr and Roberta Shepherd, Brunnstorm’s Movement Therapy,
Proprioceptive
Neuromuscular Facilitation (PNF) technique and Electromyography Feedback
Therapy
(EMG). The main problem of hemiplegic patients is that of abnormal coordination
of movement patterns combined with abnormal postural tonus.49 Therefore,
according to Bobath, the assessment and treatment of the patient’s motor
patterns is the only way of leading directly to
functional
use. In addition to it, muscles are not paralyzed and deficits of muscular
activity can
be
remedied by their action in more normal functional patterns. Thus, basic
concept of Bobath
method
is a holistic approach that deals with patterns of coordination and not with
problems of
muscle
function. The method has undergone many changes from 1970 to 1990, but the
underlying
concept has not changed. These changes can be summarized as following:50
•
All static ways of treatment like ‘reflex-inhibiting postures’ have been
discarded.
•
A strong emphasis on movement and functional activity has been introduced.
•
New ways of activating the patient through movements of the trunk have been
found,
combined
with the inhibition of the spastic patterns of the limbs distally by the
therapist.
•
As the spasticity is reduced, patient is encouraged to control movements more
and more
distally,
while the help of therapist is reduced.
•
Treatment in supine is reduced for the patients who can sit or stand.
•
More than ever before, all treatment is done in real life situations.
In
1985, Pat Davies introduced Neuro-Developmental Treatment (NDT) that is based
on
Bobath’s
approach; in it, the ideas of Bobath have been extended to training in functional
tasks
such
as grasping, standing up, climbing stairs, bouncing a ball, getting dressed,
preparing
meals,
washing clothes, brushing teeth and having a bath.51
Brunnstorm has described seven recovery stages in post-stroke
hemiplegic patients:
Stage 1. Flaccidity is
present. No movement, on either a reflex or a voluntary basis, can be
initiated.
Stage 2. Spasticity begins to
develop. Flexion synergy in upper extremity and extension synergy
in
lower extremity may appear as associated reactions. There are minimal voluntary
movement
responses.
(semivoluntary)
Stage 3. Spasticity reaches its
peak. Patient is able to control the basic synergy patterns.
Stage 4. Spasticity begins
to decline. Some movement combinations that do not follow the
paths
of basic limb synergies are mastered.
Stage 5. Spasticity
continues to decline. More difficult movement combinations are mastered
as
the basic limb synergies lose their dominance.
Stage 6. As spasticity
disappears, the patient becomes capable of a full spectrum of movement
patterns.
Coordination approaches normalcy.
Stage 7. Normal motor
function is restored.
According
to Brunnstorm, these stages of recovery following a stroke bear a resemblance
to
normal infantile motor development on a continuum from reflex to voluntary
movement,
from
gross to fine movement and from control of proximal movements to that of distal
movements.
She developed the treatment strategies so as to facilitate this “natural and
lawful”
process.
The techniques of facilitation used by her are synergies, reflexes, associated
reactions,
resistance,
tapping and stretch.
With
the exception of the training of basic functional activities such as grasping,
sitting and
walking,
training for ADL is hardly discussed by Brunnstorm.1 In addition to it, the use
of
reflexes
and synergistic movement in treatment is controversial and the concept of the
hierarchical organization of the nervous system has been modified in
neurophysiology in recent years.
However,
Brunnstorm’s observations of motor recovery and motor behavior are valid and
the
techniques
are useful in treatment.
The
Motor Relearning Program (MRP), formulated by Carr and Shepherd, is an approach
to
functional training. There is a major shift, in emphasis, away from the
exercise or facilitation
therapy
to the relearning of motor control. In view of these applied movement
scientists, the
unique
contribution of physiotherapy to the rehabilitation of stroke lies potentially
in the training
of
motor control based on an understanding of the kinematics and kinetics of
normal movement,
motor
control processes and motor learning. Thus, MRP is based on four factors known
to be
essential
for the learning of motor skill and therefore assumed to be essential for the
relearning
of
motor control following stroke:
•
The elimination of unnecessary muscle activity
•
Feedback
•
Practice
•
Interrelationship between postural adjustment and movement
The
research studies have indicated that all of the available approaches appear to
promote
improvement
in functional ability. A better theoretical understanding of the deficits In
author’s
view,
a treatment program consisting of mainly three components may be useful:
I.
Traditional techniques of exercise therapy
II.
The specific treatment approaches
III.
Function-based techniques
• Passive movements: In a recent
study, it has been demonstrated that passive elbow movements
in
hemiplegic stroke patients before clinical recovery elicit some of the brain
activation
patterns
described during active movement after substantial motor recovery.4 This
indicates
that
the recruitment of ipsilateral sensory and motor pathways early after stroke
may be
critical
for return of voluntary control. Therefore, it is recommended that patient
should be
involved
actively while performing passive movements in the early stage after stroke. He
must
be instructed to pay attention towards the position of joints, stability of
proximal parts,
movement of distal parts and the segmental alignment
In
the recovery stage, passive movements are performed to get complete elongation
of the
shortened
muscle groups. The pattern of elongation for an upper extremity is scapular
protraction
and
upward rotation, shoulder lateral rotation and abduction, elbow extension,
forearm supination, and wrist and finger extension. According to Odeen, the
elongation of the shortened muscle groups at the point of maximally tolerated
muscle length results in the reduction of hypertonicity.
• Active movements: Patient should
be encouraged to do the movements actively or better
said
voluntarily, as soon as the muscle function begins to return. However, it must
be kept
in
mind that in hemiplegia, the return in muscle function is usually accompanied
by the
emergence
of synergistic movement patterns. Sahrmann and Norton have demonstrated
that
as voluntary function increases, the dependence on synergistic movement
decreases.
This
suggests that the patient must be encouraged to produce the movements
voluntarily.
Physical
therapist may use her voice or touch to stimulate the patient’s voluntary
effort so
as
to produce the movements in the more normal patterns.
• Functional stretching: This is
the process of elongation of the shortened muscle groups
through
weight-bearing . In hemiplegia, “Functional stretching” rather than
“orthopedic
stretching” is more effective to improve range of motion.
• Mobilization exercise: Joint
dysfunction of the shoulder, scapula, hand, fingers, ankle and
forefoot
may result as the secondary problem in hemiplegic patients. Mobilizing the
scapula
is
particularly important to improve the mobility of arm at shoulder and also to
prevent
shoulder
pain. This may be carried out in supine or side lying.
• Progressive resisted exercise:
Weakness from stroke differs from generalized weakness and
orthopedic weakness: it involves one entire side of the body and
includes the trunk and
extremities.46
Traditionally, progressive resisted exercise was believed to cause a marked
loss
of coordination and an increase in co-contraction. Therefore, this exercise was
avoided
to
the patients post-stroke. However, the latest studies have reported that
patients with
hypertonicity
may get benefit from progressive resisted exercise.
• Aerobic exercise: Aerobic
exercise is advised to patients of hemiplegia to improve the functional status.
The research studies have indicated that aerobic exercise has the potential to
develop the overall sensorimotor function after stroke.8 Walking on a
treadmill, in particular, has
produced
impressive positive findings in terms of independent walking.
• Functional activities: The
functional approach is well accepted by the patient. It makes the
treatment
more meaningful. It includes task-specific activities such as
–
Rolling
–
Sitting control
–
Sit to stand
–
Standing control
–
Transfers
–
Gait
–
Reaching activities
• Gait training: In hemiplegic
gait, there is disordered frequency, or phase relationship, between
pelvic
and thoracic rotation and arm and leg movements. This may be due to a lack of
timing
within coordination patterns and the general inability to switch between
coordination
patterns.1
The training of essential components of walking can be started in early stage.
Examples
of some of the activities are as following.
–
Stimulating planter aspect of foot in supine lying. This may facilitate
dorsiflexion of
foot.
–
Extending hip with knee flexion over the side of the bed. This may prepare the
affected leg for the start of swing phase.
–
Controlling hip movement while flexing the knee keeping ankle in dorsiflexion
on affected
side,
in the position of supine lying. This may prepare the affected leg for swing
phase.
–
Controlling knee flexors both eccentrically and concentrically throughout a
small range
in
prone lying. This may train flexion of affected knee at start of swing phase.
–
Pelvis bridging in supine lying. This may facilitate extension of both hips.
–
Pelvis bridging on affected leg. This may facilitate extension of affected hip.
–
Weight transfer from side to side in sitting. This may facilitate balance
reactions.
–
Training the quadriceps for eccentric and concentric activity in sitting
–
Standing with arms in extension held by therapist. This may facilitate
extension of affected
hip.
–
Stepping forward and backward with normal leg, keeping affected hip and knee in
extension. This may facilitate weight bearing and balancing on affected leg.
–
Stepping up and down with normal leg
–
Shifting body weight from one foot to another in standing. This may facilitate
training of
lateral
horizontal pelvic shift
–
Practicing controlled knee flexion in standing. This may train flexion of
affected knee at
start of swing phase.
–
Shifting body weight forward so as to put heel down while therapist holds the
affected
foot
in dorsiflexion with knee in extension. This may prepare the patient for heel
strike.
–
Bearing weight on affected leg. This may facilitate balance reactions.
–
Rotating pelvis while walking. This may facilitate lateral rotation of both
legs, in addition
to
improving balance and walking pattern.
– Walking sideways
–
Walking sideways while crossing the legs.
–
Improving walking velocity. This may cause positive influence on the disordered
coordination
patterns in trunk rotation and arm and leg movements.
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