The term “stroke” in medical terminology refers to a sudden interruption of blood supply to the brain, resulting in the rapid loss of brain function.
This interruption can be caused by a blockage of blood flow (ischemic stroke) or the rupture of a blood vessel (hemorrhagic stroke). As a result, the affected part of the brain may not receive enough oxygen and nutrients, leading to the death of brain cells.
Incidence in India
The annual incidence rate of stroke in India is 13/1000,00 population with 15.2/ 1000,00 in males and 10.8/1000,00 in females (Abraham J et al. 1972, Sunder Rao PSS 1971).
Etiology
When discussing the etiology of stroke, there are several factors and conditions that can contribute to its occurrence.
Emboli
Hemorrhage
Ischemia
Hypertension
Atherosclerosis
Risk factor
Risk factors for a stroke are conditions or behaviors that increase the likelihood of having one. Here are some common risk factors:
High Blood Pressure: This is the leading risk factor for stroke. Consistently high blood pressure can damage blood vessels in the brain, making them more likely to rupture or become blocked (>160/90mm Hg)
Smoking: Smoking contributes to the buildup of plaque in the arteries, increasing the risk of stroke.
Diabetes: Diabetes can increase the risk of stroke by contributing to the buildup of fatty deposits in blood vessels.
High Cholesterol: High levels of low-density lipoprotein (LDL) cholesterol can lead to the formation of plaques in the arteries, which can restrict blood flow to the brain.
Heart Disease: Conditions like atrial fibrillation, heart valve disease, and other heart problems can increase the risk of stroke.
Obesity: Being overweight or obese can increase the risk of high blood pressure, diabetes, and high cholesterol, all of which contribute to stroke risk.
Physical Inactivity: Lack of exercise can contribute to obesity, high blood pressure, and other health issues that increase stroke risk.
Excessive Alcohol Consumption: Drinking large amounts of alcohol can increase blood pressure and contribute to other health issues that raise stroke risk.
Warning signs
Sudden numbness or weakness of the face , arm, or leg especially one side of the body
Sudden confusion
Trouble in speaking or understanding
Sudden trouble in walking
Dizziness
Loss of balance and coordination
Sudden , severe headache
Types of Stroke
There are main three types of stroke:
Ischemic stroke: These are the result of a thrombus, or embolism leading to block to the cerebral blood flow which deprives the brain of needed oxygen and glucose , disrupts the cellular metabolism , and leads to injury and death of the tissue.
Hemorrhagic stroke: This type occurs when a blood vessel in the brain bursts, leading to bleeding (hemorrhage) in or around the brain. It can result from conditions such as high blood pressure, aneurysms, or arteriovenous malformations.
Transient ischemic stroke: Often called a “mini-stroke,”. If the patient recovers from neurological dysfunction within 24 hours of attack , then it is termed TIA.
PHYSIOTHERAPY ASSESSMENT OF STROKEThe term “stroke” in medical terminology refers to a sudden interruption of blood supply to the brain, resulting in the rapid loss of brain function.
This interruption can be caused by a blockage of blood flow (ischemic stroke) or the rupture of a blood vessel (hemorrhagic stroke). As a result, the affected part of the brain may not receive enough oxygen and nutrients, leading to the death of brain cells.
Incidence in India
The annual incidence rate of stroke in India is 13/1000,00 population with 15.2/ 1000,00 in males and 10.8/1000,00 in females (Abraham J et al. 1972, Sunder Rao PSS 1971).
Etiology
When discussing the etiology of stroke, there are several factors and conditions that can contribute to its occurrence.
Emboli
Hemorrhage
Ischemia
Hypertension
Atherosclerosis
Risk factor
Risk factors for a stroke are conditions or behaviors that increase the likelihood of having one. Here are some common risk factors:
High Blood Pressure: This is the leading risk factor for stroke. Consistently high blood pressure can damage blood vessels in the brain, making them more likely to rupture or become blocked (>160/90mm Hg)
Smoking: Smoking contributes to the buildup of plaque in the arteries, increasing the risk of stroke.
Diabetes: Diabetes can increase the risk of stroke by contributing to the buildup of fatty deposits in blood vessels.
High Cholesterol: High levels of low-density lipoprotein (LDL) cholesterol can lead to the formation of plaques in the arteries, which can restrict blood flow to the brain.
Heart Disease: Conditions like atrial fibrillation, heart valve disease, and other heart problems can increase the risk of stroke.
Obesity: Being overweight or obese can increase the risk of high blood pressure, diabetes, and high cholesterol, all of which contribute to stroke risk.
Physical Inactivity: Lack of exercise can contribute to obesity, high blood pressure, and other health issues that increase stroke risk.
Excessive Alcohol Consumption: Drinking large amounts of alcohol can increase blood pressure and contribute to other health issues that raise stroke risk.
Warning signs
Sudden numbness or weakness of the face , arm, or leg especially one side of the body
Sudden confusion
Trouble in speaking or understanding
Sudden trouble in walking
Dizziness
Loss of balance and coordination
Sudden , severe headache
Types of Stroke
There are main three types of stroke:
Ischemic stroke: These are the result of a thrombus, or embolism leading to block to the cerebral blood flow which deprives the brain of needed oxygen and glucose , disrupts the cellular metabolism , and leads to injury and death of the tissue.
Hemorrhagic stroke: This type occurs when a blood vessel in the brain bursts, leading to bleeding (hemorrhage) in or around the brain. It can result from conditions such as high blood pressure, aneurysms, or arteriovenous malformations.
Transient ischemic stroke: Often called a “mini-stroke,”. If the patient recovers from neurological dysfunction within 24 hours of attack , then it is termed TIA.
PHYSIOTHERAPY ASSESSMENT OF STROKE
The physiotherapy assessment starts with taking the demographic data, history taking from the patient or from medical records.
OBSERVATION
Observe the general body build of the patient( ectomorphic, mesomorphic or endomorphic)
Observe the posture and attitude of the limb including facial symmetry.
Check for the tropical changes of the skin. (in stroke , due to the muscular inactivity , thecircular disturbances are common , leading to tropical changes of the skin.
Observe for any swelling , scars over the upper and lower limbs.
Observe for any contracure or deformity.
Observe any abnormal movements like tremors.
Observe for any muscle wasting present or not.
PALPATION
Palpate and compare with uneffected side for temperature.
Palpated and graded the edema whether it is localised or generalised , indurated or non-indurated, pitting or non-pitting type.
Palpate for any tender point over the affected limb.
EXAMINATION
Examine the higher mental function like memory , intelligence, level of consciousness, behaviour and trophographical orientation and speech.
Test the cranial nerve bilaterally and check for any abnormalities.
SENSORY EXAMINATION
Sensory examination would be very important to identify the level of lesion and type of lesion. Sensory examination include superficial deep and cortical sensation.
1. SUPERFICIAL SENSATION
A. LIGHT TOUCH
Procedure: Use a cotton wisp or a light brush to touch different parts of the patient’s body.
Instructions: Ask the patient to close their eyes and report when and where they feel the touch.
Comparison: Compare responses on both sides of the body and different areas.
B. PAIN SENSATION
Procedure: Use a pin or a sharp object to lightly prick the skin.
Instructions: Ask the patient to identify if they feel a sharp sensation and if it is the same on both sides.
Comparison: Assess for differences in pain perception between sides.
C. Temperature Sensation
Procedure: Use a test tube with hot and cold water or a thermal testing device.
Instructions: Ask the patient to identify the temperature and note any differences between sides.
Comparison: Compare temperature sensation on both sides of the body.
2. DEEP SENSATION
A. Vibration Sense
Procedure: Use a tuning fork.
Instructions: Place the tuning fork on bony areas (like the ankle or wrist) and ask the patient to tell you when the vibration starts and stops.
Comparison: Compare the ability to sense vibrations on both sides.
B. Proprioception
Procedure: Move the patient’s finger or toe up or down and ask them to identify the direction of movement.
Instructions: Ask the patient to close their eyes and describe the direction of movement.
Comparison: Compare proprioceptive ability on both sides.
3. CORTICAL SENSATION
A. Two-Point Discrimination
Procedure: Use a caliper or a similar tool to touch the skin with two points.
Instructions: Ask the patient to determine if they feel one point or two.
Comparison: Compare two-point discrimination between different areas and sides.
B. Stereognosis
Procedure: Place a familiar object (e.g., a coin or a key) in the patient’s hand and ask them to identify it by touch alone.
Instructions: Ensure the patient can’t see the object while identifying it.
Comparison: Compare ability to identify objects between sides.
C. Graphesthesia
Procedure: Draw a number or letter on the patient’s palm.
Instructions: Ask the patient to identify the number or letter while their eyes are closed.
Comparison: Compare ability to recognize drawn numbers or letters on both hands.
REFLEX EXAMINATION
A reflex examination in the context of a stroke is important for assessing neurological function and identifying any abnormalities in reflexes that might indicate damage to the nervous system. Reflexes can be classified into superficial, deep tendon, and pathological reflexes. Here’s how to conduct a comprehensive reflex examination:
1. Superficial Reflexes
These reflexes are elicited by stimulating the skin and involve the superficial muscles and skin:
Abdominal Reflexes:
Procedure: Gently stroke the skin of the abdomen in a horizontal direction (toward the umbilicus) using a blunt instrument or your fingers.
Normal Response: The abdominal muscles should contract and move toward the area being stroked.
Abnormal Findings: Absence of the reflex could indicate neurological issues or damage to the abdominal muscles.
Cremasteric Reflex:
Procedure: Gently stroke the inner thigh of a male patient.
Normal Response: Contraction of the cremaster muscle and elevation of the testicle on the same side.
Abnormal Findings: Absence of the reflex may indicate damage to the L1-L2 nerve roots.
Plantar Reflex:
Procedure: Use a blunt object to stroke the sole of the foot from the heel to the toes.
Normal Response: The toes should curl downward (flexor response).
Abnormal Findings: An upward movement of the toes (Babinski sign) may suggest an upper motor neuron lesion, commonly seen in stroke.
These reflexes assess the integrity of the spinal cord and peripheral nerves:
Biceps Reflex:
Procedure: Place your thumb over the biceps tendon in the antecubital fossa and tap your thumb with a reflex hammer.
Normal Response: Contraction of the biceps muscle and slight flexion of the elbow.
Abnormal Findings: Diminished or absent response may indicate peripheral nerve damage, while an exaggerated response might suggest an upper motor neuron lesion.
Triceps Reflex:
Procedure: Support the patient’s arm and tap the triceps tendon just above the elbow.
Normal Response: Contraction of the triceps muscle and extension of the elbow.
Abnormal Findings: Similar to the biceps reflex, an absent or exaggerated response can provide clues about neurological damage.
Patellar Reflex:
Procedure: Tap the patellar tendon just below the kneecap while the patient’s leg is relaxed.
Normal Response: Extension of the knee.
Abnormal Findings: An exaggerated reflex might indicate an upper motor neuron lesion, while a diminished or absent reflex could indicate lower motor neuron damage.
Achilles Reflex:
Procedure: Hold the foot in dorsiflexion and tap the Achilles tendon.
Normal Response: Contraction of the calf muscle and plantar flexion of the foot.
Abnormal Findings: Absent or reduced reflex can suggest peripheral nerve issues, while an exaggerated reflex might indicate an upper motor neuron lesion.
3. Pathological Reflexes
These reflexes are typically present in adults only when there is a neurological impairment:
Babinski Sign:
Procedure: Stroke the lateral aspect of the sole of the foot from the heel to the toes.
Normal Response: The toes curl downward.
Abnormal Findings: The toes fan out and the big toe extends upward, indicating possible upper motor neuron damage.
Hoffman’s Sign:
Procedure: Flick the distal phalanx of the middle finger.
Normal Response: No movement of the thumb or fingers.
Abnormal Findings: If the thumb and/or fingers flex, it may suggest an upper motor neuron lesion.
Clonus:
Procedure: Rapidly dorsiflex the foot while supporting the leg.
Normal Response: No clonus (sustained rhythmic contractions).
Abnormal Findings: Presence of clonus may indicate an upper motor neuron lesion.
MOTOR EXAMINATION
The motor examination of a stroke patient focuses on assessing the impact of the stroke on motor function. This involves evaluating muscle strength, coordination, and movement. Here’s a general approach to conducting a motor examination for a stroke patient:
1. Initial Assessment
Observe: Look for any obvious signs of weakness or asymmetry in movement. Note the patient’s posture and any involuntary movements.
2. Muscle Strength Testing
Upper Extremities:
Shoulder Abduction: Ask the patient to raise their arm sideways to shoulder level and hold it there. Compare both sides.
Elbow Flexion/Extension: Ask the patient to bend and straighten their elbows against resistance.
Wrist Extension/Flexion: Have the patient extend and flex their wrists against resistance.
Lower Extremities:
Hip Flexion/Extension: Ask the patient to lift their leg while sitting or lying down and to extend their leg against resistance.
Knee Flexion/Extension: Ask the patient to bend and straighten their knees against resistance.
Ankle Dorsiflexion/Plantarflexion: Have the patient flex and point their foot against resistance.
3. Coordination and Dexterity
Finger-to-Nose Test: Ask the patient to touch their nose and then your finger, alternating between the two. Observe for any tremors or difficulty with precision.
Heel-to-Shin Test: Ask the patient to slide the heel of one foot down the shin of the opposite leg. This tests coordination and balance.
4. Gait and Balance
Walking: Observe the patient walking, noting any difficulties with balance, asymmetry, or irregular gait.
Romberg Test: Have the patient stand with their feet together and eyes closed. Observe for any swaying or loss of balance.
5. Assessment of Muscle Tone
Spasticity: Check for resistance to passive movement. Spasticity is common in stroke patients and can be assessed by moving the patient’s limbs through their range of motion and noting any increased resistance.
Rigidity: Assess for rigidity by passively moving the patient’s limbs and checking for uniform resistance.
PHYSIOTHERAPY MANAGEMENT
Treatment Goals
To improving Motor Function.
To enhancing Balance and Coordination.
Facilitating Independence:
Managing Spasticity and Pain:
Treatment Techniques
Neuroplasticity-Focused Approaches:
Constraint-Induced Movement Therapy (CIMT): Involves constraining the unaffected limb to encourage use of the affected limb.
Bilateral Training: Exercises that involve both sides of the body to improve motor control and coordination.
Functional Training:
Simulated Activities: Practicing real-life tasks in a controlled environment to improve functional outcomes.
Cognitive and Perceptual Training: Addressing any cognitive or perceptual deficits that impact motor function.
Education and Support:
Patient and Family Education: Providing information about stroke recovery, home exercises, and ways to manage stroke-related challenges.
Support and Motivation: Encouraging patients and their families throughout the rehabilitation process.
Recovery and Rehabilitation Process
Early Intervention: Starting physiotherapy as soon as possible after a stroke can significantly impact recovery outcomes.
Individualized Plans: Treatment plans should be tailored to each patient’s specific needs and goals.
The physiotherapy assessment starts with taking the demographic data, history taking from the patient or from medical records.
OBSERVATION
Observe the general body build of the patient( ectomorphic, mesomorphic or endomorphic)
Observe the posture and attitude of the limb including facial symmetry.
Check for the tropical changes of the skin. (in stroke , due to the muscular inactivity , thecircular disturbances are common , leading to tropical changes of the skin.
Observe for any swelling , scars over the upper and lower limbs.
Observe for any contracure or deformity.
Observe any abnormal movements like tremors.
Observe for any muscle wasting present or not.
PALPATION
Palpate and compare with uneffected side for temperature.
Palpated and graded the edema whether it is localised or generalised , indurated or non-indurated, pitting or non-pitting type.
Palpate for any tender point over the affected limb.
EXAMINATION
Examine the higher mental function like memory , intelligence, level of consciousness, behaviour and trophographical orientation and speech.
Test the cranial nerve bilaterally and check for any abnormalities.
SENSORY EXAMINATION
Sensory examination would be very important to identify the level of lesion and type of lesion. Sensory examination include superficial deep and cortical sensation.
1. SUPERFICIAL SENSATION
A. LIGHT TOUCH
Procedure: Use a cotton wisp or a light brush to touch different parts of the patient’s body.
Instructions: Ask the patient to close their eyes and report when and where they feel the touch.
Comparison: Compare responses on both sides of the body and different areas.
B. PAIN SENSATION
Procedure: Use a pin or a sharp object to lightly prick the skin.
Instructions: Ask the patient to identify if they feel a sharp sensation and if it is the same on both sides.
Comparison: Assess for differences in pain perception between sides.
C. Temperature Sensation
Procedure: Use a test tube with hot and cold water or a thermal testing device.
Instructions: Ask the patient to identify the temperature and note any differences between sides.
Comparison: Compare temperature sensation on both sides of the body.
2. DEEP SENSATION
A. Vibration Sense
Procedure: Use a tuning fork.
Instructions: Place the tuning fork on bony areas (like the ankle or wrist) and ask the patient to tell you when the vibration starts and stops.
Comparison: Compare the ability to sense vibrations on both sides.
B. Proprioception
Procedure: Move the patient’s finger or toe up or down and ask them to identify the direction of movement.
Instructions: Ask the patient to close their eyes and describe the direction of movement.
Comparison: Compare proprioceptive ability on both sides.
3. CORTICAL SENSATION
A. Two-Point Discrimination
Procedure: Use a caliper or a similar tool to touch the skin with two points.
Instructions: Ask the patient to determine if they feel one point or two.
Comparison: Compare two-point discrimination between different areas and sides.
B. Stereognosis
Procedure: Place a familiar object (e.g., a coin or a key) in the patient’s hand and ask them to identify it by touch alone.
Instructions: Ensure the patient can’t see the object while identifying it.
Comparison: Compare ability to identify objects between sides.
C. Graphesthesia
Procedure: Draw a number or letter on the patient’s palm.
Instructions: Ask the patient to identify the number or letter while their eyes are closed.
Comparison: Compare ability to recognize drawn numbers or letters on both hands.
REFLEX EXAMINATION
A reflex examination in the context of a stroke is important for assessing neurological function and identifying any abnormalities in reflexes that might indicate damage to the nervous system. Reflexes can be classified into superficial, deep tendon, and pathological reflexes. Here’s how to conduct a comprehensive reflex examination:
1. Superficial Reflexes
These reflexes are elicited by stimulating the skin and involve the superficial muscles and skin:
Abdominal Reflexes:
Procedure: Gently stroke the skin of the abdomen in a horizontal direction (toward the umbilicus) using a blunt instrument or your fingers.
Normal Response: The abdominal muscles should contract and move toward the area being stroked.
Abnormal Findings: Absence of the reflex could indicate neurological issues or damage to the abdominal muscles.
Cremasteric Reflex:
Procedure: Gently stroke the inner thigh of a male patient.
Normal Response: Contraction of the cremaster muscle and elevation of the testicle on the same side.
Abnormal Findings: Absence of the reflex may indicate damage to the L1-L2 nerve roots.
Plantar Reflex:
Procedure: Use a blunt object to stroke the sole of the foot from the heel to the toes.
Normal Response: The toes should curl downward (flexor response).
Abnormal Findings: An upward movement of the toes (Babinski sign) may suggest an upper motor neuron lesion, commonly seen in stroke.
These reflexes assess the integrity of the spinal cord and peripheral nerves:
Biceps Reflex:
Procedure: Place your thumb over the biceps tendon in the antecubital fossa and tap your thumb with a reflex hammer.
Normal Response: Contraction of the biceps muscle and slight flexion of the elbow.
Abnormal Findings: Diminished or absent response may indicate peripheral nerve damage, while an exaggerated response might suggest an upper motor neuron lesion.
Triceps Reflex:
Procedure: Support the patient’s arm and tap the triceps tendon just above the elbow.
Normal Response: Contraction of the triceps muscle and extension of the elbow.
Abnormal Findings: Similar to the biceps reflex, an absent or exaggerated response can provide clues about neurological damage.
Patellar Reflex:
Procedure: Tap the patellar tendon just below the kneecap while the patient’s leg is relaxed.
Normal Response: Extension of the knee.
Abnormal Findings: An exaggerated reflex might indicate an upper motor neuron lesion, while a diminished or absent reflex could indicate lower motor neuron damage.
Achilles Reflex:
Procedure: Hold the foot in dorsiflexion and tap the Achilles tendon.
Normal Response: Contraction of the calf muscle and plantar flexion of the foot.
Abnormal Findings: Absent or reduced reflex can suggest peripheral nerve issues, while an exaggerated reflex might indicate an upper motor neuron lesion.
3. Pathological Reflexes
These reflexes are typically present in adults only when there is a neurological impairment:
Babinski Sign:
Procedure: Stroke the lateral aspect of the sole of the foot from the heel to the toes.
Normal Response: The toes curl downward.
Abnormal Findings: The toes fan out and the big toe extends upward, indicating possible upper motor neuron damage.
Hoffman’s Sign:
Procedure: Flick the distal phalanx of the middle finger.
Normal Response: No movement of the thumb or fingers.
Abnormal Findings: If the thumb and/or fingers flex, it may suggest an upper motor neuron lesion.
Clonus:
Procedure: Rapidly dorsiflex the foot while supporting the leg.
Normal Response: No clonus (sustained rhythmic contractions).
Abnormal Findings: Presence of clonus may indicate an upper motor neuron lesion.
MOTOR EXAMINATION
The motor examination of a stroke patient focuses on assessing the impact of the stroke on motor function. This involves evaluating muscle strength, coordination, and movement. Here’s a general approach to conducting a motor examination for a stroke patient:
1. Initial Assessment
Observe: Look for any obvious signs of weakness or asymmetry in movement. Note the patient’s posture and any involuntary movements.
2. Muscle Strength Testing
Upper Extremities:
Shoulder Abduction: Ask the patient to raise their arm sideways to shoulder level and hold it there. Compare both sides.
Elbow Flexion/Extension: Ask the patient to bend and straighten their elbows against resistance.
Wrist Extension/Flexion: Have the patient extend and flex their wrists against resistance.
Lower Extremities:
Hip Flexion/Extension: Ask the patient to lift their leg while sitting or lying down and to extend their leg against resistance.
Knee Flexion/Extension: Ask the patient to bend and straighten their knees against resistance.
Ankle Dorsiflexion/Plantarflexion: Have the patient flex and point their foot against resistance.
3. Coordination and Dexterity
Finger-to-Nose Test: Ask the patient to touch their nose and then your finger, alternating between the two. Observe for any tremors or difficulty with precision.
Heel-to-Shin Test: Ask the patient to slide the heel of one foot down the shin of the opposite leg. This tests coordination and balance.
4. Gait and Balance
Walking: Observe the patient walking, noting any difficulties with balance, asymmetry, or irregular gait.
Romberg Test: Have the patient stand with their feet together and eyes closed. Observe for any swaying or loss of balance.
5. Assessment of Muscle Tone
Spasticity: Check for resistance to passive movement. Spasticity is common in stroke patients and can be assessed by moving the patient’s limbs through their range of motion and noting any increased resistance.
Rigidity: Assess for rigidity by passively moving the patient’s limbs and checking for uniform resistance.
PHYSIOTHERAPY MANAGEMENT
Treatment Goals
To improving Motor Function.
To enhancing Balance and Coordination.
Facilitating Independence:
Managing Spasticity and Pain:
Treatment Techniques
Neuroplasticity-Focused Approaches:
Constraint-Induced Movement Therapy (CIMT): Involves constraining the unaffected limb to encourage use of the affected limb.
Bilateral Training: Exercises that involve both sides of the body to improve motor control and coordination.
Functional Training:
Simulated Activities: Practicing real-life tasks in a controlled environment to improve functional outcomes.
Cognitive and Perceptual Training: Addressing any cognitive or perceptual deficits that impact motor function.
Education and Support:
Patient and Family Education: Providing information about stroke recovery, home exercises, and ways to manage stroke-related challenges.
Support and Motivation: Encouraging patients and their families throughout the rehabilitation process.
Recovery and Rehabilitation Process
Early Intervention: Starting physiotherapy as soon as possible after a stroke can significantly impact recovery outcomes.
Individualized Plans: Treatment plans should be tailored to each patient’s specific needs and goals.