PST 422: NEUROLOGICAL

DISORDERS AND

REHABILITATION: STROKE

Instructors:

Prof MOB Olaogun

Dr. F. Adepoju

Recommended texts

• Bobath B. Adult Hemiplegia: Evaluation and Treatment (3rd ed.). Oxford: Butterworth-Heinemann, 1990.

• Carr JH, Shepherd RB. Neurological Rehabilitation: Optimizing Motor Performance. Oxford: Butterworth-Heinemann, 1998.

• O' Sullivan SB, Schmitz TJ, eds. Physical Rehabilitation: Assessment and Treatment. Philadelphia: F.A. Davis Company, 2001

• Porter S. Tidy’s Physiotherapy (13th

ed). Oxford: Butterworth-Heinemann,

2003.

• Stokes M. Physical management in

neurological rehabilitation (2nd ed.).

Edinburgh: Elsevier Mosby, 2004.

Introduction

Definition of Neurorehabilitation

Nervous System

Basic units

Divisions

Overall functions

Effects of Abnormal/Underdevelopement

Diseases and Injury/Trauma

Introduction contd

• Rehabilitation

• Procedure in neurorehabilitation

• Team Concept and Composition

• The Role of Pty in1. Health promotion,

2. Prevention,

3. Treatment and

4. Rehabilitation

• Common Lesions of the Nervous System viz:

• Stroke, Parkinson’s Diseases, Cerebral Palsy, Multiple Sclerosis and Traumatic Injuries

Causes of neurological dysfunction

The principal causes of neurological dysfunction

are:

• Trauma (head injury, spinal cord injury)

• Disease of the nervous system (multiple

sclerosis, Parkinson’s disease etc)

• Lesions of the circulatory system (stroke)

• Congenital defects ( e.g. spina bifida)

DEFINITION OF STROKE

• Stroke is defined by the World Health Organization (WHO) as ‘a clinical syndrome characterized by rapidly developing clinical symptoms and/or signs of focal and at times global (applied to patients in deep coma and to those with subarachnoid haemorrhage) loss of cerebral function, with symptoms lasting more than 24 hours or leading to death, with no other apparent cause other than that of vascular origin’ (Hatano, 1976).It has also been defined as a sudden attack of weakness affecting one side of the body’ resulting from an interruption of the flow of blood to the brain by thrombosis, embolus or ruptured aneurysm (WHO Monica, 1988).

Prevalence of Stroke in

Nigeria• Prevalence is 613/100,000 (Ogunniyi et al, 2001).

• Urban Nigeria prevalence is 1.14/1000 (male:

female=1.51:0.69) and lower in urban Nigeria than

in most developed country (Danesi, Okubanjo and Ojini, 2007)

• 3.6% of all medical admission, with case fatality of

45% with majority occurring in 1st week at OAUTHC (Komolafe et al, 2007)

• Mean stroke age of 52 years reported in Abuja (Imam

and Omorunfemi, 2002)

Neuroanatomic and Neurophysiologic Basis of

Stroke

• Cerebral circulation

• Somatotopic map on primary somatosensory cortex

• Risk factors

• Types of stroke

• Implication of types

• Physical manifestation

• Neuroplasticity

Physical Manifestations Include:

• Perceptual,

• Cognitive,

• Sensory,

• Communication (e.g.foreign accent syndrome)

• Motor problems.

•Most common physical consequence is Motor.

• This brain's incredibly adaptive nature,

ability to act and react in ever-changing

ways, also respond to injuries or

diseases -- known as “neuroplasticity.”

Neuroplasticity

• Ability of the brain to

adjust itself functionally, by reorganizing the cortical maps and

reorganize itself by forming new neural connections throughout life.

• This capacity for rewiring of the neuronalsynapses to allow for re-development of entire regions of the brain is present in adults as well as children

By re-developing

• Neuroplasticity allows the neurons in the

brain to compensate for injury and

disease and to adjust their activities in

response to new situations or to changes

in their environment.

• This special characteristic allows the

brain’s estimated 100 billion neurons to

constantly lay down new pathways for

neural communication and to rearrange

existing ones throughout life, thereby

aiding the processes of learning,

memory, and adaptation through

experience.

General clinical features of

neurological conditionsThese are determined partly by the site and severity of the damage. Damage to one part of the CNS usually results in a disruption of function of other parts. Some of the common features are:

1. Movement dysfunction – incoordination, ataxia, involuntary movements, tremor etc

2. Muscle tone disturbance – hypertonia or hypotonia.

3. Pain

4. Sensory disturbances – parasthesia (diminished), anaesthesia (absent), hyperaesthesia (increased), allodynia

5. Cognitive impairments – memory impairment, reduced attention span, reduced motivation

6. Emotional disturbance – depression or euphoria

7. Visual disturbances – hemianopia, diplopia, nystagmus

8. Communication disturbances – e.g. aphasia

Diagnosis of neurological

conditions

• Diagnosis is the determination of the nature or cause of a disease. It involves the evaluation of a patient’s medical history, signs and symptoms and laboratory tests to confirm or establish the presence of the disease. Diagnosis of neurological conditions entails having a good knowledge of the neurological conditions, taking a case history, and

• carrying out appropriate examinations and investigations.

(1) Case History

This is a subjective assessment process aimed at (i) localising where the pathological process is taking place within the nervous system; (ii) identifying the nature of the disease process. This is achieved with the knowledge of the onset, evolution and course of the illness.

(2) Neurological examination

This involves observations and tests to

determine gait, balance, speech defects,

memory impairments, muscle tone,

muscle weakness, co-ordination, reflexes,

sensation, posture etc. The examination

helps to localise the site of the pathology.

(3) Neurological investigations

• These are carried out to confirm a diagnosis or for the purpose of differential diagnosis. Some of these investigations are:-

1. Neuroimaging techniques such as plain radiography of the skull and spinal cord, computed tomography (CT) scanning, magnetic resonance imaging (MRI), positron emission tomography (PET) and angiography.

2. Electrodiagnostic tests such as electro-

encephalography (EEG),

electromyography (EMG), nerve

conduction tests and evoked potentials.

3. Lumbar puncture and examination of

CSF.

4. Muscle biopsy

Assessment of neurological

patients

• Assessment is an integral part of treatment; it is needed to establish the patient’s strengths and difficulties. It includes history-taking and clinical examination.

History taking – This is an interview session during which information is obtained from medical notes, the patient, relatives and carers.

• It involves getting details of the nature of

the problem, pattern of the symptoms,

previous treatments, difficulties with ADL

etc. During the history taking, clues should

be observed on posture, emotion,

cognition, communication and span of

attention.

Clinical examination

• This includes physical and functional

assessments. It enables us to obtain information

on the patient’s difficulties and level of functional

ability. The assessments are carried out in the

context of WHO International Classification of

Functioning (ICF). Emphasis is on body function,

activity and participation rather than on

impairments, disabilities and handicap (ICIDH).

• As far as physiotherapy is concerned,

body functions that need to be assessed

are those that are related to functions of

the:

1. joints (range, contracture),

2. muscles (bulk, strength, tone)

3. movements (balance, coordination)

• 4. sensation (touch, temperature)

• The clinical examination should also

include assessment of activities such as

hand and arm function, observation of gait

and assessment of gait.

Outcome measures

• A wide range of outcome measures are

available for the determination of the

effectiveness of an intervention. They

describe the results or effects of health

interventions by expressing their relative

value or importance in absolute or relative

terms. A good outcome measure should

be valid, reliable and sensitive. Examples

of

• outcome measures frequently used in

clinical setting are Barthel Index, Berg

balance scale, MAS, London Handicap

Scale, Modified Ashworth Scale and 10-

metre walk time test, Forward Upward

Leading Step Test….

Risk factors/Causes of stroke

• Risk factors are traits and lifestyle habits that increase the risk of disease. The most significant risk factor for stroke is hypertension (BP > 160/95). Also, persons who have previously had a stroke are at a markedly increased risk for a recurrent stroke. Generally, risk factors for stroke may be classified into 2 major groups:

Stroke risk factors

• Some stroke risk factors are hereditary. Others are a function of natural processes. Still others result from a person's lifestyle.

• Age; Heredity (family history) and race ;sex (gender); prior stroke, TIA or heart attack; high blood pressure; cigarette smoking; diabetes mellitus; carotid or other artery disease; atrial fibrillation; sickle cell disease; high blood cholesterol; poor diet; physical inactivity and obesity; geographic location; socioeconomic factors; alcohol abuse; drug abuse (AHA, 2007)

Nonmodifiable risk factors

• Age: Stroke can affect people of all ages, including children. However, the incidence of stroke increases with age. Hence, many people with stroke are older (60 or more years old).

• Gender: At each age, stroke is more common in men than women. However, women account for more than half of all stroke deaths.

• Race: Stroke is more common among blacks

than whites. This is partly because blacks have

higher risks of high blood pressure, diabetes and

obesity. Also, blacks have a much higher risk of

death from a stroke than Caucasians do.

• Heredity or family history: The chances of having

a stroke are greater if a close relative (parent,

grandparent, sister or brother) has had a stroke.

Modifiable risk factors

• These include hypertension, previous transient ischaemic attack (TIA), atrial fibrillation, cardiac disease, cardiac surgery, meningitis, cigarette smoking, hyperlipidaemia, diabetes mellitus, sickle cell disease, physical inactivity, obesity, alcohol abuse, drug abuse, and oral contraceptive use.

Stroke prevention

• There is substantial evidence from clinical

trials that a first or recurrent stroke can

often be prevented. A key to stroke

prevention is the control of multiple stroke

risk factors via comprehensive lifestyle

modification and the appropriate use of

pharmacological therapy. Stroke

prevention strategies are:

• Reducing blood pressure

• Lowering blood cholesterol levels

• Eating a diet low in salt and saturated

fats; and rich in fresh fruit, vegetables

and fish oils

• Taking regular exercise

• Avoiding smoking

Clinical Features of stroke

• The signs and symptoms of stroke depend upon

the size and location of the lesion. The specific

clinical features include:

• 1. Paralysis - Usually, there is paralysis of the

muscles on one side of the body, contralateral to

the side of the brain in which the lesion

occurred. This is called hemiplegia. One-sided

weakness is called hemiparesis.

• 2. Loss of sensation - Stroke patients may

have impairments in sensation, on the

hemiplegic side, which rarely disappears.

There is loss of superficial touch and

temperature sensation. Pain is common

e.g. shoulder pain syndrome especially if

there is mismanagement during the initial

stages.

• 3. Motor impairments - At the early stages of stroke there is flaccidity with no voluntary movement. This is later replaced by spasticity, hyperreflexia and mass patterns of movement (synergies). Patients present with paresis or weakness, which does not affect all muscle groups equally. They are unable to

generate levels of force necessary for initiating and controlling movement or for maintaining posture.

• 4. Contractures and deformities - The loss of voluntary movements, loss of flexibility of connective tissue and disuse atrophy generally lead to decreasing range of movement, contracture and deformity.

generate levels of force necessary for initiating and controlling movement or for maintaining posture.

• 4. Contractures and deformities - The loss of voluntary movements, loss of flexibility of connective tissue and disuse atrophy generally lead to decreasing range of movement, contracture and deformity.

• 6. Communication disorders - The speech

centre is located in the cortex of the

dominant hemisphere (typically the left

hemisphere). If the lesion affects this

region, the patient may have speech and

language impairments.

• 7. Loss of coordinated movement -

Damage to a lower part of the brain, the

cerebellum, can affect the body's ability to

coordinate movement, a disability called

ataxia, leading to problems with body

posture, walking, and balance.

Outcome of stroke

• About 20% of stroke patients die within a month,

the prognosis being much better for cerebral

infarction than for intracerebral haemorrhage

(about 10% vs 50% dead). Death is usually due

to the brain lesion itself or indirect

consequences of the brain lesion (pneumonia

and pulmonary embolism) or concurrent cardiac

diseases. After the first month, death can occur

in 10% of the patients

from a further stroke or ischaemic diseases. 30% the patients may make a full recovery while 40% will have a residual neurological deficit. Among the survivors, predictors of final recovery are the initial mild deficit, no cognitive impairment and the patient’s age. Poor prognosis is associated with incontinence and poor premorbid status of the patient.

Pattern of recovery after stroke

• In ischaemic infarct lesions, the full extent

of the initial injury is apparent. The

extensive impairment initially seen in

haemorrhagic stroke is due to localized

inflammation; and the initial recovery in

this type of stroke can be attributed to the

resolution of this inflammation.

• Majority of the patients who do not regain

consciousness within 24 hours after the

CVA may not regain consciousness. For

those who regain consciousness, greatest

recovery may occur in the first 3 months.

Thereafter, potential for improvement may

exist for many months or years.

Management of stroke

• The comprehensive management of

stroke survivors is multidisciplinary in

nature, involving a team of rehabilitation

specialists with a collaborative and

integrated plan of care. It is achieved by

joint efforts of physicians,

physiotherapists, occupational therapists,

speech therapists, nurses, social workers,

psychologists, the patient and the family.

(a) Medical management

This depends on the type of stroke and it is

based on making a correct diagnosis and

knowing the underlying cause of the

lesion. It involves maintenance of vital

functions, treatment of systemic

complications and neurological

deterioration, management of

complications (e.g. pneumonia)

and treatment of comorbid disorders e.g.

cardiac failure and angina.

Also, good nursing care is needed to

ensure that the patient is monitored

regularly, well-positioned, turned regularly,

fed and toileted; and to keep the airway

clear.

(b) Physiotherapy management

• This can be considered to take place in 4 distinct stages:

i. Acute stage

This is the immediate period following the CVA. The aims of treatment are

(a) to improve respiratory function - This is achieved by –

Regular and frequent turning, breathing exercises / percussion and

vibration to the chest and postural

drainage.

• (b) to maintain musculoskeletal

integrity - Passive ROM exercises,

positioning and early systematic

mobilisation. The specific activities

are:

• - all joints should be taken through full-range passive exercises. Particular attention should be paid to the shoulder.

• - The limbs should be placed in correct recovery patterns. Pillow support should be used to put the upper limb in shoulder extension, external rotation and abduction with supination of the forearm and extension of the wrist. The lower

• limb should be in internal rotation of hips, slight flexion of the knee and ankle dorsiflexion.

• - turning over and moving up and down while in bed.

• - weight bearing on affected side e.g. sitting on edge of bed with foot on a stool or floor and arms extended by the side or behind.

ii. Intermediate stage

• This stage commences once the patient is

medically stable and conscious. It may

start within 48 hours after CVA. The aims

are to prevent further deterioration of the

condition and to prepare the patient and

relatives for the tasks ahead. An

assessment is made to obtain an initial

database comprising personal

• details, functional and motor abilities as well as psychological and social details. Early intervention is essential and it has been shown to promote early discharge and ability to walk independently.

• Specific activities include:

• - Reeducation of movement patterns by passive and active mobilization

• of joints.

• - reduction of spasticity with massage and

passive ROM exercises.

• - reeducation of movement

• - functional reeducation e.g. activities of

daily living (ADL).

iii. Discharge and transfer stage

• This is the period immediately prior, to and

following, discharge from formal

rehabilitation. An assessment of residual

disability is made and most of the activities

of the previous stage are continued and

intensified. Necessary modifications

should be made to the patient’s

environment.

iv. Long-term stage

• This is the period following the cessation

of formal regular rehabilitation. Activities

for this stage include regular assessment

of the patient, task-specific treatments and

modification of treatment strategies.

Psychological Stages of the Stroke Survivors

(Kerr’s, 1963)

• CRISIS Sudden onset of incapacitation-Shock

• Therapy Hopeful of full recovery- “I will be well soon”

• Realization* That some deficit may be permanent- “All is lost, No Hope”

• Adjustment** “I will live with this obstacle; part of me (Defence) now- not necessarily a bad thing”

*In 50% of cases, depression sets in with suicidal tendency, inadequacy, dependence and hostilty

**Acceptance varies with cultural background

Common neurological deficits after stroke

Left-Sided Stroke (CVA)

• Right sided paralysis

• Speech Language Deficit

• Slow cautious behaviour

• Hemianopia of the right visual field (homonymous)

• Memory loss in language

• Right sided dysarthria

• Aphasia

• Apraxia

Right-Sided Stroke (CVA)

• Left sided paralysis

• Spatial/perceptual deficits/neglect

• Quick impulsive behaviour

• Hemianopia of the left visual field (homonymous)

• Memory loss in performance

• Left sided dysarthria

Complete the statements

• The principal causes of neurological

dysfunctions are ……

• The possible stages of motor recovery in

stroke survivors are……

• Stages of physiotherapeutic management

include……..

• The psychological stages of stroke

survivors may include……

Write letters that correspond to the right answers in

completing the following

The primary cells of the nervous system are the ?? while

the ?? are the supportive cells. The bulk of the human

brain is formed by the ??. A motor unit consists a ??, ??,

with ?? and ??, while a muscle unit consists of the ??

and the?? innervated. Lesion of the optic tract following

a CVA on a cerebral hemisphere can result in??.

Whereas lesion of the optic nerve may result in ??.

A=Bitemporal Hemianopia; B=Homonymous hemianopia; C=Nerve cell;

D=Nerve fiber; E=Cerebellar Hemispheres; F= Fasciculi supplied;

G=axon; H=muscle fibres innervated; I=Neuroglia; J=Cells;

K=Neurons; L=Cerebrum; M=the branches.