Understanding Stroke and Rehabilitation __________________ Michelle Camicia, MSN, RN, CRRN

Objectives Learn the signs and symptoms of a stroke and what actions to take Know how to reduce your risk for having a stroke Become familiar with treatment of stroke, including rehabilitation

Be Stroke Smart Recognize: stroke symptoms Reduce: stroke risk Respond : at the first sign of stroke, Call 911 immediately! The 3 R’s of Stroke:

Stroke Facts Third leading cause of death in the United States 795,000 Americans suffer strokes each year 144,000 deaths each year in U.S. - From 1995 to 2005, the stroke death rate fell 29.7% 6 million stroke survivors in U.S.

Stroke Facts The leading cause of adult disability –1/3 severely impaired –1/3 moderately impaired –1/3 mild or no impairment Up to 80% of all strokes are preventable Every 45 seconds, someone suffers a stroke –Someone dies every 3 minutes from a stroke

Women & Stroke Stroke kills more than twice as many American women every year as breast cancer More women than men die from stroke –Account for > 60% of all stroke deaths –Women tend to be older at time of stroke Women over age 30 who smoke and take high-estrogen oral contraceptives have a stroke risk 22 times higher than average

African Americans & Stroke Incidence is nearly double that of Caucasians African Americans suffer more extensive physical impairments Twice as likely to die from stroke Disproportionately high incidence of risk factors for stroke –Hypertension –Diabetes –Obesity –Smoking –Sickle cell anemia

Well-known Stroke Survivors Mary Kay Ash Charles Schultz Harry Caray Charles Dickens Teddy Bruschi Ted Williams President Gerald Ford Ed Koch Sharon Stone Della Reese Kirk Douglas Roy Horn of Siegfried & Roy

Definition of Stroke Sudden brain damage Lack of blood flow to the brain caused by a clot or rupture of a blood vessel Ischemic = Clot (makes up approximately 85% of all strokes) Hemorrhagic = Bleed - Bleeding around brain - Bleeding into brain EmbolicThrombotic

Blood Supply to the Brain Many arteries and their branches carry blood to the brain. Each artery supplies specific areas of the brain, but some brain areas are supplied by more than one artery. Lack of blood supply to the brain by a blockage or rupture causes a stroke.

Ischemic Stroke There are two types of ischemic or clot-caused strokes, thrombotic and embolic. A blood clot that forms within an artery that supplies blood to the brain may lead to a thrombotic stroke. A plaque fragment or blood clot that travels to the brain from the heart or another artery supplying the brain causes an embolic stroke. These types of blockages in the arteries may be due to atherosclerosis or hardening of the arteries caused by cholesterol or plaque build-up.

Intracerebral Hemorrhage Hemorrhages that are caused by bleeding from blood vessels within the brain are called intracerebral. High blood pressure may cause small blood vessels to bulge and eventually burst spilling blood into the brain. The bleeding damages brain cells and the damaged area cannot function properly.

Aneurysm A weakness in an arterial wall may balloon out, forming a thin-walled bubble on an artery (aneurysm, inset). A rupture in an aneurysm may lead to subarachnoid hemorrhage.

Motor and Sensory Function, side view The human brain is divided into regions that control various motor (movement) and sensory functions. Some of these regions are shown in this view of the right side of the brain. The damage from stroke to a specific region may affect the functions it controls, causing symptoms such as paralysis (loss of movement), difficulty speaking, or loss of coordination.

Left Hemisphere The left side (or hemisphere) of the brain controls the motor and sensory functions of the right side of the body. Right Hemisphere The right side of the brain controls the motor and sensory functions of the left side of the body. Functions of the Cerebral Hemispheres The right cerebral hemisphere of the brain controls artistic functions, such as music, art awareness, and insight. The left hemisphere is responsible for scientific functions, understanding written and spoken language, number skills, and reasoning.

Brain Attack! Stroke is a “Brain Attack.” Stroke happens in the brain not the heart Stroke is an emergency. Call 911 for emergency treatment.

Stroke Symptoms Sudden and severe headache Trouble seeing in one or both eyes Sudden dizziness Trouble walking Sudden numbness or weakness of face, arm or leg Sudden confusion Trouble speaking If you observe any of these symptoms, call 911 immediately. Every minute matters!

Think FAST! F = Face: ask the person to smile A = Arm: ask the person to raise both arms S = Speech: ask the person to speak a simple sentence T = Time: to call 911 Every minute matters!

Some Reasons People Don’t Seek Immediate Treatment Don’t recognize symptoms Denial – don’t want fears confirmed Think symptoms will go away – “wait & see” Worry about cost Think nothing can be done Fear of hospitals *only 40% reach hospital within 24 hours

TIA or Mini-Stroke Transient ischemic attack (TIA) is a warning sign of a future stroke - more than 1/3 of TIA patients will have a future stroke –11% will have a stroke within 3 months Symptoms of TIAs are the same as stroke TIA symptoms can resolve within minutes or hours It is important to seek immediate medical attention if you suspect that you are having or have had a TIA

The Perceptions of Stroke Myth Stroke is not preventable Stroke cannot be treated Stroke only strikes the elderly Stroke recovery ends after 6 months Reality Up to 80% percent of strokes are preventable Stroke requires emergency treatment Anyone can have a stroke Stroke recovery can last a lifetime

Risk Factors for Stroke Non-modifiable Age Gender Race Family History Previous stroke Modifiable High blood pressure High cholesterol Smoking Obesity Diabetes Atrial fibrillation Alcohol use

Up to 80% of strokes are preventable! National Stroke Association developed the following guidelines to help people reduce their risk for stroke…

National Stroke Association’s Stroke Prevention Guidelines 1.Know your blood pressure. Have it checked at least annually. If it is elevated, work with your doctor to control it. 2.Find out if you have atrial fibrillation (AF) – a type of irregular heartbeat. If you have it, work with your doctor to manage it. 3.If you smoke, stop.

National Stroke Association’s Stroke Prevention Guidelines (continued) 4. If you drink alcohol, do so in moderation. 5. Know your cholesterol number. If it is high, work with your doctor to control it. -If Total cholesterol > 200 mg/dl, or LDL cholesterol is > 100 mg/dl 6. If you are diabetic, follow your doctor’s recommendations carefully to control your diabetes.

National Stroke Association’s Stroke Prevention Guidelines (continued) 7. Include exercise in your daily routine 8. Enjoy a lower sodium (salt) and lower fat diet 9.If you have circulation problems, work with your doctor to improve your circulation. 10.If you experience any stroke symptoms, call 911 immediately. Every minute matters!

Acute Stroke Treatments

Ischemic stroke (Brain Clot) Clot busting medication: t-PA (Tissue Plasminogen Activator) Clot-removing devices: MERCI Retriever, Penumbra Hemorrhagic Stroke (Brain Bleed) Clipping, Coiling

tPA for Acute Ischemic Stroke “clot-buster” drug Can reduce the effects of stroke and reduce disability FDA-approved in 1996 Must be administered within 3 hours –“time window” may be expanded to 4.5 hrs Only 1.3 to 3% receive it

MERCI Retriever FDA approved 2004 For patients ineligible for or failed tPA Mechanical Embolus Remover in Cerebral Ischemia

Penumbra Device FDA-approved late 2007 Aspiration and Extraction of large-vessel thromboembolism Up to 8 hours after stroke

Aneurysm Clipping for hemorrhagic stroke

Coil Embolization for hemorrhagic stroke

Stroke Recovery and Rehabilitation

Physical Medicine and Rehabilitation An established medical specialty “Physicians of Function” Work with other rehab specialists and doctors on complex problems like stroke, brain injury, spinal cord injury The Physiatrist

Possible impairments after stroke Weakness Swallowing difficulties Speech problems Language problems Loss of Bowel and bladder control Loss of sensation or numbness Memory / thinking difficulties Vision problems Muscle tightness

Life Changes for Stroke Survivors and Family Behavior Depression & Anger Emotional Liability One-sided Neglect Memory Loss Communication Problems Daily living skills Dressing and grooming Diet, nutrition and eating difficulties Skin care problems Pain Sexuality/Intimacy

Prevent / manage complications Help patient regain functional independence –Mobility, ADLs, communication Learn techniques to offset or adapt to any physical disabilities Evaluate for adaptive equipment Elements of Stroke Rehabilitation

Educate patient and family Reduce caregiver burden Maintain long-term function Resume family and community life

The Rehabilitation Continuum Acute hospitalization Acute Inpatient Rehabilitation Home-health therapy Home with outpatient therapy Skilled Nursing Facility therapy Community-based programs

Interdisciplinary Treatment in Rehabilitation Physician Occupational Therapists Psychologist Recreation Therapist Rehab nurses Physical Therapists Speech pathologists Case Manager Social Worker

Mobility Pain Incontinence Daily activities Interdisciplinary Treatment in Rehabilitation Swallowing Thinking Communication Emotions

Interdisciplinary Treatment in Rehabilitation Rehab team meets twice weekly Set functional goals Identify strengths and barriers to progress Personalize treatment plan

General Recovery Guidelines 10% of survivors recover almost completely 25% recover with minor impairments 40% experience moderate to severe impairments requiring special care 10% require care within either a skilled-care or other long-term care facility 15% die shortly after the stroke

Natural History of Motor Recovery Greatest neurologic recovery during first 3 to 6 months slow recovery up to one year slower functional recovery continues

Stroke Recovery Some brain cells may be only temporarily damaged and may resume functioning In some cases, the brain can “relearn” what was lost Often a region of the brain “takes over” for a region damaged by the stroke

Recent Advances in Rehabilitation

BOTOX for muscle spasticity

ITB therapy for muscle spasticity

Evolution of AFOs

Functional Electrical Stimulation Devices

Body Weight Support Treadmill Training

YOU Can Reduce the Impact of Stroke Stroke is a Brain Attack and is often preventable and treatable Remember the 3 R’s of Stroke and Act FAST! –Reduce Risk –Recognize Stroke Symptoms –Respond immediately: Call 911 Every minute matters!

National Stroke Association STROKES ( )