hemiplegic strokes

STROKE (HEMIPLEGIA)

Nurul Nadhiroh Mohamad Naser KED120014Nurul Nadia Ashikin Zakaria KED120015Nurul Naemah Md Salleh KED120016Siti Nur Nabilah Lutfi KED120020Siti Zubaidah Hassan KED120022

stroke

ischemic

disruption of blood flow to a portion of the brain. This usually stems from a blood clot in a blood vessel in the neck or brain causing cell

damage in that area

hemorrhagic

result of bleeding into

the brain, causing injury to brain tissue.

Acute Ischemic Strokes

cell hypoxia and depletion of cellular adenosine triphosphate (ATP).

No energy to maintain ionic gradients across the cell membrane and cell depolarization

Influx of sodium and calcium ions and passive inflow of water into the cell lead to

cytotoxic edema

Signs and symptoms• Hemiparesis, monoparesis, or (rarely) quadriparesis• Hemisensory deficits• Monocular or binocular visual loss• Visual field deficits• Diplopia• Dysarthria• Facial droop• Ataxia• Vertigo (rarely in isolation)• Aphasia• Sudden decrease in the level of consciousness

Diagnosis

• CT angiography and CT perfusion scanning

• Magnetic resonance imaging (MRI)• Carotid duplex scanning• Digital subtraction angiography

DiagnosisLaboratory test• Complete blood count (CBC): A baseline study

that may reveal a cause for the stroke or provide evidence of concurrent illness (eg, anemia)

• Coagulation studies: May reveal a coagulopathy and are useful when fibrinolytics or anticoagulants are to be used

• Toxicology screening: May assist in identifying intoxicated patients with symptoms/behavior mimicking stroke syndromes

Differential DiagnosisStroke mimics commonly confound the clinical diagnosis of stroke. One study reported that 19% of patients diagnosed with acute ischemic stroke by neurologists before cranial CT scanning actually had non-cerebrovascular causes for their symptoms.

The most frequent stroke mimics include the following:

• Seizure (17%)• Systemic infection (17%)• Brain tumor (15%)• Toxic-metabolic disorders, such as hyponatremia and

hypoglycemia (13%)• Positional vertigo (6%)• Conversion disorder

RISK FACTORNonmodifiable:• Age• Race• Sex• Ethnicity• History of migraine

headaches• Fibromuscular dysplasia• Heredity: Family history of

stroke or transient ischemic attacks (TIAs)

Modifiable:• Hypertension • Diabetes mellitus• Cardiac disease• Hypercholesterolemia• TIAs• Lifestyle issues• Obesity• Oral contraceptive

use/postmenopausal hormone use

• Sickle cell disease

COMPLICATIONS• Paralysis or loss of muscle movement

– usually on one side of body(HEMIPLGIA)– loss of sensation on one side of body– lose control of certain muscles

• Difficulty talking or swallowing– difficulty with language (aphasia), including speaking or

understanding speech, reading, or writing– less control over the way the muscles in mouth and throat move

• Memory and concentration difficulties– experience some memory loss– Others may have difficulty thinking, making judgments,

reasoning and understanding concepts.

• Emotional problems– more difficulty controlling their emotions– psychological problems such as anxiety or depression

• Extreme tiredness and sleep problems• Problems with vision, such as double vision or

partial blindness• Difficulty controlling bladder and bowel movements

(incontinence or constipation)• Changes in personality, behaviour and self care

ability– more withdrawn– less social or more impulsive– need help with grooming and daily chores.

• Pain– pain, numbness or other strange sensations in parts of the bodies

affected by stroke– For example: if a stroke causes lose feeling in left arm, itcan develop an

uncomfortable tingling sensation in that arm.– sensitive to temperature changes, especially extreme cold (central stroke

pain or central pain syndrome)

• Dynamic balance and gait symmetry– The former has been linked to fall risk, whereas the later has been

associated with both fall risk and poor balance. – drop foot which is a lack of dorsiflexion during the swing phase of gait

and equinovarus deformity.– lack of knee and hip stability (an incorrect ankle position during their

gait cycle).– toe contact at the initial stance phase of gait.– unaffected side is always turned forward– equinovarus deformity of the foot and ankle often accompanied by a

hyperextension or recurvatum at the knee joint

If patient can’t move because of stroke, they could be at risk of:

• Bed sores (pressure ulcers)• Deep vein thrombosis (DVT)• Pneumonia • Contractures (altered position of your

hands, feet, arms or legs because of muscle tightness)

OCCUPATIONAL THERAPY

INTERVENTION FOR STROKE PATIENT

Goals of Occupational Therapy Intervention

• Prevent secondary impairments • Restore performance skills • Modify activity demands and the contexts

in which activities are performed• Promote a healthy and satisfying lifestyle • Maintain performance and health

Intervention to Prevent Secondary Impairments

• Abnormal changes in postural alignment (postural deformities) – using available motor control in the affected and nonaffected limbs to begin a self-

exercise program designed to stretch muscles gently throughout the body• Pain associated with immobility or abnormal joint alignment

• Learned nonuse – Therapists use every opportunity to teach the stroke survivor to be aware of and to use

the paretic limbs to the limits of current available motor function.• Injury due to falls

– develop strategies for adjusting to shifts in their body's center of mass to enhance their balance skill and efficacy

• Aspiration during feeding, eating, and swallowing– use techniques to improve sensation, strength, and muscle tone of oral structures to

maximize the potential for safe of independent eating. • Depression following stroke

– by promoting independence, autonomy, participation

Intervention to Restore Performance Skills

• To generalize their new skills to enhanced performance of activities in their daily lives

• Cognitive skills include the abilities to attend to environmental stimuli; remember relevant information; plan, organize, and sequence activity performance; and assess actions.

• Perceptual skills include the abilities to interpret sensory information and navigate the spatial environment.

• Emotional coping skills include a core of effective strategies that stroke survivors must develop to negotiate their interactions with others and return to full participation in their communities


• Prevent secondary impairments • Restore performance skills • Modify activity demands and the

contexts in which activities are performed

• Promote a healthy and satisfying lifestyle • Maintain performance and health

Intervention to Modify Activity Demands and the Contexts in Which Activities Are

Performed

• Environmental Modifications– Depend on each client's ambulation status and

capacity to use the paretic arm• Adaptive Equipment– Equipment selection is highly individualized and is

based on the constellation of factors assessed in the occupational therapy evaluation



in which activities are performed• Promote a healthy and satisfying

lifestyle • Maintain performance and health

Intervention to Promote a Healthy and Satisfying Lifestyle

• Help stroke survivors establish performance patterns in:– Medication routine– Appropriate diet– Appropriate levels of physical activity– Satisfying levels of engagement in social

relationships and activities

Intervention to Maintain Performance and Health

• Education of clients, family, and caregivers to maintain performance and health after services have ended

• Establish active, healthy daily routines:– Maintaining the performance capacities – Preventing an avoidable decline toward inactivity,

loss of social roles, and emotional depression.

CPO INTERVENTION FOR STROKE PATIENT

UPPER EXTREMITY

LOWER EXTREMITY

PROSTHETIST & ORTHOTIST• The role are – To assess patient condition.– To produce (prescribe and design) suitable

devices for patient. – To fit and help patient learn to wear the

devices.– To educate regarding the use and care of an

appropriate orthosis/prosthesis that serves an individual’s requirements.

LOWER EXTREMITY• In general ankle foot orthosis(AFO) is given to

improves stroke patient’s stability, safety, and efficiency of walking.

• Types of orthosis given based on–patient condition.–muscle strength in ankle, calf, and lower leg.

• In order to improve biomechanical correction of deformity, the footplate will be put on the base of polypropylene AFO.

AFO candidates

Patient with drop foot or unable to

lift their leg to swing

To prevent foot dragging on the

ground when walk

Patient with knee recurvatum

Aid in managing and controlling

recurvatum of the knee.

Types of AFO

Solid AFO Hinged AFO

• Knee ankle foot orthosis (KAFO) not a suitable choice for stroke patient.

• Reason:– Heavy– No strength to lift it to walk properly.– Can control the problem at the knee by correctly

addressing the problem at the foot and ankle.

UPPER EXTREMITY• The majority of orthotic prescriptions for upper

extremity stroke patients are for the wrist, hand or both.

Preserve functional position of hand

and wrist , keeping it in a neutral

position

No moveable

parts

Static splinting

• Sling- Support the arm when sublaxation occur.- Used to hold joint and assist in long term stability

Splint

Resting splint Patient with low muscle tone.

Anti-spastic splint

Patient with high muscle tone.

Intervention of CPO and OT in stroke

patient Lower extremity

Upper extremity

Upper Extremity

• Historically, OT has primarily been involved in the provision of upper extremity orthotic.

• In upper extremity orthotic practice for stroke patient, OT typically design, fabricate, fit and supervise functional training.

• OT manage every stage of the upper extremity orthotic delivery process therefore able to adapt each step to individual need in stroke patient

Lower Extremity

• In contrast, OT are not direct providers of lower extremity orthotic care.

• Orthotist design, fabricate and fit lower extremity and PT provide functional gait training with the orthotics.

• OT collaborates in the delivery of the lower extremity orthotic services to ensure that the orthosis is designed to facilitate occupational performance at each stage of development.

• The orthosis may address a biomechanical goal such as providing a stable base of support and a functional gait training goal such as increasing the ankle dorsiflexion during toe-off.

• However, if the orthosis does not address the occupational performance goal (such as donning and doffing the device independently) the person may discard the orthosis.

• Thus, OT plays important role to anticipate such patient’s performance issues and initiate effective interventions before design and fabrication decisions have been completed by the orthotist.

Designing the orthosis

• The OT and orthotist works closely during the design phase. • Considerations must be made based on:

Patient’s strength• the weight and force required to use the device

Fine motor strength and coordination• Design and material strapping system

Skin integrity and sensation• Material selection

Status of activities of daily living and functional capabilities• Donning and doffing

Conclusion • Although the orthotics devices is made by the

orthotist, the occupational therapist is typically the one who teaches the user how to perform daily activities while wearing it.

THANK YOU

hemiplegic strokes

Health & Medicine