Concorde Career College Physical Therapist Assistant

1. Concorde Career CollegePhysical Therapist Assistant PTA 150: Fundamentals of Treatment IIDay 9 & 10 CVA Concorde Career College

2. Objectives • Describe the pathophysiology of a CVA • Describe physical and neurological impairments associated with CVA • Describe physical therapy treatment interventions for patients after a CVA Concorde Career College

3. Cerebrovascular Accident (CVA)Sudden loss of neurological function caused by an interruption of the blood flow to the brain O’Sullivan, pg. 705 Concorde Career College

4. CVA Epidemiology • The 3rd leading cause of death in the US • THE most common cause for disability in US adults • Incidence of stroke 1.25 times greater for males than females • Compared to whites, African-Americans have 2x the risk of first-ever stroke (higher also with Mexican-Americans, American Indians, and Alaska Natives) Concorde Career College

5. Definitions • CVA is used interchangeably with the term “stroke” • Neurological deficits must remain for > 24 hours to be classified as a stroke • Transient Ischemic Attack (TIA) • Temporary interruption of blood flow to brain • Symptoms resolve quickly (within 24 hours) • Few if any permanent signs or symptoms • Precursor to stroke • About 14% of persons surviving an initial stroke or TIA will experience another one within a year Concorde Career College

6. Types of Strokes • Hemorrhagic Stroke • Blood vessels rupture, blood leaks into the brain • 1˚ Cerebral Hemorrhage results from ruptured blood vessels weakened by atherosclerosis • Results in ↑ ICP and restricts blood flow to the brain • Subarachnoid Hemorrhage (SAH) – bleeding b/w arachnoid layer and pia mater • Common cause: aneurysm & AVM • Subdural Hemorrhage (SDH) – bleeding b/w dura mater and arachnoid layer • Common cause is trauma Concorde Career College

7. Types of Strokes • Ischemic Stroke • Most common (~80%) • A clot blocks or impairs blood flow to the brain • Can result from a Thrombosis • Results from platelet adhesions & aggregation on plaques • Cerebral Thrombosis: Blood clot forms in cerebral artery • Thrombi lead to ischemia = cerebral infarction • Can result from an Embolus • Dislodged matter; blood clot, plaque, fat, gas, air, tissue that dislodges in the body and travels to the brain occluding cerebral circulation Concorde Career College

8. Impact • Severity and symptoms of stroke depend on • Location of ischemic process • Size of the ischemic area • Nature & function of structures involved • Availability of collateral flow • O’Sullivan , page 708 Concorde Career College

9. Anterior Cerebral Artery SyndromeMiddle Cerebral Artery SyndromePosterior Cerebral Artery SyndromeVertebrobasilar Artery SyndromeInternal Carotid Artery SyndromeLacunar Syndrome Vascular Syndromes Concorde Career College

10. Concorde Career College

11. Anterior Cerebral Artery (ACA) • Supplies medial part of the frontal and parietal lobe, basal ganglia and corpus callosum Concorde Career College

12. ACA Syndrome • Contralateral sensory & motor loss with LEs affected more than UEs • Urinary incontinence • Mental impairment (confusion, amnesia) • Apraxia affecting ability to imitate or perform bimanual tasks • Abulia (lack of desire to carry out an action), slowness, delayed movements, lack of spontaneous movements • Behavioral changes Concorde Career College

13. Medial Cerebral Artery (MCA) • Supplies lateral cerebral hemispheres (incl. frontal, parietal and temporal lobes) Concorde Career College

14. MCA Syndrome • Contralateral hemiparesis of face and UE mainly • Pure motor hemiplegia (lacunar stroke) • Contralateral hemisensory loss of face & UE mainly • Speech impairment: Broca’s aphasia, Wernicke’s aphasia, global aphasis • Perceptual deficits: unilateral neglect, depth perception difficulties, agnosia • Apraxia • Ataxia of contralateral limbs (sensory ataxia) • Contralateral hemianopsia • Table 18.2 (O’Sullivan) Concorde Career College

15. Posterior Cerebral Artery (PCA) • Supplies occipital lobe, medial and inferior temporal lobe, thalamus & brain Concorde Career College

16. PCA Syndrome • Contralateral sensory & motor loss (hemianesthesia) • Hemianopsia • Visual agnosia, prosopagnosia and cortical blindness • Oculomotor nerve palsy • Involuntary movement • Choreoathetosis, intention tremor, hemiballismus • Thalamic pain • Pusher syndrome Concorde Career College

17. Hemiballismus - Video http://www.bing.com/videos/search?q=hemiballismus&view=detail&mid=290D280B1B53C5E9CDEB290D280B1B53C5E9CDEB&first=0&FORM=LKVR Concorde Career College

18. Vertebrobasilar Artery • Vertebral artery arises from the subclavian artery, travels into the brain and then merge to form the basilar artery • Vertebral artery supplies the cerebellum and medulla • Basilar artery supplies the pons, internal ear, and cerebellum Concorde Career College

19. Vertebrobasilar Artery Syndrome • Wide variety of symptoms with ipsilateral and contralateral signs • Numerous cerebellar and cranial nerve abnormalities • Refer to Table 18.4 in O’Sullivan for details Concorde Career College

20. Internal Carotid Artery (ACA) Syndrome • Supplies both the MCA and ACA • Complete occlusion leads to ↑↑ cerebral edema = coma & possible death • Incomplete occlusion = mix of ACA & MCA syndromes Concorde Career College

21. Lacunar Infarct • Caused by small vessel disease deep in cerebral white matter Concorde Career College

22. Lacunar Syndrome • Contralateral weakness • Sensory loss • Dystonia/Involuntary movement • Choreoathetosis, hemiballismus • Ataxia Concorde Career College

23. CVA – Major Risk Factors Primary Secondary Obesity Hypercholesteremia Physical Inactivity ↑ Alcohol consumption • Atherosclerosis • HTN • Heart disease • Diabetes • Smoking • TIA Concorde Career College

24. Stroke Warning Signs TIME IS BRAIN • 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 www.StrokeAssociation.org Concorde Career College

25. Imaging - CT • Frontal lobe stroke Concorde Career College

26. Imaging - MRI Concorde Career College

27. CVA Medical Management • Reestablish cerebral circulation and oxygenation • Control blood pressure • Maintain sufficient cardiac output • Restore/maintain fluid & electrolyte balance • Maintain blood glucose levels • Control ICP • Maintain bladder function (possible use of catheter) • Maintain integrity of skin and joints Concorde Career College

28. Pharmacological Management • Anticoagulants (heparin, coumadin); to reduce clots and maintain profusion) • Antiplatelets (aspirin); used to decrease the risk of recurrent stroke • Antihypertensives Concorde Career College

29. Surgical Intervention • Endarterectomy – surgical removal of lining and plaque in an artery • Used to prevent strokes (not treat them) • In the case of hemorrhage – surgery to repair rupture, prevent further bleeding evacuate the clot • Resection of unruptured AVM if found and risk is high Concorde Career College

30. Primary Impairments • Sensation Impairments • ↓ sensory perception & ability to process sensory information • Touch, temperature, position, kinesthetic, pain • ASTEROGNOSIS • The inability to identify an object by touch without visual input • Pain • Can experience severe headaches, neck or facial pain • Central post-stroke (thalamic) pain: constant, severe burning with intermittent sharp pains Concorde Career College

31. Primary Impairments • Visual Impairments • Eye movements (sluggish, reflexive, ataxic) • Hemianopsia: Blindness in half of each eye’s visual field (loss on the nasal side and half on temple side) • Visual neglect • Difficulties w/ depth perception & spatial relationships • Forced gaze deviation • Brainstem strokes may result in diplopia, oscillopsia or visual distortions Concorde Career College

32. Primary Impairments Motor Impairments – Stages of Motor Recovery • Stage 1 - Flaccidity • Stage 2 - Minimal voluntary movement; may see synergies and spasticity develop • Stage 3 – Voluntary control the movement synergies; spasticity may ↑ further • (Continued) Concorde Career College

33. Primary Impairments Motor Impairments – Stages of Motor Recovery • Stage 4 – movement combinations that do not follow the path of synergy are mastered; spasticity ↓ • Stage 5 – Difficult movement combinations are learned • Stage 6 – disappearance of spasticity, individual joint movements become possible and coordination approaches normal Concorde Career College

34. Primary Impairments • Motor Impairments • Weakness (paresis) • Occurs in 80-90% of all patients after stroke • Varies depending on location and size of stroke • Can result in complete paralysis/hemiparesis • Typically, more distal muscles exhibit greater weakness • May even see weakness on the “normal” side • Changes in muscle composition 2˚ weakness & disuse • Atrophy, ↓ Fast twitch type II, ↑ slow twitch type I • ↑ effort and fatigability Concorde Career College

35. Primary Impairments • Motor Impairments • Changes in tone • Flaccidity – present immediately as a result of cerebral shock; usually short-lived but sometimes persists • Spasticity/hypertonicity • Occurs in about 90% of patients after stroke • Posturing of limbs is common with mod → severe spasticity • Spasms (internal or external stimulation) Concorde Career College

36. Posturing Concorde Career College

37. Primary Impairments • Motor Impairments • Abnormal synergistic movement patterns • Associated with spasticity, may ↓ with recovery • Review Table 18.5 in O’Sullivan • Impaired reflex responses (mild to severe) • Vary according to stage of recovery • Hyporeflexia with flaccidity → hyperreflexia with spasticity • ↑ stretch reflex – clonus, clasp-knife, (+) Babinski • ATNR • Associated reactions Concorde Career College

38. Primary Impairments • Motor Impairments • Impaired coordination responses • Cerebellar strokes = ataxia & weakness • Basal Ganglia involvement = slow movements (bradykinesia) & involuntary movements (choreoathetosis, hemiballismus) Concorde Career College

39. Video - Cerebellar Ataxia • http://www.bing.com/videos/search?q=cerebellar+ataxia&view=detail&mid=F8130C8EBA0E3DD338C5F8130C8EBA0E3DD338C5&first=1&FORM=LKVR3 • http://www.bing.com/videos/search?q=cerebellar+ataxia&view=detail&mid=08E8A16F23E5E860EE9008E8A16F23E5E860EE90&first=21&FORM=LKVR18 Concorde Career College

40. Primary Impairments • Motor Impairments • Altered motor programming • Motor praxis • Ideational apraxia • Ideomotor apraxia • Diminished muscle performance for ADL • Strength, Power, Endurance Concorde Career College

41. Primary Impairments • Postural Control & Balance Impairments • May experience difficulty with balance 2˚ to an external force or during self-initiated exercises • Corrective responses to perturbations are often inadequate = fall • Asymmetry typically noted in posture • Typically see falls to the same side as weakness • Pusher Syndrome • Active pushing of the uninvolved side offsets muscle control of the involved side (falls, leaning) Concorde Career College

42. Primary Impairments • Speech and Language Impairments • Aphasia – an acquired communication disorder caused by brain damage and is characterized by an impairment of language comprehension, formulation and use. (O’Sullivan, pg. 722) Concorde Career College

43. Primary Impairments • Speech and Language Impairments • Receptive Aphasia • aka. Wernicke’s/Sensory/Fluent Aphasia • Auditory and reading comprehension impaired • Speech is functional • Expressive Aphasia • aka. Broca’s/Nonfluent Aphasia • Difficulty finding words to express ideas • Global Aphasia • Receptive and Expressive Concorde Career College

44. Primary Impairments • Speech and Language Impairments • Dysarthria • Nasal quality of speech, slurred words • Dysphonia • Difficulty producing sounds • Dysphagia • Difficulty in swallowing Concorde Career College

45. Primary Impairments • Altered Perception • Body scheme – relationship of body parts to one another as well as the body’s relationship to the environment • Body image – visual and mental image of one’s body may be altered following a stroke • Includes the individual’s feelings about this image Concorde Career College

46. Primary Impairments • Examples of body scheme/image impairments: • Unilateral Neglect • Visual recognition or attention on involved side • Limb neglect or attention on involved side • Anosognosia – denial, neglect or unawareness of one’s paralysis • Somatoagnosia – lack of awareness of one’s body structure and its relationship to the environment • Right-left discrimination • Finger agnosia Concorde Career College

47. Primary Impairments • Altered Perception • Agnosia - inability to recognize incoming information despite intact sensory capabilities (O’Sullivan, pg 723) • Visual object agnosia • Auditory agnosia • Tactile agnosia (astereoagnosia) • Spatial relationship – difficulty determining the relationship between the body and 2 or more objects in the environment Concorde Career College

48. Primary Impairments • Cognitive Impairments • ↓ alertness • ↓ attention • Altered orientation • Diminished memory • Impaired executive function Concorde Career College

49. Primary Impairments • Cognitive Impairments – Vocabulary • Confabulation • Perseveration • Multi-infarct dementia • Delirium Concorde Career College

50. Primary Impairments • Alterations in Affect • Pseudobulbar Affect • A.k.a. emotional dysregulation syndrome or emotional lability • Emotional outbursts (crying, laughing) • Apathy • Euphoria • ↑ irritability or frustration • Social inappropriateness • Depression Concorde Career College