A stroke, previously known medically as a cerebrovascular accident (CVA), is the rapidly developing loss of brain function(s) due to disturbance in the blood supply to the brain. This can be due to ischemia (lack of blood flow) caused by blockage (thrombosis, arterial embolism), or a hemorrhage (leakage of blood).As a result, the affected area of the brain is unable to function, leading to inability to move one or more limbs on one side of the body, inability to understand or formulate speech, or an inability to see one side of the visual field.
A stroke is a medical emergency and can cause permanent neurological damage, complications, and even death. .
A stroke is occasionally treated in a hospital with thrombolysis (also known as a "clot buster"). Post-stroke prevention may involve the administration of antiplatelet drugs such as aspirin and dipyridamole control and reduction of hypertension, the use of statins, and in selected patients with carotid endarterectomy, the use of anticoagulants. Treatment to recover any lost function is stroke rehabilitation, involving health professions such as speech and language therapy, physical therapy and occupational therapy.
Definition
The traditional definition of stroke, devised by the World Health Organization in the 1970s, is a "neurological deficit of cerebrovascular cause that persists beyond 24 hours or is interrupted by death within 24 hours".
Epidemiology
Stroke could soon be the most common cause of death worldwide.It affects approximately 700,000 individuals each year; about 500,000 are new strokes and 200,000 are recurrent strokes.The incidence of stroke increases exponentially from 30 years of age, and etiology varies by age. 95% of strokes occur in people age 45 and older, and two-thirds of strokes occur in those over the age of 65 years. A person's risk of dying if he or she does have a stroke also increases with age. However, stroke can occur at any age, including in fetuses.
Family members may have a genetic tendency for stroke or share a lifestyle that contributes to stroke. Higher levels of Von Willebrand factor are more common amongst people who have had ischemic stroke for the first time, the only significant genetic factor was the person's blood type.
Men are 25% more likely to suffer strokes than women, yet 60% of deaths from stroke occur in women.Some risk factors for stroke apply only to women. Primary among these are pregnancy, childbirth, menopause and the treatment thereof (HRT).
The prevalence of stroke, WHO estimated that in 1990, out of 9.4 million deaths an India 6,19,000 were due to stroke.
Etiology
Narrowing or complete closure of the vessels supplying the brain by thrombosis or embolism.
Arteritis
Collagen vascular diseases-SLE, Polyarteritis Nodosa
Haemorrhage
Vertical compression
Arterial spasm
Thrombotic stroke:
In thrombotic stroke a thrombus (blood clot) usually forms around atherosclerotic plaques. A thrombus itself (even if non-occluding) can lead to an embolic stroke, if the thrombus breaks off, at which point it is called an "embolus."
Embolic stroke
An embolic stroke refers to the blockage of an artery by an arterial embolus, a travelling particle or debris in the arterial bloodstream originating from elsewhere. An embolus is most frequently a thrombus, but it can also be a number of other substances including fat (e.g. from bone marrow in a broken bone), air, cancer cells or clumps of bacteria (usually from infectious endocarditis).
Venous thrombosis
Cerebral venous sinus thrombosis leads to stroke due to locally increased venous pressure, which exceeds the pressure generated by the arteries. Infarcts are more likely to undergo hemorrhagic transformation (leaking of blood into the damaged area) than other types of ischemic stroke.
Intracerebral hemorrhage
It generally occurs in small arteries or arterioles and is commonly due to hypertension, intracranial vascular malformations (including cavernous angiomas or arteriovenous malformations), cerebral amyloid angiopathy,or infarcts into which secondary haemorrhage has Occurred .Other potential causes are trauma, bleeding disorders, amyloid angiopathy, illicit drug use (e.g. amphetamines or cocaine).
Types of Stroke
Strokes can be classified into two major categories: ischemic and hemorrhagic.
Ischemic strokes are those that are caused by interruption of the blood supply.
Hemorrhagic strokes are the ones which result from rupture of a blood vessel or an abnormal vascular structure. About 87% of strokes are caused by ischemia, and the remainder by hemorrhage. Some hemorrhages develop inside areas of ischemia ("hemorrhagic transformation"
Ischemic Stroke
In an ischemic stroke, blood supply to part of the brain is decreased, leading to dysfunction of the brain tissue in that area. There are four reasons why this might happen:
Thrombosis (obstruction of a blood vessel by a blood clot forming locally).
Embolism (obstruction due to an embolus from elsewhere in the body).
Systemic hypoperfusion (general decrease in blood supply, e.g. in shock).
Venous thrombosis.
Stroke without an obvious explanation is termed "cryptogenic" (of unknown origin); this constitutes 30-40% of all ischemic strokes.
Haemorrhagic Stroke
Intracranial hemorrhage is the accumulation of blood anywhere within the skull vault. A distinction is made between intra-axial hemorrhage (blood inside the brain) and extra-axial hemorrhage (blood inside the skull but outside the brain).
Intra-axial hemorrhage is due to intraparenchymal hemorrhage or intraventricular hemorrhage (blood in the ventricular system).
The main types of extra-axial hemorrhage are epidural hematoma (bleeding between the dura mater and the skull), subdural hematoma (in the subdural space) and subarachnoid hemorrhage (between the arachnoid mater and pia mater). Most of the hemorrhagic stroke syndromes have specific symptoms (e.g. headache, previous head injury).
Signs and symptoms
Common Signs of a Stroke:
Numbness or weakness of the face, arm, or leg, especially on one side of your body.
Trouble seeing in one or both eyes.
Difficulty walking, dizziness, loss of balance or coordination.
Confusion or trouble speaking or understanding speech .
Severe headache with no known cause.
Symptoms may include:
Stroke symptoms typically start suddenly, over seconds to minutes, and in most cases do not progress further. The symptoms depend on the area of the brain affected. The more extensive the area of brain affected, the more functions that are likely to be lost. Most forms of stroke are not associated with headache, apart from subarachnoid hemorrhage and cerebral venous thrombosis and occasionally intracerebral hemorrhage.
Simple Test for the Presence of Stroke: If the patient is conscious, have him/her stick their tongue out and request them to move it from left to right. If they can not perform this simple task chances are they are having a stroke.
Hand Grasps: Have the patient grab your hands and squeeze. Marked difference in the strength between left and right denotes possible stroke. The weaker side is the side the stroke is occurring on.
Mouth Droop: If you notice a decidedly downward droop on either side of the mouth also can be a sign of a cerebrovascular accident is happening.
A simple weakness may progress to an inability to move the arm and leg on one side of the body.
Stroke Warning Signs:
According to; The American Stroke Association the warning signs of stroke are:
Sudden numbness or weakness of the face, arm or leg, especially on one side of the body.
Sudden confusion, trouble speaking or understanding.
Sudden trouble seeing in one or both eyes.
Sudden trouble walking, dizziness, loss of balance or co-ordination.
Sudden, severe headache with no known cause.
Pathophysiology:
Interruption of Blood Flow for few minutes
↓
Complete cerebral circulatory arrest ( Ischaemia )
↓
Ischaemic cascade - a number of damaging but reversible events
↓
Disturbance of Energy Metabolism due to release of excess Neurotransmitters (glutamate, aspartate )
↓
Inability of brain cells to produce energy
↓
Increased calcium influx
Ca+ Intracellular phospholipid Stimulates release of nitric oxide & cryptokines
forms
Free radicals
Damages the brain cells further
Risk factors
Modifiable risk factors
High blood pressure and atrial fibrillation.
High blood cholesterol levels
Diabetes
Cigarette smoking (active and passive)
Heavy alcohol consumption and drug use
Lack of physical activity
Obesity
Unhealthy diet.
Oral contraceptives
Transient Ischemic Attacks
Non-Modifiable risk factors
Age
Race
Gender
Family History of Stroke
Impairments and functional disability due to stroke
Disability affects 75% of stroke survivors enough to decrease their employability. Stroke can affect patients physically, mentally, emotionally, or a combination of the three dysfunctions correspond to areas in the brain that have been damaged.
Physical disabilities that can result from stroke include:
Muscle weakness,
Numbness,
Pressure sores,
Pneumonia,
Incontinence,
Apraxia (inability to perform learned movements),
difficulties carrying out daily activities,
Appetite loss,
Speech loss, vision loss,
Pain.
If the stroke is severe enough, or in a certain location such as parts of the brainstem, coma or death can result.
Emotional problems resulting from stroke can result from direct damage to emotional centers in the brain or from frustration and difficulty adapting to new limitations. Post-stroke emotional difficulties include anxiety, panic attacks, flat affect (failure to express emotions), mania, apathy, and psychosis.
Cognitive deficits resulting from stroke include perceptual disorders, speech problems, dementia, and problems with attention and memory. A stroke sufferer may be unaware of his or her own disabilities, a condition called anosognosia. In a condition called hemispatial neglect, a patient is unable to attend to anything on the side of space opposite to the damaged hemisphere.
Complications:
Inability to participate in activities of daily living
Pain
Recurrent strokes.
Emotional difficulties
Effect of stroke on arm and hand function
Stroke is the number one cause of neurological disability in many countries. About 85% of patients admitted to hospital for stroke present with problems with their arms and hands. Stroke-related physical impairments such as muscle weakness, pain, and spasticity can lead to a reduction in the ability to use the stroke-affected arm and hand in daily activities. In fact, the avoidance of using one's stroke-affected arm is so common, that there is even a name for it "learned non-use syndrome". Unfortunately, not using the stroke-affected arm can lead to a further loss in strength, range of motion, and fine motor skills. These can then result in contractures, pain and severe bone loss (osteoporosis).
Management
Medical management:
Minimising residual defects
Hypovolaemic haemodilution
Anticoagulants
Antiplatelet therapy
Antihypertensive drugs
Physiotherapy Management:
Passive mobilization
Passive neuromuscular facilitation
Constraint induced movement therapy
Balance training
Bobath therapy
Introduction & definition:
According to World Health Organisation[WHO];
Stroke defined as "rapidly developed clinical signs of focal[or global] disturbance of cerebral function ; lasting more than 24 hours or leading to death,with no apparent cause other than vascular origin."
Epidemiology:
Susan B.O'Sullivan,PT,EdD ; Thomas J . Schmitz, PT, PhD -Physical Rehabilitation -5th edition [page no 706]
Stroke is the leading cause of death world-wide.The incidence of stroke increases dramatically with age. It is about 1.25 times greater for males than females. About 14 % of persons who survive an initial stroke or TIA will experience another one within 1 year.
Pathophysiology:
According to American Heart Association,Diagnosis and Management
of Stroke ,1979, p 4.
Atherosclerosis is a major contributory factor in CVA. Most common site for lesion to occur are at the origin of the common carotid artery. Ischemic strokes are the results of a thrombus, embolism or condition that produce low systemic perfusion pressures the resulting lack of cerebral blood flow(CBF).
Risk Factors:
4. Whisnant JP (1996). "Effectiveness versus efficacy of treatment of hypertension for stroke prevention." Neurology 46 (2): 301-7.
5.Collins R, Peto R, MacMahon S, et al. (1990). "Blood pressure, stroke, and coronary heart disease." Part 2, Short-term reductions in blood pressure.
Hypertension accounts for 35-50% of stroke risk.Epidemiological studies suggest that even a small blood pressure reduction (5 to 6 mmHg systolic, 2 to 3 mmHg diastolic) would result in 40% fewer strokes.Lowering blood pressure has been conclusively shown to prevent both ischemic and hemorrhagic strokes. It is equally important in secondary prevention.
Complications:
6."Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). UK Prospective Diabetes Study (UKPDS) Group". Lancet 352
7.Dormandy JA, Charbonnel B, Eckland DJ, et al. (2005). "Secondary prevention of macrovascular events in patients with type 2 diabetes in the PROactive Study
Patients with diabetes mellitus are 2 to 3 times more likely to develop stroke, and they commonly have hypertension and hyperlipidemia. Intensive disease control has been shown to reduce microvascular complications such as nephropathy and retinopathy but not
macrovascular complications such as stroke
Warning Signs:
8.According to American Stroke Association: stroke warning signs..American Heart Association, Dallas Texas, 2000.
Sudden numbness or weakness of the face, arm or leg, especially on one side of the body
Sudden confusion, trouble speaking or understanding
Sudden trouble seeing in one or both eyes
Sudden trouble walking, dizziness, loss of balance or coordination
Sudden, severe headache with no known cause.
Effect of stroke on arm &hand:
9. Janice Eng, PhD, PT/OT and Jocelyn Harris, PhD, OT with valuable assistance from Andrew Dawson, MD, FRCP and Bill Miller, PhD, OT and with funding from the Heart and Stroke Foundation of BC and Yukon.
Stroke is the number one cause of neurological disability.About 85% of patients admitted to hospital for stroke present with problems with their arms and hands. Stroke-related physical impairments such as muscle weakness, pain, and spasticity can lead to a reduction in the ability to use the stroke-affected arm and hand in daily activities.
10.Pang MY, Harris JE, Eng JJ. A community-based upper-extremity group exercise program improves motor function and performance of functional activities in chronic stroke: a randomized controlled trial. Archives of Physical Medicine and Rehabilitation. 2006 Jan;87(1):1-9
The pilot study showed that a community-based exercise program can improve upper-extremity function in persons with chronic stroke. This outcome justifies a larger clinical trial to further assess efficacy and cost effectiveness.
Evidence for GRASP
11. Susan B.O'Sullivan,PT,EdD ; Thomas J . Schmitz, PT, PhD -Physical Rehabilitation -5th edition [page no 752]
Meaningful task-oriented repetitive practice involving grasp and manipulation is important for stimulating recovery.The patient should encouraged to use the weaker hand to assist in ADL.
12.According to Butefisch,C,et al: J Neurol Sci 103:59,1995.
Repetitive training of isolated movements improves the outcome of motor rehabilitation of the centrally paretic hand.
13.Sunderland, A et al: J Neurol Neurosurg Psychiatry 55:30, 1992
Enchanced physical therapy improves recovery of arm function after stroke.
14.Barreca S, Stratford P, Lambert C, Masters L & Streiner D. (2005). Test-retest reliability, validity, and sensitivity of the Chedoke Arm and Hand Activity Inventory: A new measure of upper-limb function for survivors of stroke. Arch Phys Med Rehabil; 86: 1616-1622
15.The Canadian Journal of OccupationalTherapy,Authour:Gustafsson,LousieA,June 1,2010
The Chedoke Arm and Hand Activity Inventory (CAHAI) is an assessment that measures upper limb ability on bilateral functional tasks and has been promoted for use in stroke rehabilitation settings as an outcome measure and intervention planning tool.
15. Australian Journal of Physiotherapy 2008 Vol. 54 - © Australian Physiotherapy Association 2008
The Action Research Arm Test (ARA or ARAT) is an
observational test used to determine upper limb function. Inter-rater and retest reliability
have been shown to be high (ICC > 0.98) in studies
involving patients with stroke (Van der Lee et al 2001).
16.See Lyle (1981); Van der Lee JH, De Groot V, Beckerman H, Wagenaar RC, Lankhorst GJ, Bouter LM. The intra- and interrater reliability of the
action research arm test: a practical test of upper extremity function in patients with stroke. Arch Phys Med Rehabil 2001;82(1):14-9.
The Action Research Arm Test (ARAT) is an evaluative measure to assess specific changes in limb function among individuals who sustained cortical damage resulting in hemiplegia (Lyle, 1981). It assesses a client's ability to handle objects differing in size, weight and shape and therefore can be considered to be an arm-specific measure of activity limitation (Platz, Pinkowski, Kim, di Bella, & Johnson
Graded Repetitive Arm Supplementary Program
GRASP is a novel method which is practical and inexpensive to deliver greater amounts of therapy with a focus on functional tasks of the upper extremities. Greater amounts of upper extremity therapy during inpatient rehabilitation can improve the ability to use one's arms and hands.
GRASP is a self-directed arm and hand exercise program which is supervised by a therapist, but done independent by the patient (and with their family if possible). This program has been designed to improve arm and hand function in people living with a stroke and serves as a complement to the regular therapy that one receives in the hospital. It was not meant to replace existing therapy services, but to add critical upper extremity practice time for the patient
Benefits of GRASP
It increases the potential for functional recovery,
Facilitates the eventual transition to self-managed exercise programs post-discharge,
Prevents the "learned non-use" syndrome commonly found after stroke,
Engages the client in the therapy process,
Places an expectation of active participation on the patient, promotes independent activity, and facilitates family involvement
Components of GRASP Harris et al. (2009) have components of strengthening, range of motion, weight-bearing, and trunk control. In addition, gross and fine motor skills are practiced. Both unilateral movements of the stroke-affected arm/hand are practiced, as well as bilateral functional movements.
Range of motion and stretching
There is increasing evidence that contractures commonly develop post-stroke and interfere with upper extremity function. It is important to maintain extensibility of the muscles to promote subsequent strengthening through full range of motion.
Functional strengthening
Previously, clinicians discouraged muscle strengthening post-stroke, however, intensive muscle strengthening has not been found to increase spasticity. Furthermore, strengthening has been found to be effective in improving upper extremity function in sub-acute stroke. We have also found that upper extremity muscle strength is the major predictor of bone density and the ability to perform activities of daily living which involve the upper extremities..
Weight-bearing through hand
With a reduction in arm use, there is reduced loading to muscle, bone and sensory receptors. Controlled weight-bearing through the hand is one method to increase muscle activation without weights (e.g., while sitting, lean forward on hands on table and perform a partial push-up). In addition, weight-bearing will help to reduce the known bone loss which occurs early post-stroke. Bone loss is a major predictor of upper extremity fractures resulting from a fall.
Trunk control
Better trunk control is known to facilitate arm reaching. Thus, exercises to challenge trunk movements are important for upper extremity function.
Repetitive paretic arm practice
Forced-use of the upper extremity has produced strong evidence of functional improvements primarily in chronic stroke, although more recent studies have utilized sub-acute stroke. Varying accuracy and speed requirements are integrated within the fine motor and gross motor tasks.
Repetitive bilateral arm tasks
The majority of daily tasks are bilateral. Repetitive bilateral arm training has been shown to improve arm and fine motor function. Bilateral tasks are realistic of the many activities of daily living which require bilateral arm and hand coordination
GRASP PROGRAM :
There are three levels of books (1,2,3) which are prescribed based on the fugl-meyer score of the patient.
Discussion
"Learned non-use syndrome" is a common motor compensation used by stroke patients which leads to a reduction in the ability to use the stroke- affected arm and hand in daily activities .As increased compensation of using the stroke-affected arm can lead to a further loss in strength, range of motion, and fine motor skills. These can then result in contractures, pain and severe bone loss (osteoporosis).As these all limit recovery .It is essential to describe training paradigms that both improve motor function while reducing compensation.
The data collected through the study showed improvement on recovery in patients with stroke in approach through a self-administered GRASP program. All the patients treated through these techniques were able to do their activities of daily living(ADL)of arm and hand function .this result obeys the abstracts of Harris JE, Eng JJ, Miller WC, Dawson AS(2009).
The mean improvement in arm and hand recovery performance as assessed by avoidance of using one's stroke-affected arm is so common, that there is even a name for it "learned non-use syndrome". Unfortunately, not using the stroke-affected arm can lead to a further loss in strength, range of motion, and fine motor skills. These can then result in contractures, pain and severe bone loss (osteoporosis). Chedoke Arm and Hand Activity Inventory is .The patient treated with this technique had significant gain in arm and hand function.
The data showed high degree of consistency at a standard deviation of in Chedoke Arm and Hand Activity Inventory score. Hence it is stated that graded repetitive arm supplementary program gives a better prognosis in patients with stroke.
