1. Stroke & Brain Injury
Madison Magilton

2. Overview Statistics Pathophysiology & Etiology Diagnosis Treatment
Exercise

3. Statistics 5th leading cause of death A stroke occurs every 40 seconds
A leading cause of disability in the U.S.
15-30% of stroke survivors are permanently disabled
800,000 Americans have a stroke each year

4. What is a Stroke? A brain injury caused by:
Lack of blood flow (vascular ischemia)
Intracerebral hemorrhage
The sudden death of brain cells in a localized area due to inadequate blood flow

5. Types of Strokes
Ischemic: Blockage of a blood vessel supplying the brain
Thrombotic
Embolic
Hemorrhagic: Bleeding in or around the brain
Intracerebral
Subarachnoid
Transient Ischemic Attack: “mini stroke”

6. Risk Factors
Hypertension, dyslipidemia, hypercholesterolemia, diabetes mellitus, sickle cell disease, atrial fibrillation, coronary artery disease, previous TIA
Unhealthy diet, physical inactivity, obesity, excessive alcohol consumption, tobacco use
Age, gender, ethnicity, family history

7. Acute Signs & Symptoms
Blurred vision, sudden confusion, sudden loss of coordination or balance, sudden severe headache
Act “FAST”
Face
Arm
Speech
Time

8. Myelinated Fibers Lost
Time is Brain
Estimated Pace of Neural Circuitry Loss in Typical Large Vessel, Supratentorial Acute Ischemic Stroke
Neurons Lost
Synapses Lost
Myelinated Fibers Lost
Accelerated Aging
Per Stroke
1.2 billion
8.3 trillion
7140 km/4470 miles
36 y
Per Hour
120 million
830 billion
714 km/447 miles
3.6 y
Per Minute
1.9 million
14 billion
12 km/7.5 miles
3.1 wk
Per Second
32 000
230 million
200 meters/218 yards
8.7 h

9. Chronic Complications
Memory loss and paralysis
Brain damage causes paralysis on opposite side of the body
Hemiplegia
Hemiparesis
Pneumonia, seizures, depression, bed sores, deep vein thrombosis (DVT)
Limb contractures

10. Diagnosis Ischemic strokes: Hemorrhagic strokes:
Ultrasound, MRI, and angiography
Hemorrhagic strokes:
CT scan
Must determine the cause of the stroke!

11. Treatment: Prevention
Goal: Treat underlying risk factors
Pharmacological
Antihypertensive medications
Anticoagulation medications
Surgical
Carotid endarterectomy
Angioplasty/ stents

12. Treatment: Immediately after Stroke
Depends on type of stroke
Ischemic:
Tissue plasminogen activator (tPA) is the gold standard
Anticoagulants, antiplatelet medicine
Intra-arterial thrombolysis
Mechanical clot removal in cerebral ischemia (MERCI)

13. Treatment: Immediately after Stroke
Hemorrhagic:
Stop the bleeding
Aneurysm clipping
Coil embolization
AVM repair

14. Treatment: Post-stroke Rehabilitation
Standard stroke care: months after stroke focuses on basic mobility function and recovery of ADL
Physical therapy
Occupational therapy
Speech therapy

15. Exercise after Stroke Hemiplegic gait Reduced functional capacity
Effects on Exercise
Exercise Testing
Hemiplegic gait
Reduced functional capacity
Increased energy demands
Decreases in muscular strength and endurance
Compromised range of motion
Same contraindications as a normal population
Be aware of hypertension and unstable angina
Graded treadmill test with handrail support is appropriate if patient can achieve a walking speed of 0.5 mph

16. American Heart Association Recommendation
Mode of Exercise
Major Goals
Frequency/Intensity/Duration
Aerobic
Increase independence in ADLs, increase walking speed/efficiency, improve tolerance for prolonged physical activity, reduce risk of CVD
RPE 11-14
3-7 days/week
20-60 min/session (or multiple 10 min sessions)
Strength
Increase independence in ADLs
1–3 sets of 10–15 repetitions of 8–10 exercises involving the major muscle groups
2-3 days/week
Flexibility
Increase ROM in involved extremities, prevent contractures
2-3 days/week (before or after strength or aerobic exercise)
Hold seconds

17. Case Study
Robert is a 65 year old male referred by a physician to your facility after experiencing a stroke. He wants to improve his quality of life. Your screening reveals the following:
Height 6’0 (1.83m) – weight 253.5lbs (115kg)
Resting Blood Pressure: 124/88mmHg; Resting Heart Rate: 82 bpm
4 months post-stroke; currently inactive
Non-smoker
Left side hemiparesis, speech impediment
History of sudden death on father’s side at age 43, mother had an MI at age 70
FBG: 90 mg/dl
LDL: 110 mg/dl; HDL: 45 mg/dl
Medications: Hydrochlorothiazide (diuretic), ramipril (ACE inhibitor)

18. Case Study: Continued
Patient has 5 cardiovascular disease risk factors (obesity, sedentary lifestyle, hypertension, age, family history)
HIGH RISK
Medical exam required before exercise; MD supervision of exercise test
Exercise BP will be lower than expected due to ACE inhibitor and diuretic medication
Program will focus on overall improvement in health with focus on functional capacity

19. Exercise Testing
Aerobic
Resistance/ ROM
A graded treadmill test with ECG was performed with handrails for support
The speed was self-selected by the patient
2% increase in grade every 2 minutes
Result: No significant ECG findings, peak HR 140 bpm, peak BP 146/88
10 RM was performed for various exercises
Timed Get Up and Go test
Sit to Stand test
Range of motion measured with goniometer
Sit and Reach test

20. Exercise Prescription
Training Method
Frequency
Intensity
Time
Type
Aerobic
3-5 days/week
40-50% of HRR, progression to ~80%
15 min, progression to 30 min
Supported treadmill walking, water exercises
Resistance
As tolerated
10-15 repetitions, 1 set
Body weight exercises, elastic resistance bands
Range of Motion
Below a point of discomfort
10-20 minutes
Passive movement

21. Conclusion Stroke is a medical emergency Act “FAST”
ACSM considers stroke patients high risk
Be aware of patient’s comorbidities and medications
Exercise program should focus on improving functional capacity and ability to perform ADLs

22. References
Gordon, N. (2004). Physical Activity and Exercise Recommendations for Stroke Survivors: An American Heart Association Scientific Statement From the Council on Clinical Cardiology, Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention; the Council on Cardiovascula.Circulation, 
How Is a Stroke Treated? (n.d.). Retrieved December 30, 2015, from
Let's Talk About Stroke Patient Information Sheets. (n.d.). Retrieved December 30, 2015, from About-Stroke-Patient-Information-Sheets_UCM_310731_Article.jsp#.VoQ2S_krLIX
Pescatello, L., Arena, R., Riebe, D., & Thompson, P. (Eds.). (2014). ACSM's guidelines for exercise testing and prescription (9th ed.). Lippincott Williams & Wilkins.
Saver, J. (2005). Time Is Brain--Quantified. Stroke, 36,
Stroke. (2013). In J. Ehrman, P. Gordon, P. Visich, & S. Keteyian (Eds.), Clinical Exercise Physiology (3rd ed., pp ). Human Kinetics.
Stroke. (n.d.). Retrieved December 30, 2015, from dictionary.thefreedictionary.com/stroke
Stroke. (2015, November 3). Retrieved December 30, 2015, from