As many of you asked, you wanted to learn more about stroke rehab and what that looks like. So, let's start by getting a full understanding of what a stroke exactly is. The term "stroke" is interchangeable with the medical term, cerebrovascular accident, commonly abbreviated as a "CVA". A stroke is a neurological condition that can have lasting impairments. A CVA occurs when there is a reduced amount of blood supply to the brain which deprives the brain of oxygen and nutrients for a small or long duration of time. This can occur from a blockage or a rupture/bleeding in the brain. When the brain is deprived of oxygen, the brain is not adequately supplied with blood and is not being fed the nutrients it needs in order to function properly. A stroke tends to occur abruptly and will require immediate medical attention. The sooner medical attention is received, the higher the possibility of reversing symptoms and decreasing the severity of symptoms. The amount of oxygen deprivation dictates how severe the symptoms of a CVA is and depending on where the blockage/hemorrhage occurs, which dictate what symptoms occur based on the location of the brain functions. Time is of the essence when it comes to seeking initial medical attention for individuals who have just experienced a stroke. Here are several different types of strokes.
Types of CVAs
1. Ischemic stroke: An ischemic stroke occurs when there is a blockage in an artery supplying blood to the brain. This can be a blood clot or stenosis of the arteries. This is the most common type of stroke.
2. Hemorrhagic stroke: A hemorrhagic stroke occurs when an artery ruptures or leaks blood into the brain. This causes intracranial pressure and damages brain cells. High blood pressure and aneurysms are a common cause of hemorrhagic strokes. There are two types of hemorrhagic strokes.
a. Intracerebral hemorrhage: This is the most common type of hemorrhagic stroke. This occurs when an artery bursts in the brain and floods the surrounding tissue with blood.
b. Subarachnoid hemorrhage: This occurs when there is bleeding in between the space of the tissue and the subarachnoid layer. This type of stroke occurs less often.
3. Transient Ischemic Attack (TIA): Referenced as a mini-stroke. TIA is caused by a blockage, but a temporary blockage. The blockage usually lasts for less than 5 minutes. During a TIA, the blood supply to the brain is temporarily blocked. TIAs can be a warning sign for future strokes if medical attention is not sought out. Symptoms are generally less severe, and temporary.
Treatment Options for Prompt Medical Attention (within 24 hours of Symptom Onset)
tPA: Tissue Plasminogen Activator (tPA) is a clot bursting medication given to dismantle the clots of ischemic strokes. This MUST be given to the individual within 4.5 hours of the start of symptoms in order to be effective.
Endovascular Treatment: This is a surgical option to remove the clot. This must be done within 24 hours of first experiencing symptoms.
Signs of a Stroke
B E F A S T
This is a good acronym to remember the key signs of a stroke.
Balance- Is the individual having sudden difficulties balancing and walking?
Eyes- Is the individual experiencing impaired vision?
Face- Is there any single side facial dropping?
Arms- Is the individual having difficulty lifting one arm in full flexion?
Speech- Is the individual slurring their speech or having difficulty talking?
Time- It's time to call 9-1-1. The sooner the symptoms are recognized, the better the chances to decrease the severity of the symptoms.
Sometimes, individuals will also experience dizziness and a sudden severe headache.
Effects of Stroke:
Depending on where the lesion occurs in the brain, dictates what is affected. A stroke can occur on the left hemisphere, right hemisphere, cerebellum, or brain stem. These symptoms will depend on the individual and the severity of the CVA.
Right hemisphere effects:
Left-sided weakness/paralysis/sensory impairments
Left side neglect
Denial of impairments
Visual disturbances (left visual field of each eye)
Poor body awareness
Left hemisphere effects:
Right-sided weakness/paralysis/sensory impairments
Aphasia (speech impairments/challenging understanding)
Visual disturbances ( right visual field of each eye)
Difficulty with logic
Impaired ability to read, write and learn new information
Ataxia (inability to walk, challenges with coordination and balance)
Impairments with vital functions
Body temperature control
Balance and coordination
Chewing, swallowing and speaking
CVA Related Assessments
Here are some common assessments that will be done when an individual experiences a CVA. These assessments do depend on the setting. Some assessments might look different from acute care vs inpatient rehab vs outpatient facility.
ROM- You will always test ROM. The individual may not be able to perform AROM, and that's okay. They may be very weak and not have the brain to muscle connection to fire the muscle on command to lift their affected limb. Encourage them to try to lift or bend as you assist them to see if you can feel the muscle firing as going through the range of motion for AAROM. But always test for PROM. Get a feel for what the end feels are and get an idea of what their functional range is. Is the end feel hard- does it feel stuck? Be gentle with PROM and ensure to ask them how it feels as you get closer to the end of the range.
-PROM, AAROM, AROM
-Vibratory tools are great for assisting with AAROM. Place the vibratory stimulation tool on the muscle belly to fire the muscle you are trying to contract. This may fatigue the muscle, but it is intended to help stimulate that contraction and help rewire that connection from the brain to limb.
-Shoulder arc (most rehab facilities will have this)
MMT- It is important to get an understanding of what the strength is in the non-affected side to see what the functional abilities are of the individual in terms of strength. Depending on the severity of the affected side, you may not test the affected side if it is flaccid. That being said, the affected could be flaccid or it could present with a lot of tone.
Cognition- A mini-mental exam is always conducted with patients who have had a stroke. Ask their name, date of birth, where they are and a simple question like what month is it?
Vision (checking for unilateral neglect -H test)- This is a test that can often get overlooked. There may be unilateral neglect present. And if so, sometimes the patient won't acknowledge a whole side of their body. So when you perform vision tests, ensure that you cross the midline and follow their eyes as it crosses over to both sides. For instance, if they only complete half of the H test and only see the part of the H on the R side, that is a concern for L sided neglect.
Sensation- We always test sensation. This is important to see if they can feel dull/sharp pain and get an understanding if there are impairments for temperature for ADLs such as bathing, washing face/hands, etc.
Barthel Index- More advanced assessment, but may be used in later stages of therapy to assess ADL abilities and limitations.
Fatigue scale- More advanced assessment, but good to get an idea of what their endurance looks like for ADLs/IADLs.
Balance- Assessing balance will be seen in rehab settings. This will be critical in assessing their safety for bed mobility, transfers, and gait training.