STROKE
CONTENTS
1. INTRODUCTION
2. ANATOMY
3. AETIOLOGY
4. PATHO PHYSIOLOGY
5. PATHOLOGHY
6. CLINICAL MANIFESTATION
7. DIAGNOSTIC PROCEDURES
8. MEDICAL MANAGEMENT
9. ASSESMENT
10. TYPE OF APROXIA
11. PHYSIO THERAPY MANAGEMENT
i. THERETICAL FRAME WORK
ii. TREATMENT
13. COMPLICATIONS
14. CASE STUDIES
15. CONCLUSTION
16. BIBLIOGRAPHY
INTRODUCTION
INTRODUCTION
Stroke is a neurological deficit of cerebrovascular cause that persists beyond 24hrs or
is interrupted by death within 24hrs
Stroke is the third leading cause of the death and the most common cause of disability
among adults 30 to 40% of the survivors after stroke are estimated to have significant
disability.
Degree of disability that fallows a stroke depends upon which area of the brain is
damaged.
With the resent medical and surgical advances the death rate of primary stroke is
reducing drastically and with advances in physiotherapy they are able to overcome the
motor disability.
In sub acute stage of stroke, where the recovery is quite rapid and maximum by
functional re organization of the CNS (functional induced plasticity) occurs. The
stimulation from active rehabilitation and an enriched environment plays an important
part in brain repair and recovery. Thus apraxia management at this stage plays a
major role in rehabilitation.
But, the main them of rehabilitation is making the person independent, this primary
goal is not being attained in the person in whom MIDDLE CEREBRAL ARTERY is
involved.
Lesions of the right parietal lobe of the non dominant hemisphere (usually the right
hemisphere) typically produce PERCEPTUAL DISSORDERS [Unilateral neglect,
agnosica apraxia and disorganization]
Among the perceptual disorders “APRAXIA” causes disability of “VOLUNTARY
LEARNED MOVEMENTS” mainly affecting the UPPER LIMBS as they perform
wide range of skilled movements and more complex movements. So, if not treated
and neglected person cannot overcome his disability and causes obstacle to fulfill the
goal of rehabilitation
Praxis is a Greek word which is used to describe the learned ability to plan and to
carry out sequences of coordinated movements in order to achieve an objective.
Praxis means “action based on will” and comes from Greek words for “doing,
acting, deed, practice.” (Safire 1989.)
Praxis pertains primarily to the planning of a motor act. It is a process that requires
knowledge of actions and of objects, motivation and intention on the part of the
person.
It is that ability by which we figure out how much to use our hands in simple task’s
[to play with toys, use a pencil, or fork, build a tower, tidy up a room] or up to
engage in many “human” occupations.
Apraxia: a psycho motor defect characterized by the inability to make proper use of
a known object.
Researcher’s interest in praxis arose from investigations with adults who had
sustained traumatic brain injury, primarily to the left frontal or parietal lobe
resulting in the inability to perform voluntary or goal directed actions (Frederick’s
and Saladin 1996)
The Aim of the Project
The present project is a descriptive study on apraxia in hemiplegics [lesion of the
right parietal lobe of non dominant hemisphere.] and is intended to present the
identification assessment and its management, which is otherwise causing
hindrance to the neurological rehabilitation.
ANATOMY
CIRCULUS ARTERIOSUS OR CIRCLE OF WILLIS
IT IS AN ARERIAL CIRCLE SITUATED IN THE
INTERPEDUNCULAR CISTERN at the base of the brain.
It is formed anteriorly by the anterior communicating artery
Anterolaterally by the anterior cerebral arteries,
Laterally by the posterior communication
The middle cerebral artery (MCA)
The middle cerebral artery (MCA) is one of the three major paired arteries
that supplies blood to the cerebrum. The MCA arises from the internal
carotid and continues into the lateral sulcus where it then branches and
projects to many parts of the lateral cerebral cortex. It also supplies blood
to the anteriortemporal lobes and the insular cortices.
The left and right MCAs rise from trifurcations of the internal carotid
arteries and thus are connected to the anterior cerebral arteries and
the posterior communicating arteries, which connect to the posterior
cerebral arteries.
The MCAs are not considered a part of the Circle of Willis
BRANCHES:
The middle cerebral artery can be classified into 4 parts
M1: The sphenoidals egment, so named due to its origin and loose lateral
tracking of the sphenoid bone. Although known also as
the horizontalsegment, this may be misleading since the segment may
descend, remain flat, or extend posteriorly the anterior (dorsad) in different
individuals. The M1 segment perforates the brain with
numerous anterolateral central (lateral lenticulostriate) arteries, which
irrigate the basal ganglia.
M2: Extending anteriorly on the insual, this segment in known as
theinsular segment. It is also known as the Sylvian segment when the
opercular segments are included. The MCA branches may bifurcate or
sometimes trifurcate into trunks in this segment which then extend into
branches that terminate towards the cortex.
M3: The opercular segments and extends laterally exteriorly from the insula
towards the cortex. This segment is sometimes grouped as part of M2.
M4: These finer terminal or cortical segments irrigate the cortex. They
begin at the external of the Sylvian fissure and extend distally away on the
cortex of the brain.
Outer surface of cerebral hemisphere, showing areas supplied by
cerebral arteries. ( Pink is region supplied by middle cerebral artery. )
CEREBRUM:
Functional divisions
1. Archi cortex
2. Paleo cortex
3. Neo cortex
Archi cortex:
• It is the core of the brain.
• It is comprised of the hippocamPai formation, which is involved
in learning and memory.
• The archi cortex is believed to be phylogenitically ancient.
paleo cortex:
• It is the outer layer that sits over the core.
• It includes the para hippocampai. gyrus. it relays information
between the hippocarnpus and other brain regions.
Neo cortex:
• It is the newest part of the brain phylogenitically.
• It includes primary motor, sensory and association cortices.
LESION:
• Causes loss of Storage of motor plans.
• Inability to think cognitively about how to carry out a motor task,
which was once known before injury or disease.
CORPUS CALLOSUM:
• It is the largest commeasure in the brain.
• It allows the right and left cerebral hemispheres to communicate with
each other.
• The corpus callosum arches around the anterior horn of the lateral
ventricles.
Etiology
Stroke is a rapid loss in brain function due to an alteration in blood
supply.
Atherosclerosis:-is a major contributory factor in cerebrovascular
disease it is characterized by plaque formation with an accumulation of
lipids, fibrin, complex carbohydrates and calcium deposits on arterial
walls that leads to progressive narrowing of blood vessels.
The most common sites for lesions to occur are at the origin of the
common carotid artery or at its transition into the middle cerebral
artery at the main bifurcation of the middle cerebral artery.
Risk Factors
Modifiable:-
Hypertension
Type II Diabetes
Obesity
Sedentary life style
Oral contraceptive use
Smoking – Heavy alcohol use
Non – Modifiable:-
Hyper Cholesterolemia
MI
Age
Gender – Males are more affected
Race
PATHO PHYSIOLOGY
PATHO PHYSIOLOGY
THE FIRST HORIZONTAL SCHEMA OF LIEPMANN (1900)
A lesion in the left « sensomotorium » (1) gives rise to a left hemiplegia and
aphasia and to a motor apraxia of the left hand, due to the absence of information
linking the left and right « sensomotorium » via callosal connections
(C), kinæsthetic images are engrammed, and the left sensomotorium leads to an
ideomotor apraxia of the right hand.
SECOND HORIZONTAL SCHEMA OF LIEPMANN (1920),
Lesions resulting in a dyspraxia of the left hand may be localized in the cortical
motor representation
(4) Leads to paralysis of the right hand without dyspraxia of the left
hand.
PATHOLOGY
PATHOLOGY
MIDDLE CEREBRAL ARTERY SYNDROME:-
The middle cerebral artery (MCA) is the second of the two main branches of
the internal carotid artery and supplies the entire lateral aspect of the
cerebral hemisphere (frontal, temporal and parietal lobes) and sub cortical
structures, including the internal capsule (Posterior portion) corona radiate,
globuspallidus (Otter part) most of the caudate nucleus and the putamen.
Sudden severe headache with sudden onset that occurs with out apparent
reasons.
Sudden loss of balance, dizziness or falling with out any apparent reason.
Symptoms:
Pares is of contra lateral face, arm, and leg (leg is least affected)
Sensory impairment over the contra lateral face, arm, and leg (pain,
temperature, touch, vibration, position, two-point discrimination,
stereo gnosis)
Homonymous hemianopia
Diagnostic Procedures
Blood Tests
Includes:
complete blood count
blood sugar
cholesterol
fat levels
clotting levels
and a check of other elements in the blood : for analysing the leval of risk.
Blood glucose: a raise in blood glucose after a troke increases infarct size and adversely
affects functional outcome. This is probably because hyperglycemia exacerbates the anaerobic
production of lactic acid in the ischaemic penembra.
Electrocardiogram (EKG) – to measure heart rhythm and check for an irregular
heart beat
Ultrasound– a test that uses sound waves to help determine if there are blockages
in the arteries supplying the brain. And systemic problems.
MRI Scan – a test that uses magnetic waves to make pictures of structures inside
the head
CT Scan – a type of x-ray that uses a computer to make pictures of structures
inside the head
Magnetic Resonance Angiography – performed prior to carotid artery surgery to
determine how much the artery has narrowed. Gadolinium, a type of dye, may beinjected into
your vein for this test
Arteriogram - during a conventional arteriogram, a contrast dye is injected and
x-ray images are produced to precisely locate the blockage and to determine how
much of the artery is blocked. This test is usually only done to confirm the need
for surgery.
Echocardiogram - an ultrasound test that looks for blood clots and valve
abnormalities within the heart.
Electroencephalogram (EEG) - a test that can detect seizures by measuring
brain waves (used only if a seizure is suspected)
MANAGEMENT
Medical Management
a. Steroids/corticosteroids given in full stomach with antacid or H2
receptorAntagonists.
b. Vitamin B complex – promote restitution of function of neurons which have
reversible damage.
nootrophil- PIRACETAM
hydergine- CODERGOCRIN
Aspirin (300mg daily): immediately after an ischaemic stroke and carries a far lower risk
of haemorrhagic complications.
Surgical Management
Endarterectomy – purpose is to remove the atherosclerotic plaque from the inner
occlude abnormal arteries or veins and prevent bleeding from the vascular lesions.
Whenever possible the affected vessels are totally removed. The surgeon ligates
craniotomy.
NURSING MANAGEMENT
shock is present.
1. Neurological
Pressure, hyperthermia.
further bleeding.
of hip.
1. Encourage self-feeding.
I. Promote elimination.
convalescence.
NEUROLOGICAL ASSESSEMENT
A. Demo Graphic Data
Name
Age
Gender
Occupation
Address
B.Chief Complaints
The Patient Should Give His Complains In His Simple Words as Completely As Possible
Vital Signs:
Pulse rate:
Blood preasure:
Temperature:
Respiratory Rate:
C.History
a. Present History:-
This Should Consist Information about the Type of Onset, Whether Acute, Sub acute or
chronic.
D. Pain History:-
Onset
Mode
Type
Side
Site
Durations
E. On Observation:-
F. On Palpation
a. Tenderness
b. Warmth
c. Crepitus
d. Muscle Spasm
e. Scar: Mobile/Adhere
f. Edema
G. On Examination
A. Higher Function Testing
Consciousness
Memory
Intelligence
Behavior
Orientation To Time, Place Etc.,
Olfactory
Optic
Oculomotor
Tracheas
Trigeminal
Abducence
Facial
Vestibule Cochlear
Glaso Pharyngeal
Vagus
Accessory
Hypoglossal
These Nerves Are Assessed For Their Involvement As Their Affection May Interfere In The
Rehabilitation Process.
A) Sensory Examination:- Evaluation Of Sensory Involvement Gives An Indication About The Severity Of
The Primary Lesion And Also Determine The Extent Of Improvement In These Patients.
B) Motor Examination:-
Tone
Ram
MMT
Contractures And Deformities
Muscle Girth, Limb Length
H. Reflexes
Biceps
Triceps
Ancones
Knee
Ankle
Superficial Reflexes:
Corneal Reflex
Cremastic Reflex Are Tested
I. Balance and Cardinal Assessment
Various Equilibrium And Non Equilibrium Test Should Be Done For Coordination And Romberg Test
Should Be Done For Balance Assessment.
J. Posture:
K. Functional Assessment:
L. Investigations:
M. Diagnosis:
N. List of Problems:
Tone Grading:-
O – No Response
1+ - Decreased Response
2+ - Normal Response
3+ - Exaggerate Response
4+ - Sustained Response.
Reflex Grading:-
O+ - Absent
1+ - Tone Charge, Slight, Transient with No Movement of Extremities.
2+ - Visible Movement of Extremities.
3+ - Exaggerated, Full Movement Of Extremities
4+ - Obligatory And Sustained Movement, Lasting For More Than 30 Sec.,
Grade IV – Initial Half Range Is Performed In Isolation and the Latter Half in Pattern
Grade V – Full Range Of Motion In Isolation But Goes Into Pattern When Resistance Is Offered.
Barthel Index
Activity
Feeding:-
O=Unable
Bathing:-
O=Dependent
5=Independent or In Shower
Grooming:-
5=Independent (Face/Hair/Teeth/Shaving)
Dressing:-
O=Dependent
Bowels:-
5=Occasional Accident
10=Continent
Bladder:-
5=Occasional Accident
10=Continent
Toilet Use:-
O=Dependent
15=Independent
Stairs:-
O=Unable
5=Needs Help
10=Independent
TYPES OF APRAXIA
TYPES OF APRAXIA
There are five of apraxia:
1. verbal apraxia
2. buccofacial or oro facial apraxia
3. Limb apraxia,
4. Constructional Apraxia,
5. Dressing apraxia.
It has to do with the translation of an object from one spatial dimension to another.
The defect appears to be in poor conceptualization of the spatial requirements of
certain activities.
The person in copying simple pictures or diagrams. When attempting to write there
may be crowding and obliquity of the words.
i The person may be unable to interet maps or find their way about {
topographagnosia)
There are two types of constructional activities used in assessment
Graphic: e. g copying line drawings and drawing
to commands.
An individual may Place both legs in the se leg hole or may not perceive that one
of the leg holes is turned inside out.
An individual may put the right shoe the left foot.
The individual may be unable to tie shoe laces because of difficulty in handling the
spatial relations aspects of manipulating shoe strings.
Arnadottir has described movements in patients with motor apraxia as clumsy and
inflexible.
It may be helpful for the therapist to give only general information about the
activity goal and leave out the specific instructions.
Simple component movements can be carried out, but not the complex movements
requiring a sequence of muscular activities.
The patient performs automatic acts normally, such as blowing his nose, shaking
hands, pushing back hair etc,and is able to formulate the idea of an act and to
describe how it Should be done, but when it comes to carlying out the movement
on command, he is unable to do it correctly.
There is a common tendency to substitute a body part for the object, for ex: using
the index finger as a tooth brush rather than pretending to hold one.
IDEATIONAL OR SENSORY APRAXIA:
It involves a disruption in the concept formation of action planning.
• The ability to select and organize movements to execute an action is impaired.
• The patient with ideational apraxia seems confused, stubborn or unco-operative.
• The most striking characteristic of this form of apraxia is the inability to
recognize objects and their uses.
The good glass and Kaplan test for apraxia is composed of universally
known movements, such as blowing, brushing teeth, hammering, shaving
and so forth.
IDEATIONAL APRAXIA:-
The tests for ideational apraxia are essentially the same for
ideational apraxias are essentially the same as those for ideomotor
apraxia.
They draw pieces of the picture without any coherent relationship to each other.
Thus their drawings tend to be complex, yet unrecognizable they have immense
difficulty with coping or constructing anything in three dimensions, are not helped
by the presence of a model or by landmarks in a picture and do not generally
improve with practice.
The drawing of patients with left – hemisphere damage are usually more
recognizable they are characterized by great simplicity.
Patients with left side lesions draw slowly and
hesitatingly are often unable to draw angles and have general difficulty in
execution in contrast to that of patients with right hemisphere stroke, their
performance often improve with the aid of a model.
The use of landmarks in drawing and with repeated trials short-term visual
memory impairment is thought to be associated with constructional apraxia
in patients with right – sided lesions verbal and comprehension
difficulties, poor manual dexterity and the presence of homonymous
hemianopia must be ruled out during assessment for this disorder.
Physiotherapy Management
6. Adaptive/Compensatory Approach:-
1. The adult brain has limited potential to 1.The adult brain can repair and
Repair and reorganize itself after injury. Reorganize itself after injury
HOME CARE
HOME CARE
Safety measures Should be taken to
compensate for weakness, confus
deficiencies, or seizures ion, sensonj
that may accompany
this problem.
Participation in normal activities is encouraged.
One should have extreme patience with people who have apraxia.
Take time to demonstrate tasks and allow enough time for person to perform the
task.
PROGNOSIS
PROGNOSIS
The prognosis for individuals with apraxia varies and depends partly on
the underlying cause.
Some individuals improve significantly while others may show very
little improvement.
Recovery from ideomotor apraxia was better from anterior lesions.
Although less than a third of the patients were followed beyond one-
year, they found improvement occurred beyond six- months.
Age, sex, lesion she, and pe did not seem to be related significantlY to
outcome.
CONCLUSION
Patients who are treated for apraxia in sub acute stage of stroke with physiotherapy
had maximum recovery and more independent and those treated in late stages
developed many perceptual complications like hemineglect thus taking long time
for recovery or sometimes rehabilitation is not successful
BIBILOGRAHY
• Neuro Science or Rehabilitation Professional
-sharonA. Gutmen.
• Text book of medical PhysiologyGuyton and Hall.
• Stroke rehabilitation -Glen Gillen, Ann
Burkhardt
• Sensory integration —
Theory and practice (2nd edition)- Anita C Bundy,
Shelly J. Lane,
Elizabeth A. Murray.
• occupational therapy for physical dysfunction (5th
edition) -CatherineA trombly
• Brain and Bannisters -Roger banniser
• physical rehabilitation(4th edition)
-Susan B.O’ Sullivan, Thomas J. SchmitZ.
• BickerstaffS neurological examination in clinical practice (6th edition) - John
Spillane.
• pathophySi010g.Y of motor systems
Christopher M. Fredericks,
Lisa K. Saladin.
• NeurO10g-’ examiflatb01 made up easy (2nd GeriafltFthl
edition)
• eUrOl0g” rehabilitation - Janet Carr,
Shephere(t
Web sites:
• WWW.emedicine.corn
• vw.medlinePlus.com
• www.google.com
• www.Msnsearch.corn