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Mind Matters

North Dakota Brain Injury Conference

March 26 & 27, 2020

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Brain Injury: StrokeA Neurorehabilitation Approach to Recovery after Stroke

Presenter: Marie Brekken PA-C

Sanford Physical Medicine and Rehabilitation

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OBJECTIVES:

u After this presentation, the attendee should be able to:

u Identify the anatomy of the brain.

u Understand basic functioning of the brain.

u Understand that a stroke is a brain injury.

u Identify two types of strokes.

u Understand BEFAST in seeking medical care for stroke.

u Identify the basic circulation in the brain involved in common strokes.

u Understand basic treatment of a stroke.

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BRAIN INJURYNORTH DAKOTA BRAIN INJURY NETWORK

Defined as an injury to the brain that produces an altered mental state and results in a decrease in cognitive,

behavioral, emotional, or physical functioning.

u ACQUIRED BRAIN INJURY

u TRAUMATIC BRAIN INJURY

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BRAIN INJURYNORTH DAKOTA BRAIN INJURY NETWORKu ACQUIRED BRAIN INJURY (ABI):

u An injury to the brain caused by both internal and external forces

u Examples/Causes:

u STROKE

u Anoxic/Hypoxic such as cardiac arrest, near drowning

u Metabolic disorders such as acute kidney failure, acidosis

u Brain tumors

u Infection

u Drug overdose/alcohol

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BRAIN INJURYNORTH DAKOTA BRAIN INJURY NETWORK

u TRAUMATIC BRAIN INJURY (TBI)u A type of ABI caused by an external source.

u Concussion is a mild TBI without injury evidence on brain scans but results in chemical changes to cells resulting in TBI symptoms.

u Examples/Causes:

u Fall

u Motor Vehicle Accident

u Struck by an object

u Sports

u Shaking syndrome in children

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BRAIN INJURYNORTH DAKOTA BRAIN INJURY NETWORK

Currently, more than 3.1 million children and adults in the U.S. live with a lifelong disability as a result of traumatic brain injury, and 6.4 million have a disability due to stroke. This translates to more than 22,000 North Dakotans living with disability from acquired brain injury – close to the population of Mandan.

Source: NDBIN website.

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FUN FACTS:u The average adult brain weighs 3 pounds.

u The average newborn brain weighs 3/4 of a pound and grows to a little over 1.5 pounds by 3 months.

u Brain maturity is reached by 24 to 25 years of age.

u In women, parts of the frontal lobe and limbic cortex (areas associated with problem-solving and emotional regulation), tend to be bigger than those of men.

u In men, the parietal cortex (associated with the perception of space) and amygdala (linked to social and sexual behavior) tend to be larger than those in women.

u Neurons are the structures that serve as building blocks of the brain and nervous system. They transmit and carry information, allowing different parts of the brain to communicate with one another as well as allowing the brain to communicate with various parts of the body. Researchers estimate that there are around 86 billion neurons in the human brain.

u Information travels at different speeds within different types of neurons (nerve cells). Signals can travel as slow as about 1 mph or as fast as about 268 mph. Involuntary response: 0.3 seconds.

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BASIC ANATOMY OF THE BRAIN

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BRAIN OVERVIEW:u Protected within the skull made up of 8 bones, fused together in an adult.

u Controls all functions of the body.

u Interprets information from the outside world.

u Embodies the essence of who we are: mind and soul.

u Brain is divided into the cerebrum, cerebellum and brainstem

u Consists of two types of brain tissue

u grey matter (cortical: surface of the brain)

u white matter (subcortical: underneath the surface)

u Also contains structures deep in the brain that act to organize and assist communication of messages within and outside of the brain.

u The cerebral cortex is made up of tightly packed neurons and is the wrinkly, outermost layer that surrounds the brain.

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BRAIN OVERVIEW (CONTINUED)

u Our brain governs:u Intelligenceu Creativityu Emotionu Memoryu Cognition (thinking)

u Speech u Movement

u Receives simultaneous information from our five sensesu Sightu Smell

u Touchu Tasteu hearing

u Assembles these messages so that it has meaning for us.u Can store this information in our memory, organize it and retrieve it.

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BRAIN OVERVIEW (continued)

u Neurons are the basic cells of the brain and are connected by axons and dendrites; axons bring in messages, dendrites send out messages.

u Brain has two hemispheres, right and left side.

u The right hemisphere controls the left side of the body.

u The left hemisphere controls the right side of the body.

u The two halves are connected by the corpus callosum.

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TYPES OF BRAIN TISSUE

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CEREBRUM

u The cerebral cortex is divided into four different lobes, frontal, parietal, temporal, and occipital, which are each responsible for processing different types of sensory information.

u Each lobe does not function independently.

u The surface is not smooth and consists of folds (gyrus) and valleys (sulcus) in order to expand the surface area of the brain.

u Complex relationships exist between each lobe and the right and left side of the brain

u The majority of humans are right-handed (85-90%) and this makes sense as our right hand is controlled by the left hemisphere of the brain which is responsible for speech and writing.

u The right hemisphere of the brain controls the left hand and is associated with creativity and imagination.

u About a third of left handed people will have their language center in the right side of the brain.

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RIGHT AND LEFT HEMISPHERES

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CORPUS CALLOSUMConnects the right brain to the left brain.

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CROSS SECTION OF BRAIN

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BASIC IMAGE OF A NEURON

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FUNCTIONS OF THE BRAIN

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FOUR LOBES OF THE CEREBRUM

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OVERVIEW OF FUNCTIONAL AREAS OF THE BRAIN

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DEEP STRUCTURES OF THE BRAIN

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DEEP STRUCTURES OF THE BRAIN

u Hypothalamus

u Body temperature, blood pressure, thirst, sleep, emotions

u Pituitary gland

u Master gland controlling endocrine glands throughout the body

u Pineal gland

u Regulates body’s internal clock, secretes melatonin

u Thalamus

u Relay station for pain sensation, attention, alertness and memory

u Basal ganglia

u Works with cerebellum to coordinate fine motor movements

u Limbic system

u Involved with emotional reactions, learning and memory

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STROKE = BRAIN INJURY

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STROKE FACTS IN THE UNITED STATESu Stroke kills almost 130,000 Americans each year—that’s 1 out of every 20 deaths.

u On average, one American dies from stroke every 4 minutes.

u Every year, more than 795,000 people in the United States have a stroke.

u About 610,000 of these are first or new strokes.

u Roughly 185,00 strokes—nearly one of four—are in people who have had a previous stroke.

u About 87% of all strokes are ischemic strokes.

u Stroke costs the United States an estimated $34 billion each year. This total includes the cost of health care services, medications to treat stroke, and missed days of work.

u Stroke is a leading cause of serious long-term disability.

u Young people are also having an increase in the number of strokes occurring.

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WARNING SIGNS OF STROKE

u Know the warning signs and symptoms of stroke so that you can act fast if you or someone you know might be having a stroke. The chances of survival are greater when emergency treatment begins quickly.

u In one survey, most respondents—93%—recognized sudden numbness on one side as a symptom of stroke. Only 38% were aware of all major symptoms and knew to call 9-1-1 when someone was having a stroke.

u Patients who arrive at the emergency room within 3 hours of their first symptoms often have less disability 3 months after a stroke than those who received delayed care.

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STROKE TYPESu Ischemic Stroke

u Ischemic stroke occurs when a vessel supplying blood to the brain is obstructed.

u It accounts for about 87 percent of all strokes.

u Hemorrhagic Stroke (Bleeds)

u Occurs when a weakened blood vessel ruptures.

u Hemorrhagic strokes make up about 13 percent of stroke cases.

u Transient Ischemic Attack (TIA)

u Not considered a stroke type

u A temporary blockage of blood flow to the brain that doesn’t cause permanent damage.

u TIAs may signal a full-blown stroke ahead; 50% occurrence within 2 days

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TYPES OF STROKES

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ISCHEMIC STROKE (CLOT)u Fatty deposits lining the vessel walls, called atherosclerosis, are the

main cause for ischemic stroke.

u Two types of obstruction:

u Cerebral thrombosis is a thrombus (blood clot) that develops at the fatty plaque within a large blood vessel in the brain.

u Cerebral embolism is a blood clot that forms at another location in the circulatory system, usually the heart and large arteries of the upper chest and neck. Part of the blood clot breaks loose, enters the bloodstream and travels through the brain’s blood vessels until it reaches vessels too small to let it pass called a lacunar stroke,

u A main cause of embolism is an irregular heartbeat called atrial fibrillation. It can cause clots to form in the heart, dislodge and travel to the brain.

u A clot stroke can occasionally lead to a hemorrhagic conversion.

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HEMORRHAGIC STROKE (BLEED)

u The most common cause of hemorrhagic stroke is uncontrolled high blood pressure.

u The two types of hemorrhagic strokes

u intracerebral (within the brain) hemorrhage - ICH

u subarachnoid hemorrhage - SAH

u The blood accumulates and compresses the surrounding brain tissue.

u A hemorrhagic stroke occurs when a weakened blood vessel ruptures.

u Two types of weakened blood vessels usually cause hemorrhagic stroke

u aneurysms

u arteriovenous malformations(AVMs)

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ARTERIAL BLOOD SUPPLY TO THE BRAIN

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MOST COMMON BLOOD VESSELS IN STROKE

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FUNCTIONAL AREAS THAT CAN BE AFFECTED BY A STROKE

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STROKE MANAGEMENTu Restore circulation to the brain as soon as possible (“clot buster”)

u Treat blood pressure

u Start on prevention medications

u Blood pressure

u Antiplatelet (prevent/minimize blood clots)

u High dose statin (cholesterol drug)

u Control blood sugar

u Strive for reducing weight if overweight/obese

u Increase exercise

u Rehabilitation

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MULTIDISCIPLINARY APPROACH IN STROKE RECOVERY

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REHABILITATION

u Multidisciplinary teamu Many membersu Speech therapy

u Occupational therapy

u Physical therapy

u Seen as soon as medically stabilized and diagnostic work up is completed.

u Better outcome/recovery the sooner intensive rehabilitation can begin.

u Inpatient rehabilitation followed by outpatient therapy is ideal.

u Recovery depends on many factors but neurologic return does not happen quickly, can take months.

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Speech Language Pathology A Neurorehabilitation Approach to Recovery after Stroke

Heidi Fiskness, MS CCC-SLP

Certified Brain Injury Specialist

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Speech Language Pathology (SLP)

u Speech-language pathologists (SLPs) work to assess, diagnose, prevent, and treat speech, language, voice, social communication, cognitive-communication, and swallowing disorders

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SLP + Strokeu Provide care at the acute hospital, inpatient rehab, home health, outpatient, or community

levels

u Review neuroimaging and medical charts

u Interview patient and their family members

u Assess patient’s skills with formal and informal evaluations

u Provide therapy interventions to meet patient goals

u Assist with return to household demands, driving, work, school, independent living

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Languageu Aphasia – difficulty with languageu Receptive Aphasia (Wernicke’s Aphasia)– impaired comprehension of language

u Difficulty understanding yes/no or simple questionsu Problems with following commands/directionsu Difficulties reading words, phrases, sentences, or paragraphsu Verbal expression is fluent, but may not make any sense

u Expressive Aphasia (Broca’s Aphasia) – impaired verbal or written language outputu Difficulty saying basic words or may omit wordsu Speak in very short sentencesu Problems with naming objects, places, or peopleu Issues with “finding” words in conversation

u Difficulties listing items or generating independent sentences/commentsu Problems writing language/information down

u Global Aphasia – impaired comprehension and expression

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Speech Production and VoiceDysarthria – unclear speech productions when talking

u Patient’s speech may be slurred or mumbled with unclear, hard to understand productions due to facial muscle weakness or coordination struggles

u Speech sounds can be distorted or unclear

u Patients can use too fast or even a very slow rate when talking

u Breathing coordination and control can result in changes in one’s vocal inflection or tone

Apraxia – deficits with the planning or motor programming for movements for speech

u Patient may produce clear and accurate words and productions in one instance, but then present with an incorrect production the next

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SwallowingDysphagia – difficulty with swallowing

u Patients muscles may lose function or strength and the coordination of these muscles may become impaired to the point that eating and drinking is no longer safe

u Patients may require diet changes for the food and liquidsu Clinical presentation may look like: food pocketing in their mouth,

repetitive swallowing to try get food down, throat clearing or coughing, complaints of food sticking, a gurgly or wet voice, recurrent pneumonia, weight loss, choking, or food avoidances.

Aspiration concerns:u Occur when patients are at risk of their foods and liquids going the wrong

way into their airway and lungsu Aspiration of food or liquids is very serious diseaseu Aspiration pneumonia it is a very debilitating disease and can be deadly

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Cognitive-Linguisticu Cognitive-Linguistic Deficits

u Patients may present with impaired attentionu Difficulty with problem solvingu Trouble with memory recallu A slower processing speed with thinking tasksu Trouble with organization or categorization of thoughts and demands;

u Impaired executive function skillsu Initiation (starting a task)

u Inhibition (stopping a task)

u Judgement

u Planning

u Execution of plan

u Working memory

u Mentally shifting

u Decreased awareness or understanding/insight into difficulties

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The overall objective of SLP services is to optimize individuals' swallowing and cognitive-linguistic abilities and thereby

improve quality of life

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Occupational TherapyA Neurorehabilitation Approach to Recovery after Stroke

Alexis Nims, MOT, OTR/L

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Occupational Therapy and Strokeu Stroke is one of the leading causes of adult disability in the United States (Go

et al., 2013)

u Following a stroke, individuals are faced with multiple challenges

u OT is instrumental in addressing these challenges at all stages of the continuum of care (AOTA, 2014)

u Hospitals

u Rehab facilities

u Home healthcare

u Outpatient therapy

u Community-based services

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Occupational Therapy’s Role

u Increase quality of life

u Help individuals achieve health, well-being, and get back to engaging in daily activities

u Collaborate with patients and their families or caregivers

AOTA, 2015

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Occupational Therapy’s Role

u Occupational therapists help individuals return to participating in daily occupations

u What are occupations?

u Daily tasks that occupy your time

AOTA, 2015

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Occupationsu Activities of daily living (ADLs)

u Feeding/eatingu Grooming/hygieneu Dressingu Toiletingu Showering/bathing

u Functional mobility

u Instrumental activities of daily living (IADLs)u Home management

u Financial managementu Medication/health managementu Caregivingu Community mobility

u Sleep and restu Work and school

u Leisureu Social engagement

AOTA, 2014

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Stroke Deficits Addressed by OT

Vision- Visual field- Ocular motility- Visual processing- Midline shift- Neglect

Functional Cognition- Attention- Memory- Executive function- Processing speed and

reaction time- Safety

Sensation- Proprioception- Stereognosis- Temperature

differentiation- Tactile

discrimination

Physical Impairments- Range of motion- Strength- Coordination- Tone- Edema/Swelling

Emotional well-being

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OT Treatment Approaches for Stroke

Restorative Approachu Task-specific training

u Constraint-induced movement therapy

u Functional electrical stimulation

u Mirror therapy

u Sensory re-education

u Edema management

u Splinting

u Stretch and strength training

u Cognitive retraining

u Vision retraining

Adaptive Approach

u Home modifications

u Adaptive equipment

u One-handed techniques

u Assistive technology

u Return to work or school accommodations

AOTA, 2015

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Occupational Therapy and Stroke

“Occupational therapy practitioners understand the importance of emotional well-being, social connections, and healthy life habits for individuals post-stroke. In addition to ongoing physical rehabilitation as needed, they engage stroke survivors and family members to take charge of their lives, create human connections, and lead healthy lifestyles.” – American Occupational Therapy Association

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Physical TherapyA Neurorehabilitation Approach to Recovery after Stroke

Diana Palm, PT, DPT

Board Certified Clinical Specialist in Neurologic Physical Therapy

Certified Exercise Expert for the Aging Adult

Certified Brain Injury Specialist

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Physical Therapist

Physical therapists (PTs) are movement experts who improve quality of life through prescribed exercise, hands-on care, and patient education. (choosept.com)

A neurologic physical therapist is a physical therapist who specializes in the evaluation and treatment of individuals with movement problems due to disease or injury of the nervous system. Physical therapists can help improve or restore the mobility you need to move forward with your life. (APTA Neuro Section)

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PT Evaluation

u Strength

u Range of Motion

u Sensation

u Reflexes

u Tone

u Transfers

u Balance

u Gait

u Equipment

u Home evaluation

u Exercise program

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Goals for PT

u Improve quality of life

u Independence

u Safety

u Return home

u Return to work

u Return to recreational or social activities

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Continuum of Careu Acute care

u Early mobilization, medical stability

u Rehab

u Maximize recovery with intense therapy and return home

u Skilled Nursing Facility

u Continued therapy working towards maximizing recovery

u Home Health

u Improve function at home and prepare for progression to outpatient

u Outpatient

u Continued recovery of function, return to previous activities

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Recovery vs Compensation

RecoveryReturn to activities how you completed them prior to stroke

u Normal strength

u Normal gait pattern

CompensationUse various adaptations to complete activities

u Bracing

u Assistive devices

u Wheelchairs

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PT Treatment

Gait

Posture

Strength

Range of Motion

Balance

Transfers

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Our goal is to help our patients be as independent and safe as possible to

allow them to participate in the activities they enjoy

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References:American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process (3rd ed.). American Journal of Occupational Therapy, 68, S1–S48. doi:10.5014/ajot.2014.682006

American Occupational Therapy Association. (2015). The Role of Occupational Therapy in Stroke Rehabilitation. Retrieved from https://www.aota.org/About-Occupational-Therapy/Professionals/RDP/stroke.aspx

American Speech-Language-Hearing Association. (2016). Scope of Practice in Speech-Language Pathology. Available from www.asha.org/policy.

Brookshire, R. H. (2007). Introduction to Neurogenic Communication Disorders. St. Louis, MS: Elsevier Mosby.

Duffy, J. R. (2005). Motor Speech Disorders: Substrates, Differential Diagnosis, and Management. St. Louis, MS: Elsevier Mosby.

Go, A., Mozaffarin, D., Roger, V. L., Benjamin, E., Berry, J. D., Borden, W., …Turner, M. (2013). Heart disease and stroke statistics 2013 update. Circulation, 127, e6–e245

Logemann, J. A. (1998). Evaluation and Treatment of Swallowing Disorders. Austin, Tx: Pro-Ed, Inc.

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QUESTIONS???

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