What ancillary procedures would be helpful in your diagnosis?

Imaging Brain scan (CT scan or MRI scan) determine the type of stoke (ischemic or hemorrhagic) and may detect rare conditions which may caused the stroke, or which may mimic stroke Ultrasound scan of the carotid arteries in the neck (Carotid Doppler Ultrasound) To look for narrowing or stenosis and decreased blood flow in carotid arteries Stroke is diagnosed through several techniques: a neurological examination (such as the Nihss), CT scans (most often without contrast enhancements) or MRI scans, Doppler ultrasound, and arteriography. The diagnosis of stroke itself is clinical, with assistance from the imaging techniques. Imaging techniques also assist in determining the subtypes and cause of stroke. There is yet no commonly used blood test for the stroke diagnosis itself, though blood tests may be of help in finding out the likely cause of stroke. A physical examination, including taking a medical history of the symptoms and a neurological status, helps giving an evaluation of the location and severity of a stroke. It can give a standard score on e.g. the NIH stroke scale.

Imaging Chest X-ray or ECG Blood tests to check for heart or lung conditions which may be a cause of stoke. (eg. Atrial fibrillation associated with embolic stroke) Blood tests To check how fast the blood would clot and whether the blood sugar is abnormally high or low or critical blood chemicals are out of balance Carotid Doppler ultrasound: A carotid Doppler ultrasound is a non-invasive test that uses sound waves to look for narrowing or stenosis and decreased blood flow in the carotid arteries (the major arteries in the front of the neck that supply blood to the brain). Blood tests to check on such things as blood sugar level and cholesterol level. High levels can increase the risk of a further stroke.

How would you grade for spasticity?

Ashworth Scale for grading Spasticity Grade Description 1 No increase in muscle tone 2 Slight increase giving a catch when part is moved in flexion or extension 3 More marked increase in tone but only after part is easily flexed 4 Considerable increase in tone 5 Passive movement is difficult and affected part is rigid in flexion or extension. The Ashworth scale is one of the most widely used methods of measuring spasticity, due in a large part to the simplicity and reproducible method.

What complications are present?

Depend on which area of the brain was damaged.

COMPLICATIONS Generally, stroke can cause five types of disabilities: paralysis or problems controlling movement Hemiplegia, hemiparesis, ataxia, dysphagia sensory disturbances including pain Paresthesia, neuropathic pain, loss of urinary continence, constipation problems using or understanding language (aphasia) problems with thinking and memory Shortened attention spans, deficit short-term memory Anosognosia and neglect emotional disturbances depression A. Paralysis is one of the most common disabilities resulting from stroke. The paralysis is usually on the side of the body opposite the side of the brain damaged by stroke, and may affect the face, an arm, a leg, or the entire side of the body. This one-sided paralysis is called hemiplegia (one-sided weakness is called hemiparesis). Stroke patients with hemiparesis or hemiplegia may have difficulty with everyday activities such as walking or grasping objects. Some stroke patients have problems with swallowing, called dysphagia, due to damage to the part of the brain that controls the muscles for swallowing. Damage to a lower part of the brain, the cerebellum, can affect the body's ability to coordinate movement, a disability called ataxia, leading to problems with body posture, walking, and balance. B. Stroke patients may lose the ability to feel touch, pain, temperature, or position. Sensory deficits may also hinder the ability to recognize objects that patients are holding and can even be severe enough to cause loss of recognition of one's own limb. Some stroke patients experience pain, numbness or odd sensations of tingling or prickling in paralyzed or weakened limbs, a condition known as paresthesia. Stroke survivors frequently have a variety of chronic pain syndromes resulting from stroke-induced damage to the nervous system (neuropathic pain). Patients who have a seriously weakened or paralyzed arm commonly experience moderate to severe pain that radiates outward from the shoulder. Most often, the pain results from a joint becoming immobilized due to lack of movement and the tendons and ligaments around the joint become fixed in one position. This is commonly called a "frozen" joint; "passive" movement at the joint in a paralyzed limb is essential to prevent painful "freezing" and to allow easy movement if and when voluntary motor strength returns. C. Damage to a language center located on the dominant side of the brain, known as Broca's area, causes expressive aphasia. People with this type of aphasia have difficulty conveying their thoughts through words or writing. They lose the ability to speak the words they are thinking and to put words together in coherent, grammatically correct sentences. In contrast, damage to a language center located in a rear portion of the brain, called Wernicke's area, results in receptive aphasia. People with this condition have difficulty understanding spoken or written language and often have incoherent speech. Although they can form grammatically correct sentences, their utterances are often devoid of meaning. D. Two fairly common deficits resulting from stroke are anosognosia, an inability to acknowledge the reality of the physical impairments resulting from stroke, and neglect, the loss of the ability to respond to objects or sensory stimuli located on one side of the body, usually the stroke-impaired side. Stroke survivors who develop apraxia lose their ability to plan the steps involved in a complex task and to carry the steps out in the proper sequence. Stroke survivors with apraxia may also have problems following a set of instructions E. Clinical depression, which is a sense of hopelessness that disrupts an individual's ability to function, appears to be the emotional disorder most commonly experienced by stroke survivors. Signs of clinical depression include sleep disturbances, a radical change in eating patterns that may lead to sudden weight loss or gain, lethargy, social withdrawal, irritability, fatigue, self-loathing, and suicidal thoughts. http://www.ninds.nih.gov/disorders/stroke/poststrokerehab.htm

What rehabilitation treatments would the patient benefit from What rehabilitation treatments would the patient benefit from? Include physical agents and exercises.

REHABILITATION TREATMENTS Process by which a stroke survivor works with a team of health care providers to regain as much function lost after a stroke as possible Directed towards educating the patient and family (about the neurologic deficit) Preventing complications of immobility (DVT, pneumonia, pressure sores) Providing encouragement and instruction in overcoming the deficit GOAL: return the patient to home and maximize recovery Includes: Physical Occupational Speech therapy

Traditional methods for rehabilitation of motor deficits after stroke, including: Conventional range of motion and muscle strengthening exercises Neurodevelopmental training (also known as the Bobath technique) Proprioceptive neuromuscular facilitation Brunnstrom technique Rood technique

Bobath’s neurodevelopmental technique approach Aims to inhibit spasticity and synergies, using inhibitory postures and movements, and to facilitate normal autonomic responses that are involved in voluntary movement.

Proprioceptive neuromuscular facilitation Relies on quick stretching and manual resistance of muscle activation of the limbs in functional directions, which often are spiral and diagonal in direction.

Brunnstrom’s Movement Therapy Approach Emphasized the synergistic patterns of movement that develop during recovery from hemiplegia. This encourages the development of flexor and extensor synergies during early recovery, hoping that with training, synergistic activation of muscle would have transition into voluntary activation.

Rood technique Involves superficial cutaneous stimulation using stroking, brushing, icing, or muscle stimulation with vibration, to evoke voluntary activation.

Occupational Therapy Primary role of the Occupational Therapist (OT) is to assist their patients to have the maximum independence in as many areas of their life as possible. According to a study, patients who had received occupational therapy after a stroke were more independent in performing their personal activities of daily living and were more likely to maintain these abilities.

SPEECH THERAPY Recommended for stroke survivors with aphasia, dysphagia Patient (+) slurred speech, dysarthria drooling