1.
STROKE
HIMANI KAUSHIK

2.
Stroke:
• Also known as Cerebrovascular Accident (CVA)
• Results in the sudden death of the brain cells due
to the:
O2 deficiency when the blood flow to the
brain is lost by obstruction/rupture of
cerebral arteries which supplies to the brain1.
• Loss of neurological functions, lasting more
than 24 hours or leading to death.

3.
• CVA is distinguished from transient ischemic
attack2:
TIA defined as a temporary interruption of
blood supply to the brain may last for few
minutes to 24 hours with no evidence of
infarction.
• Residual neurological deficits are those that persist
longer than 3 weeks3.
• Reversible ischemic neurological deficits are
resolve spontaneously as brain swelling subsides,
generally within 3 weeks3.

4.
• Worldwide, stroke is the 2nd leading cause of
mortality rate and the 3rd leading cause of
disability1.
• Globally, 70% of CVA and 87% of both CVA
related mortality rates and disability adjusted life
year (DALY) occur in low and middle income
territories1.

5.
Types and Pathology of Stroke
• The pathology and etiology of subtypes of stroke vary among
populations of different age, race, ethnic origin and
nationality.

6.
Ischemic stroke2,4:
• Most common type of stroke, affecting about 87% of all
stroke cases.
• Caused by thrombus, emboli, impaired cerebral blood
flow and lack of essential oxygen and nutrients.
• Etiologically, subtypes of ischemic stroke are classified:
i. Acc. to the TOAST classification,
ii. ASCOD phenotyping system: (A: atherosclerosis,
S:small vessels disesase, C: cardiac conditions, O:
any other causes, D: dissection (i.e. cryptogenic)),
iii. and the causative classification system.

7.
Hemorrhagic stroke2,4:
• When abnormal bleeding occurs into the extravascular
areas of the brain, results from the rupture of cerebral
blood vessels or trauma.
• Affecting about 13% of the all stroke cases.
• The most common causes are: hypertension (30-60%),
cerebral amyloid angiopathy (10-30%), anticoagulations
(1-2%) and vascular structural lesions (3-8%) and
undetermined causes (5-20%).
• It is classified according to its anatomical site or expected
etiology. The most common sites of intracerebral
hemorrhage (IH) are: supraperitoneal (85-95%),
including deep (50-75%) and lobar(25-40%).

8.
Risk factors5
• Risk factors are:
i. Modifiable (diet, PA, smoking, obesity, HTN, etc.)
ii. Non-modifiable (age, gender, genetic etc.)
• Stroke prevention requires management of the many risk
factors important to the stroke development.

9.
 Hypertension:
• Most common modifiable risk factor for stroke
• The specific target for BP less than
140/90mmHg in patients with an ischemic
stroke and 130/80mmHg for lacunar strokes
 Hyperlipidemia:
• Narrowing and hardening of artery.

10.
 Diabetes mellitus and metabolic disorders:
• Are at higher risks for recurrent ischemic stroke and
for the occurrence of new TIA cases
• Metabolic disorders increases chances of 1.5 to 2.3
times in women
 Obesity:
• one of the risk factor of ischemic stroke
• with every one unit increase in body mass index
(BMI), increases chances about 5%
 Another important risk factors for stroke is
cardiovascular disease that represents multiple
components

11.
 Cigarette smoking, tobacco and alcohol consumption
significantly increases the two times more chances of
the stroke.
 Prevalence of sedentary lifestyle is reported to be:
• 31.5% in women,
• 28.5% in men and
• increased with age about 50%
 Women with early menopause increases two times
more chances of ischemic stroke as compare to women
with late menopause.

12.
Syndromes of Stroke
• Syndromes of the stroke depends on the:
i. site of the occlusion,
ii. size,
iii. nature and
iv. availability of the collateral blood flow
• And, symptoms may depend on the rapidity of the occlusion of
cerebral blood flow .

13.
 Anterior cerebral artery syndrome6:
Areas Involved Clinical Presentation
Anteromedial caudate nucleus, anterior
limb of the internal capsule and anterior
perforated substance
Damage of B/L corticopontine fibers and
lower limb strip
Frontal lobe or posterolateral parietal lobe
B/L ACA infarct
Posteromedial superior frontal gyrus
Contralateral face and lower limb
weakness
Homolateral ataxia and crural
hemiparesis
Alien hand syndrome
Glabellar tap, utilization behavior,
graping and anoyher primitive reflexes
Urinary incontinence

14.
 Middle cerebral artery syndrome7:
Areas Involved Clinical Presentation
Primary motor cortex, somatosensory
cortical area and internal capsule
Lateral inferior frontal lobe (Broca’s
area)
Superior temporal gyrus (wernicke’s
area)
Lateral inferior frontal lobe and superior
temporal gyrus
Contralateral face, trunk and upper limbs
weakness and sensory loss
Speech production and language
comprehension
Auditory comprehension and language
development
Global aphasia

15.
Areas Involved Clinical Presentation
Frontal cortex Brodmann area 8
Lacunar infarcts of MCA
Right side hemisphere (non-dominant)
Parietal lobe
Premotor and primary cortex
Ipsilateral eye deviation is observed,
impairing planning of eye movement and
contralateral homonymous hemianopia
It is involves purely motor functions
Hemi-neglect syndrome, apraxia,
anosognosia, and hemi-spatial neglect
Ataxia of contralateral lobe (sensory loss)
Limb kinetic apraxia

16.
 Posterior cerebral artery syndrome8:
Areas Involved Clinical Presentation
Unilateral infarct if occipital lobe and
primary visual cortex
Infarction of temporal lobe involving
Meyer loop and inferior parietal lobe
supracalcarine
Posterior choroidal artery occlusion
Inferior occipital areas, occipital areas,
fusiform gyrus and anterior temporal cortex
Contralateral homonymous hemianopia
with macular sparing
Quadrantanopia
Visual deficits, neuropsychological
impairments and hemisensory deficits
Prosopagnosia

17.
Areas Involved Clinical Presentation
Parietal lobe
Posterior part of corpus callosum and
dominant calcarine
Lesion of inferomedial B/L temporal lobes
or dominant side
Non-dominant or B/L primary visual areas
Ventral posterolateral nucleus of thalamus
3rd nerve and cerebral peduncle of
midbrain
Visual agnosia
Dyslexia, without agraphia, anomia and
problem in color discrimination
Memory defect
Topographic disorientation
Pain, dysesthesias, sensory loss
Weber’s syndrome

18.
Areas Involved Clinical Presentation
Subthalamic nucleus and pallidal
connections
Cerebral peduncle of midbrain
Supranuclear fibers of 3rd CN
Involuntary movements, intentional
tremors, hemiballismus, choreoathetosis
Contralateral hemiplegia
Paresis of vertical eye movement, slight
miosis and ptosis and sluggish pupillary
eye response

19.
 Vertebrobasilar artery syndrome9:
Areas Involved Clinical Presentation
Mid basilar artery (Pontine ischemia)
(locked-in syndrome)
Intrcranial vertebral artery (lateral
medullary ischemia)
Quadriplegia, anarthria, preserved
conciousness, ipsilateral CN 7 palsy,
hemiparesis, hemiataxia, occulomotor
defect, arm posturing
Wallenburg syndrome: decrease in
pain/temp. sensation on the ipsilateral face
and contralateral body, horners syndrome,
limb ataxia, hoarse voice, dysphagia.
Dizziness
Diplopia

20.
Areas Involved Clinical Presentation
Distal basilar artery (rostral midbrain /
thalamic ischemia)
Origin of extracranial vertebral artery
(cerebellar ischemia)
Comatose state, defective gaze,
hemiparesis and hemiataxia, diplopia,
speech difficulties, altered mental status,
small poorly reactive pupils, weakness,
ataxia.
Dizziness, blurred vision, ataxia, vomitting

21.
• Wake up stroke: it is defined as the ischemic
stroke that is associated with neurological
symptoms on awakening that were not present
prior to falling asleep. {Jenny, et al; 2017}, {Mark
N. Rubin et al; 2015}
• Watershed stroke: it is also known as border zone
infarcts involves the junction of the two distal
fields of two non-anastomosing arteries, evolve in
hemodynamic risk zones. Accounts for up to 10%
of cerebral infarcts. {Ina Juergenson et al; 2011}

22.
• Young stroke: is the stroke occurs in those
patients who are younger than the 40 or 49 years.
Young stroke results in devastating of productive
years and impact on QOL of young person’s (Risk
factors like dyslipidemia, smoking, HTN and
genetics). {Smajlovic, 2015},{Dayna Griffiths et
al; 2011}
• Brainstem stroke: almost 10% of ischemic stroke
leads to the brainstem strokes affect the pons more
commonly than the midbrain or medulla.
Brainstem hemorrhage are due to ischemic events
and hypertension is the most common cause. {A.
Ortiz de Mendivil et al; 2013}

23.
• Silent brain infarction: it is often incidentally
detected in patients during MRI evaluations. SBI
can contribute to the cognitive dysfunction,
dementia, and increased overall mortality. {Ajay
Gupta et al; 2017}
• Cryptogenic Stroke: it is defined as obscure or
unknown origin of cerebral ischemia. The cause of
cryptogenic stroke is undetermined because some
causes truly remain unknown these are transitory
or reversible. {Josef Finsterer, 2010}

24.
• Lacunar infarction: are small subcortical lesions
with a size less than 15mm in diameter, caused by
penetration of large cerebral artery, most
commonly which forms the circle of willis. Most
commonly occurs in MCA and distal basilar
arteries. {Prashanth et al; 2019}.

25.
Cortical Homunculus

26.
 Hemispheric differences following of stroke3:
Right Hemisphere Left Hemisphere
Left side hemiplegia/paresis and sensory
loss
Visual perceptual impairments
Behavioral deficits (quick, impulsive, poor
judgment, inability to self control)
Intellectual deficits (difficulty in abstract
reasoning, problem solving, ridity of
thought, memory impairment)
Right side hemiplegia/paresis and sensory
loss
Speech and language impairments
Behavioral deficits (slow, cautious,
disorganized, often very aware of deficit)
Intellectual deficits (disorganized problem
solving, difficulty in initiating task, highly
distactible)

27.
Emotional deficits (difficulty to perceive
emotion and express negative emotion)
Task performance (fluctuations)
Emotional deficits (difficulty to express
positive emotion)
Task performance (apraxia)

28.
Neurological Impairments and
Associated Problems

29.
• Altered level of
consciousness
• Speech and language
impairments
• Dysphagia
• Cognitive dysfunction
• Sensory and motor deficits
• Emotional dysregulation
• Hemispheric altered
behavioral differences
• Perceptual dysfunction
• Seizures
• Bowel and bladder
dysfunction
• Cardiorespiratory
dysfunction
• DVT and Pulmonary
embolus
• Osteoporosis and fracture
risk
• Orthostatic hypotension
• Pressure sores

30.
Medical Diagnosis of Stroke2,3
• It is important to diagnose stroke as early as possible to
reduce the risk of more damage and functional loss.

31.
• Accurate history obtained from the patient or if the
patient is unconscious or uncommunicative then
from the family about the onset of neurological
symptoms is necessary.
• Typical symptoms of stroke include sudden
unilateral weakness, numbness, visual loss,
diplopia, altered speech, ataxia and non-orthostatic
vertigo.
• Associated symptoms like severe headache (worst
headache of my life) in the cases of subarachnoid
hemorrhage. An embolus occur rapidly without
any warning signs.

32.
• Diagnostically, the FAST (face, arm, speech, time)
test aids screening for stroke. It is sensitive and
specific test for the recognition of stroke in the
emergency units.
• The physical examination of the patient includes
an investigation of vital signs (HR, B.P., RR, body
temp. and SPO2).

33.
• Cerebral imaging is the important tool for
diagnosis and to rule out the ischemic,
hemorrhagic and other CNS pathologies10.
• Non-contrast CT scans has near perfect sensitivity
to detect the fresh intracranial hemorrhagic stroke
but its sensitivity is poor in detecting the ischemic
stroke if it is recent, small and in the posterior
fossa10.
• Diffusion weighted MRI detects acute ischemic
stroke in about 90% of patients and about third of
patient with transient symptoms less than 24 hours.

34.
Figure: A: axial CT scan shows right side MCA infarct with hemorrhagic transformation
transformation and midline shift to the left side.

35.
• CT angiography are more readily available is a
minimally invasive study requires a intravenous
contrast. This provides the clear images of
cerebral blood vessels. This allows for accurate
diagnosis and decisions in the clinical arena10.
If CT angiogram reveals an occlusion of a major
blood vessels within the 3 hours time limit, then it
allows to administer the tPA more confidently in
the case of stroke.

36.
 MR angiography in the setting of stroke to help in
decision making. It can be detect high grade
atherosclerotic lesions in neck and brain and also
helpful for less common ischemic stroke such as
vertebral and carotid artery dissection10.
 Transcranial doppler sonography examination of
the head and doppler imaging of carotid vessels are
helpful in evaluation of stroke. This is used for
unstable patients and patients who are not eligible
for MRI and CT scans10.

37.
 Digital subtraction angiography is the gold
standard for the diagnosis of many cerebrovascular
disease. It is a x-ray of carotid artery with a special
dye injected into an artery thru the femoral artery.
Useful tool to detect the blood flow thru the
constricted vessels and delayed filling of
capillaries. It is useful for treatment purposes10.
 Acc. to cochrane study first assessment of the
stroke must be completed in the first 48-72 hours.

38.
Management of Stroke
• Recent recommendations for the acute stroke management
based on the diagnosis of ischemic and hemorrhagic stroke
using computed tomography (CT) scans.
• It requires multiple health care specialties and multiple
approaches, depending on the mature of the patient’s deficits.

39.
Patient
Consultant
specialist
doctor
Associated
physicians
Neurologicat
physiotherapist /
occupational
thaerapist
Family
members
or care
givers
Social
support
Speech
and
language
therapist
Nursing
staff
Psycholo
gist
Dietecians
Neurosurge
ons team

40.
 GOALS:
• To improve cerebral perfusion
• Maintain adequate oxygenation
• Maintain adequate blood pressure
• Maintain sufficient cardiac output
• Restore fluid and electrolyte balance
• Maintain blood glucose level
• Control ICP, edema, seizures, infections and herniation
• Maintain cognitive skills
• Maintain bowel bladder functions and reduce risk of
DVT
• Maintain skin integrity, joints and functional activities

41.
 Drugs used:
• Thrombolytics11: (Alteplase (rtPA))
• Anticoagulants11: (warfarin, heparin)
• Antiplatelet therapy11: (aspirin, clopidogrel)
• Antihypertensive drugs12: (Angiotensin II-
inhibitors, calcium channel blockers, diuretics,
ACE-inhibitors, beta- blockers)
• Antispasmodics13: (baclofen, dantrolene,
tizanidine, tolperisone, alcohol, phenol, botulinum
toxin)

42.
• Anticonvulsants14: (carbamazepine, chlonazepam,
clobazam, ethosuximide, gabapentin, phenytoin,
zonisamide, lamotrigine, vigabtrin and diazepam)
• Antidepressants15: (paroxetine, fluoxetine (also
used for motor recovery))
• Anticholesterol agents16,17: (statins)

43.
 Intravenous thrombolysis18 (IV) with recombinant
tissue plasminogen activator (rtPA) recommended
within 3 hours to 4.5 hours of symptom onset
increases the chances of functional independence
at 3 months by one-third.
In the first 90 minutes after stroke it is more
beneficial.
• IV rtPA patient requires a BP to be <185 mmHg
systolic and <110 mmHg diastolic before the 24 hours
of treatment and to the first 24 Hours of the treament.
• Hemorrhage is the most common complication after the
thrombolysis.

44.
• Contraindications18:
Severe head trauma within 3 months
Severe ischemic stroke within 3 months
Hemorrhage
Previous history of hemorrhagic stroke
Pediatric and younger than 18 years patiens
Pregnancy
AVM and aneurysm

45.
 Mechanical Thrombectomy19,20:
• It is effective treatment modality for anterior large
vessels occlusions in acute ischemic stroke
recognized as a standard care. Thrombectomy may
be reasonable within the first 6 hours of symptom
onset but also indicated carefully up to the 24
hours of symptoms onset. It is not recommended
for the patients who are more than the 80 years of
the age.
• This approach significantly helps in improving the
functional outcomes and quality of life of the
patients.

46.
 Decompressive Craniectomy21:
• It is a old concept i.e. surgically opening the skull
to relieve raised intracranial pressure (ICP). It is a
good treatment approach for malignant stroke in all
the age groups. It is recommended within the 72
hours of the onset of the symptoms.
• Surgical complications of DC can occur at any
phase which is classified as early and late phase
complications. For e.g. hemorrhage, CSF
infections and disturbance, seizures. General
complications like DVT, UTI and pneumonia.

47.
Physiotherapy Assessment and Management of
Stroke
• Stroke recovery is inhomogeneous process therefore it is
challenging to predict the actual post stroke outcomes which
assure a wholistic approach. Rehabilitation can be provided in
in-patient or out-patient departments to the stroke survivors.
• Framework of recovery post-stroke divided into: hyper acute
phase (0-24 hours), acute phase (1-7 days), early sub-acute
phase (7 days – 3 months), late sub-acute phase (3-6 months),
chronic phase (lasting more than 6 months) and some exceptions
are always present.

48.
Figure shows: Framework of biological recovery of stroke patients.
.

49.
Environmental factors Personal factors
Most
relevant
categories
that
are
affected
after
stroke
acc.
to
ICF
model
Contextual factors

50.
Examination
• History, observation and examination all plays an important
role in deciding the rehab program of stroke patients. It gives
us the clear picture or idea of the patients impairments and
help us to plan the treatment according to the patients
requirements.

51.
Outcome Measures
These are used for:
• Assessment purpose
• Designing a treatment
• Re-evaluation (for recovery)

52.
 Higher mental functions:(using GCS scale as a gold standard or
MMSE or NHISS scale)
• Consciousness
• Orientation
• Memory
• Attention
• Speech
 Cranial nerve integrity
 Sensation
• Superficial sensation
• Deep sensation
• Combined cortical sensation

53.
 Reflexes
• Superficial reflexes
• Deep tendon reflexes
• Pathological reflexes
 Motor functions
• Muscle tone (flaccid or spastic (using modified ashworth scale)
• Range of motions
• Synergy patterns (using VMC scale)
• Limb girth
 Posture control and balance
• Check perceptual (pusher) syndrome
• BBS
• FRT or mFRT
• Time Up Go Test
• Trunk impairment scale

54.
 Coordination function:
• Equilibrium or Non-equilibrium tests
 Gait and locomotion:
• Functional gait assessment
• Dynamic gait index
 Integumentary integrity
• Grading of pressure sores
 Cardio-respiratory function:
• Type of breathing pattern
• Chest expansion
• Cough effectiveness

55.
 Bowel and Bladder function (spastic or flaccid)
 Functional capacity
• Fugl-Meyer Assessment of Physical performance (FMA)
• Stroke Rehabilitation Assessment of Movement (STREAM)
• Stroke Impact Scale (SIS)
• Motor assessment scale (MAS)
• Barthel index (BI)
• Functional independence measure (FIM)

56.
PT Treatment Goals
• Physiotherapy focused to maintain preserved
functionality, strength, improve limb functions, activity
of daily living, and quality of life of an individual and
decreases the stay duration of the stroke survivors in the
hospitals.

57.
SHORT TERM GOALS
• To improve cognitive functions
• Reduce of risk of secondary
impairment
• To maintain pulmonary functions
• To reduce pain
• To maintain mobility
• To improve transfers
• Sensory and motor re-education
• Patient and caregivers counseling
• To reduce spasticity
LONG TERM GOALS
• To improve mobility
• To improve muscle strength
• Improve balance
• To improve gait functions
• Independence in self-care and
ADL’s
• To improve QOL

58.
Hours: medical
Hours to days: early mobilisation
Days to weeks: restoring impairments in order to
regain activities
Days to months: task oriented training with
adaptive learning and compensation strategies
and specific rehabilitation techniques
Weeks to months: environmental adaptations
and home care
Months to years: maintenance of physical
condition and improving QOL
Hypothetical:
Pattern
of
recovery
post-stroke
with
time

59.
Different Techniques of PT
Treatment

60.
 EARLY MOBILIZATION22,23:
• Early mobilization (in-bed or out-bed) has been an important
part of acute stroke care unit.
• Patients are mobilized out of bed during hospital stay shows an
improvement in neurological functions, decrease muscles disuse,
improved muscle strength, reduced complications and improves
the functional independency.
• The time spent of upright position or out of bed is gradually
increased throughout the hospital stay of the stroke patients.

61.
 CONSTRAINT INDUCED MOVEMENT THERAPY24:
• CIMT was designed to overcome upper extremity (UE)
impairments poststroke. This intervention is used for stroke
patients to improve UE functions. Modified CIMT (mCIMT) has
also been used for the patients of the stroke.
• The original CIMT is a form of therapy that includes 3
components: 1) wearing a padded glove in non-paretic hand for
the 90 % of waking hours, 2) functional training with high
numbers of repetition for at least 6 hours per day, 3) behavioral
methods designed to involve patient in his real-world
environment activities.
• mCIMT does not consists of 3 components but based on the
repetitive, functional training of the paretic hand and non-paretic
hand is constrained with the padded glove.

62.
 MIRROR THERAPY (MT)25:
• Poststroke paresis or paralysis of the one side of the body is
commonly occurs which frequently cause problems in ADL’s.
• MT is one of the modality used for the stoke patients to improve
the motor functions of the paretic side of the body within the 6
months poststroke. In this mirror is placed in the patients mid-
sagittal plane so that the image of a moving non-paretic side
gives the illusion of normal movements in the paretic side of the
body. Different areas of the brain for movement, pain and
sensations are stimulated by this MT but still the working of MT
is unclear.

63.
 TASK TRAINING26:
• Task training involves the active training of functional tasks and
it is a component of recent therapy approaches in stroke
rehabilitation.
• Stroke can cause problems with upper limb and lower limb
functional movements of either side of the body.
• Repeated task training is a part of rehab protocol used to help in
recovery of functional ability after the stroke, like when we
learned any of the activities for the first time e.g. writing, eating,
dressing, walking etc.
• People who practiced functional tasks showed a small
improvement in upper limb activities, lower limb activities and
functional ambulation.

64.
 FUNCTIONAL ELECTRICAL STIMULATION27,28:
• FES is one of the interventions which are used in stroke
rehabilitation with aims to improve sensory functions, muscle
strength and endurance, gait, hand functions, prevent
shoulder subluxation and reduce spasticity.
• FES is an effective treatment therapy in order to improve
functional activities of the stroke patients and significant
results are obtained from FES when applied within the 2
months of stroke optimal results have been found when FES
is used in stroke rehabilitation program.

65.
 EMG BIOFEEDBACK29,30:
• EMG biofeedback is one of the interventions which are used
to improve the functional tasks and motor learning in the
rehabilitation of stroke. EMG biofeedback is used in
combination with the conventional therapy for improving
ADL’s and functional activities of upper extremity and lower
extremity.

66.
 TREADMILL TRAINING31:
• Treadmill training is used in rehabilitation after the stroke and
might help to improve the gait functions of the stroke patients.
• Treadmill training is used in two ways i.e. with or without the
body weight support using a harness. After the stroke patients
had some gait impairments and many could leave with these
impairments and not able to walk independently or without any
assistance.

67.
 VIRTUAL REALITY32:
• Virtual reality is a new intervention which includes video games
in stroke rehabilitation with commercial gaming in clinical
setups to increase spent time for the therapy.
• Virtual reality may be helpful in improving functional activities
and ADL’s when used as an adjunct care. After stroke many
patients have difficulty in proprioceptive and cognitive
functions. Virtual reality is an interactive treatment including
video game therapy provided to patients after the stroke.
• This protocol based on computer programs designed to stimulate
real world. This type of therapy is more motivating, interesting
and interactive sessions for stroke patients.

68.
 ROBOTICS33:
• Robots are used in rehabilitation of stroke as an innovative
therapy. Robotic devices used as assisted devices to carry out the
tasks simple and consistent. Robots are designed or capable to
program the repetitive physical activities without fatiguing the
muscles.
• Robotics is technology based intervention or incorporates with
the software to record the functional tasks and provide visual
feedbacks. Robots as exercise devices are used in current
scenario of the stroke rehabilitation.
• Robots assist the movements to improve the muscle power and
mobility of the stroke survivors.

69.
 MUSCLE STRENGTHENING34:
• Muscle weakness is commonly occurs after the stroke and can
result in a reduced physical activity. This muscle weakness
causes the imbalance in the muscular activities and results in
postural asymmetry, balance and coordination problems and gait
disturbance.
• Strengthening protocols includes the resistance training, aerobic
training, task specific training and functional electrical
stimulation. Muscle strengthening exercises shows the slight
improvement in muscle strength, mobility, functional activities,
balance and gait after the stroke.
• A low level of aerobic and endurance exercise training shows
better results in muscle strength, mobility and quality of life as
compare to the high intensity training.

70.
 PHYSICAL FITNESS TRAINING35:
• Physical fitness levels vary among everybody and it is important
for all of us to carry out ADL’s such as walking, stair climbing.
• Physical fitness levels are decreased after the stroke and it may
reduce their ability to perform ADL’s and worsens stroke related
disability. Because of this reason fitness training has been
approached as a beneficial intervention for stroke patients.
• Physical fitness training comprised of cardio-respiratory
(endurance) training, resistance (strength) training and mixed
training interventions which is a combination of cardio-
respiratory and resistance training. Cardio-respiratory training
and mixed training improved the walking speed, walking
endurance and slightly improves the balance at the end of the
intervention.

71.
 FAMILY AND CAREGIVERS SUPPORT36:
• Family/caregivers plays an important role for the poststroke
treatment plan. Stroke increases the burden on the
families/caregivers which leads to the depression and distress.
• Families/caregivers and stroke survivors both sustain a
significant impact on their psychosocial health.
• Some education programs are organized for the
family/caregivers and stroke patients to provide supportive
knowledge and information for solving their problems which
helps to improve the quality of life and decrease the burden.

72.
 KNOWLEDGE AND ATTITUDE TOWARDS
STROKE37:
• The spread of knowledge about stroke risk factors and warning
signs is important to prevent stroke morbidity and mortality
rates.
• Educational programs organized in the communities thru media,
advertisements, etc. to enhance an awareness among the
population. It has been shown that increasing stroke knowledge
with means of public resulted in shorter time presentation to the
emergency departments following stroke.
• Public education promoting awareness changes the attitude
towards the stroke and increase seriousness of stroke
management, thereby reducing the burden of stroke among
Indians and other developing countries.

73.
REFERENCES
1. Walter Johnson, Oyere Onuma, Mayowa Owolabi, Sonal
Sachdev (2016). Stroke: a global response is needed. Bull
world health organ, 94, 634–634 A.
2. Gizeme J Hankey, Stroke: www.thelancet.com Published
online September 13, 2016 http://dx.doi.org/10.1016/S0140-
6736(16)30962-X. .
3. Susan B. O’Sullivan et al; Physical rehabilitation: Stroke, 6th
edition, F.A. Davis, JAYPEE; 2014.
4. D. Mozaffarin, et al; Heart disease and stroke statics - 2015
update: a report from the American Heart Association,
Circulation, 2015.

74.
5. Amy Guzik et al; Stroke epidemiology and risk factor
management, American academy of neurology, 23(1):2017.
6. Harold et al; Anterior cerebral artery stroke, Statpearls,
2020.
7. Daniel et al; Neuroanatomy, Middle Cerebral Artery,
Statpearls, 2019.
8. Okkes et al; Posterior cerebral artery stroke, Statpearls,
2019.
9. Jessica et al; Vertebrobasilar artey occlusion, Western
journal of emergency medicine, XII, 2:2011.
10. Dale et al; Imaging in acute stroke, Western journal of
emergency medicine, XII,1:2011.

75.
11. Kameshwar parsad et al; Stroke management; Annals of
Indian academy of neurology; 2011:14(5):82-96.
12. Zonneveld TP et al; Blood pressure-lowering treatment for
preventing recurrent stroke, major vascular events, and
dementia in patients with a history of stroke or transient
ischaemic attack (Review); Cochrane Database of
Systematic Reviews 2018, Issue 7.
13. Cameron Lindsay et al; Pharmacological interventions other
than botulinum toxin for spasticity after stroke; Cochrane
Database of Systematic Reviews; 2016 Oct; 2016(10).
14. Kwan J et al; Antiepileptic drugs for the primary and
secondary prevention of seizures after stroke (Protocol) ;
Cochrane Database of Systematic Reviews; 2005.

76.
15. Gillian E. Mead et al; Selective Serotonin Reuptake Inhibitors
for Stroke Recovery A Systematic Review and Meta-analysis;
http://stroke.ahajournals.org/lookup/suppl/doi:10.1161/STR
OKEAHA.112.
16. Wang Zhao et al; The Benefits and Risks of Statin Therapy in
Ischemic Stroke: A Review of the Literature; Neurology
India; 2019:67(4):983-992.
17. Xi Liu et al; Statin, cholesterol, and sICH after acute
ischemic stroke: systematic review and meta-analysis;
Neurological Sciences; 2019.

77.
18. Alejandro A. Rabinstein, MD, FAAN (2017). Treatment of
acute ischemic stroke. American academy of neurology,
23(1), 62-81.
19. Mokin et al; Indications for thrombectomy in AIS from
emergent large vessel occlusion (ELVO): report of the SNIS
standards and guidelines committee, J Neurointervent Surg:
2019:11.
20. David et al; Long-term outcomes of mechanical
thrombectomy for stroke: A meta-analysis, the scientific
world journal; 2019.
21. Beez et al; decompressive craniectomy for acute ischemic
stroke, critical care, 2019: 23:209.

78.
22. Norvang, O. P., Hokstad, A., Taraldsen, K., Tan, X.,
Lydersen, S., Indredavik, B., & Askim, T. (2018). Time spent
lying, sitting, and upright during hospitalization after stroke:
a prospective observation study. BMC neurology, 18(1), 138.
23. Chippala, P., & Sharma, R. (2016). Effect of very early
mobilisation on functional status in patients with acute
stroke: a single-blind, randomized controlled trail. Clinical
rehabilitation, 30(7), 669-675.
24. Corbetta, D., Sirtori, V., Castellini, G., Moja, L., & Gatti, R.
(2015). Constraint‐induced movement therapy for upper
extremities in people with stroke. Cochrane Database of
Systematic Reviews, (10).

79.
25. Thieme, H., Morkisch, N., Mehrholz, J., Pohl, M., Behrens, J.,
Borgetto, B., & Dohle, C. (2018). Mirror therapy for improving
motor function after stroke. Cochrane Database of Systematic
Reviews, (7).
26. Thomas, L. H., French, B., Coupe, J., McMahon, N., Connell,
L., Harrison, J & Watkins, C. L. (2017). Repetitive task training
for improving functional ability after stroke: a major update of a
Cochrane review. Stroke, 48(4), e102-e103.
27. Auchstaetter, N., Luc, J., Lukye, S., Lynd, K., Schemenauer, S.,
Whittaker, M., & Musselman, K. E. (2016). Physical therapists'
use of functional electrical stimulation for clients with stroke:
frequency, barriers, and facilitators. Physical therapy, 96(7),
995-1005.

80.
28. Eraifej, J., Clark, W., France, B., Desando, S., & Moore, D.
(2017). Effectiveness of upper limb functional electrical
stimulation after stroke for the improvement of activities of
daily living and motor function: a systematic review and
meta-analysis. Systematic reviews, 6(1), 40.
29. Sürücü, G. D., & Tezen, Ö. The effect of EMG biofeedback
on lower extremity functions in hemiplegic patients. Acta
Neurologica Belgica, 1-6.
30. Kim, J. H. (2017). The effects of training using EMG
biofeedback on stroke patients upper extremity
functions. Journal of physical therapy science, 29(6), 1085-
1088.

81.
31. Mehrholz, J., Thomas, S., & Elsner, B. (2017). Treadmill
training and body weight support for walking after
stroke. Cochrane Database of Systematic Reviews, (8).
32. Laver, K. E., Lange, B., George, S., Deutsch, J. E., Saposnik,
G., & Crotty, M. (2018). Virtual reality for stroke
rehabilitation. Stroke, 49(4), e160-e161.
33. Weber, L. M., & Stein, J. (2018). The use of robots in stroke
rehabilitation:Anarrative review. NeuroRehabilitation, 43(1),
99-110.
34. Wist, S., Clivaz, J., & Sattelmayer, M. (2016). Muscle
strengthening for hemiparesis after stroke: A meta-
analysis. Annals of physical and rehabilitation
medicine, 59(2), 114-124.

82.
35. Saunders, D. H., Sanderson, M., Hayes, S., Kilrane, M.,
Greig, C. A., Brazzelli, M., & Mead, G. E. (2016). Physical
fitness training for stroke patients. Cochrane Database of
systematic reviews, (3).
36. Winstein et al; Guidelines for adult stroke rehabilitation and
recovery, American heart association/American stroke
association, 2016.
37. Sujata Das et al; Knowledge, attitude, practice of stroke in
Indian versus other developing countries, Ann Indian Acad
Neurol, 2013:16.

83.
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