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Recovery from Stroke
Terms in this set (59)
Stroke recovery is a complex process. It's a combination of spontaneous and learning-dependent processes.
What are some processes that occur during stroke recovery?
- Restitution = restoring the functionality of damaged neural tissue (neuroplasticity)
- Substitution = reorganisation of partly spared neural pathways to relearn lost functions (neuroplasticity)
If you've done all you can in terms of the two above:
- Compensation = improvement of the disparity between the impaired skills of a patient and the demands of their environment
What are the aims of stroke recovery?
1) Acute aims:
- Emergency management
- Investigation and treatment
Rehabilitation aims to optimise what?
- Community reintegration
- Quality of life
- Health (so they don't have another stroke etc)
We do this by doing what?
1) Addressing body structure and function limitations as appropriate (impairments) - we can improve this to some degree
2) Optimising functional ability (disability level) - help people do things with what functional level they are at
3) Adaptation (as appropriate) - occupational therapists com in here
4) Enhancing self efficacy and self management (because once at home, health care team is gone, so ensure you're not encouraging dependency)
5) Maximising health (to prevent further stroke)
6) Enabling participation/community reintegration
ICF classification - look up
Rehabilitation is a journey (to the "new me") - it's a journey that the person....?
Takes for the rest of their lives
What are some factors that determine how much recovery you'll get after stroke?
1) Type of stroke
What are the types of stroke?
1) Ischaemic stroke (80%)
- Syndrome classified according to the Oxfordshire Community Stroke Project classification)
2) Haemorrhagic stroke (15%)
- Intracerebral (10%)
- Subarachnoid (5%)
3) Not otherwise specified (5%)
Ischaemic stroke is determined by what part of the circulation is affected - and this determines what two things largely?
- Functional outcome
E.g. anterior circulation is more devastating than all the other ones
Is functional prognosis after stroke better in ischaemic stroke or haemorrhagic stroke?
Most people post-stroke end up where?
Back at home (despite lost functionality)
In terms of rehabilitation, most strokes have some spontaneous recovery - and most of the recovery occurs within....?
3 months - during this time:
- Oedema dies down
- Reduces pressure on other neural tissue, which becomes more available for use again
- Recirculation to a small extent
Impairment at presentation predicts what?
Impairment at discharge
Post-stroke, patients recover 70% of the movement that they lost due to the stroke - so if someone only had a minor stroke in the first place, and get 70% of what they lost back (which was already a minor loss), there is actually....?
Not much of a functional difference later
(but if they had a massive stroke and lost lots of movement, will only get 70% of it back)
Stroke units improve outcomes. Recovery takes....?
Time (long times) - and recovery doesn't necessarily mean you'll be the same as before your stroke
What happens in terms of spontaneous recovery/plasticity?
Some degree of spontaneous behavioural recovery is usually seen in the weeks after stroke onset
However variability in recovery is substantial across patients (even those who had the same type of stroke). Recovery is slowest in those who....?
Will ultimately have less successful outcomes
Generally the best outcomes are associated with what?
The greatest return of the normal state of brain functional organisation (so get in quick with re-establishing the circulation)
Reorganisation of surviving CNS supports behavioural recovery. What are some causes?
- Changes in interhemispheric lateralisation
- Activity of association cortices linked to injured zones
- Organisation of cortical representational maps (except hand motor function can't be recovered by other areas, whereas shoulder, trunk and hip movements can be substituted by other areas of the brain)
What are some variables that influence stroke recovery (which is why you can get people with the same damage having different recoveries)?
- Infarct size
- Pre-stroke medical comorbidities
- Pre-stroke experience and education
- Severity of initial stroke deficits
- Acute stroke interventions
- Amount of post-stroke therapy
- Medical complications after stroke
- Depression (retards rehabilitation - sort this straight after the stroke)
- Infarct location
- Prestroke disability
- Breadth of stroke deficits
- Medications during stroke recovery period
- Type of post stroke therapy
- Caregiver status
What are some good outcome predictors?
- Social interaction
- Previous independence
- Absence of depression
- Improvements at 2 weeks in speech, motor function, activities of living (because they've had a mild stroke)
What are some poor outcome predictors?
- Increasing age
- Confusion, incontinence, neglect or conjugate gaze abnormality at 2 weeks (because this means they've had a massive stroke)
Functional recovery after strokes:
Stroke teams (interdisciplinary or transdisciplinary) are vital to stroke rehabilitation, so there should be immediate referral. What does this involve?
- Occupational therapy
- Social work
- Stroke foundation
What is a stroke unit (best place a manage stroke)?
Organised stroke unit care is provided by interprofessional teams that exclusively manage patients with stroke:
- In a ward dedicated to stroke
- With a mobile stroke team or
- Within a generic disability service (mixed rehabilitation ward)
Patients with stroke who receive organised inpatient care in a stroke unit are more likely to be alive, independent, and living at home one year after stroke. Benefits are most apparent in units that are based in....?
A discrete ward
There is no systematic increase in the length of inpatient stay. Note there are hyperacute stroke units (stay there for 24 hours) and after this you move into the....?
Acute stroke unit
Early supported discharge is also very good (after acute stroke unit stay, when patient is medically stable) - this involves what?
- Community stroke rehabilitation service
- Earlier return to home (learn to rehabilitate in their context and environment)
- Interdisciplinary team (go visit them in their homes)
Early supported discharge is best in....?
Tracking rehabilitation outcomes is important. Australasian rehabilitation centres use what to do this?
- Use FIMth instrument to measure function (measures what people can do functionally) -> everyone in NZ that is rehabilitated is rated on this
- Modified Rankin Scale (MRS) -> done in medical settings by admitting doctors (this is more a disability rating)
There are many challenges to recovery. What are some motor challenges to recovery?
- Weakness impairing mobility or function (often not the most concerning one)
- Muscle tone (can vary - spasticity or flaccidity)
- Muscle contractions (once this happens it's too late, your muscle will be stuck in this position)
What are some sensory challenges to recovery?
- Proprioception changes (for gait and balance)
- Subjective sensory deficits
- Sensory neglect
The recovery of motor function goes through what stages?
1) Acute stage -> patients appear to most want to walk again (linked to discharge)
2) In patient rehab is focused on "preparation for discharge" -> focuses on mobility
3) On discharge, there is a home-based stroke rehabilitation focused on "preparation for life" -> focuses mainly on upper limb function (often more impactful than loss of walking is loss of memory, or hand/speech issues)
Aids to rehabilitation (physiotherapy and OT help with this):
What algorithm helps predict if you get upper limb recovery?
The PREP algorithm
- TMS sends impulses down your corticospinal tract (get twitch in muscles if it's an intact tract)
- If the corticospinal tracts aren't working, then do an MRI (if >0.15 then can tell them they will not get upper limb recovery -> now rehabilitation focuses on compensation of the lost function)
What are some pain challenges to recovery?
- Central post stroke pain syndrome (thalamic pain syndrome) -> look at medications to help
- Shoulder subluxation (due to weakness of rotator cuff muscles) -> physio can help
What are some vision and hearing challenges to recovery?
These are helped by OT and specific visual testing
What are some emotional barriers (as challenges to recovery)?
- Depression (20-30%)
- Cognitive change
- "Emotionalism" ("doing fine" and then burst into tears = confusing emotions)
Refer to OT + neuropsychology
What are some challenges to recovery in terms of dyspraxia/sequencing?
- Programming and execution of motor function
- E.g. Gait, speech, dressing -> often people can't do things like walk on command, but can do it spontaneously in response to other things
Can be due to specific cortical functions
Refer to physio + OT
Here we can see left sided neglect and constructional apraxia:
Swallowing is impaired in up to 50% of strokes -> most recover in....?
There are therefore aspiration risks after strokes - what can help?
Nutrition may be impaired after stroke for multiple reasons, but unsafe swallow demands for....?
Alternative feeding strategies:
- Nasogastric or PEG feeding are options
Who do you refer to with swallowing and nutrition problems?
What are some speech issues that can occur with stroke?
- Dysphasia (expressive and receptive)
- Dysphonia (can't get air out)
Language problems need to be recognised -> classic cases of aphasia are sometimes labelled as....?
Speech therapy has an important role in assessing what two things?
- Speech recovery and
- Swallow strategies
What is an agnosia?
Inability to interpret sensory information
(the same sensory information doesn't trigger perception, as you have lost the associated sensory memory)
What are the different types of agnosias?
1) Tactile agnosia = inability to discern object without visual cue
2) Sensory agnosia = neglect
3) Left/right agnosia
4) Body image agnosia = e.g. "missing limb" or "limb not belonging to me"
Who do you refer to for agnosias?
There are physical activity and exercise recommendations for stroke survivors (very important!!!). PA remains a cornerstone in the current armamentarium of risk reduction therapies for the prevention and treatment of stroke. What is the single most powerful predictor of participation in an exercise-based risk reduction program?
The fervour of the physician's recommendation -> refer to physio!!!
Life after stroke involves self-efficacy and self management:
Supporting self-management can improve what?
- Quality of life
- Clinical outcomes
- Health service use
Self-management initiatives can be categorised along a continuum. There is little evidence about the best way to provide support:
- Engagement in programmes can be limited
- Difficult to make direct comparisons between different interventions and their impact over time
- Low intensity didactic interventions are least effective
What is self-management support?
Not leaving people to "get on with it" on their own - but supporting them to build the skills and behaviours needed to live with their long-term condition
Bridges Stroke Self-Management Programme:
Local model = Taking charge after stroke
What are some issues that occur once a stroke patient is back home?
- Carer stress
- Driving (or alternatives)
Consider these issues prior to discharge can help to develop strategies to manage. Who should be involved in this?
- Interprofessional team
- Stroke foundation
- Carer's society
- Stroke clubs
- The community
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