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stroke.html
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<!-- We don't need full layout here, because this page will be parsed with Ajax-->
<!-- Top Navbar-->
<!-- Dynamic navbar for iOS theme -->
<div class="navbar">
<div class="navbar-inner">
<div class="left sliding">
<a href="#" class="back">
<i class="icon icon-back"></i><span>Back</span>
</a>
</div>
<div class="center sliding">Stroke Rehabilitation</div>
</div>
</div>
<div class="pages">
<!-- Page, data-page contains page name-->
<div data-page="stroke" class="page">
<!-- Scrollable page content-->
<div class="page-content">
<div class="list-block accordion-list">
<ul>
<li class="accordion-item">
<a href="#" class="item-content item-link">
<div class="item-inner">
<div class="item-title">Recovery</div>
</div>
</a>
<div class="accordion-item-content">
<div class="content-block">
<div class="content-block-inner">
<h3>Brunnstrom's Order of Recovery</h3>
<div class="data-table">
<table>
<tbody>
<tr>
<td>1</td>
<td>Flaccidity (immediately after onset): no voluntary movement initiated</td>
</tr>
<tr>
<td>2</td>
<td>Spasticity: basic synergy patterns appear, minimal voluntary movement possible</td>
</tr>
<tr>
<td>3</td>
<td>Voluntary control over synergies: with increase in spasticity</td>
</tr>
<tr>
<td>4</td>
<td>Some movement patterns out of synergy can be mastered: synergy still predominates, decrease in spasticity</td>
</tr>
<tr>
<td>5</td>
<td>If progress continues, more complex movement combinations can be learned as basic synergies lose their dominance: more decrease in spasticity can be seen</td>
</tr>
<tr>
<td>6</td>
<td>Spasticity disappears: more individual joint movements and normal coordination </td>
</tr>
<tr>
<td>7</td>
<td>Normal function is restored</td>
</tr>
</tbody>
</table>
</div>
<h3>Other Predictors of Revovery</h3>
<p>Severity of UE weakness at onset (complete arm paralysis at onset has poor prognosis for recovery of useful hand function)</p>
<p>Timing of hand movement return (some motor recovery of hand by 4 weeks has 70% chance of making full/good recovery)</p>
<p>Poor prognosis: no measurable grasp by 4 weeks, severe proximal spasticity, prolonged flaccidity, late return of tapping response (facilitation)</p>
</div>
</div>
</div>
</li>
<li class="accordion-item">
<a href="#" class="item-content item-link">
<div class="item-inner">
<div class="item-title">Spasticity</div>
</div>
</a>
<div class="accordion-item-content">
<div class="content-block">
<div class="content-block-inner">
<p>Abnormal <span style="font-style: italic">velocity</span>-dependent resistance to passive movement of involved muscles at rest and posturing during ambulation or with noxious stimuli</p>
<h3>Treatments</h3>
<div class="data-table">
<table>
<tbody>
<tr>
<td rowspan=5>Non-invasive</td>
<td>stretching</td>
</tr>
<tr>
<td>splints, orthoses</td>
</tr>
<tr>
<td>serial casting</td>
</tr>
<tr>
<td>electrical stimulation</td>
</tr>
<tr>
<td>cold modalities</td>
</tr>
<tr>
<td rowspan=2>Chemo-<br/>neurolysis</td>
<td>Botulinum toxin<br />
(useful in focal control of spasticity like at wrist and finger flexors or ankle invertors)</td>
</tr>
<tr>
<td>Phenol/alcohol<br />
(rarely used, limited by adverse effects like pain with injection, post-injection dysesthesia/chronic pain)</td>
</tr>
<tr>
<td rowspan=2>Baclofen</td>
<td>Oral</td>
</tr>
<tr>
<td>Intrathecal baclofen pump:<br />
some evidence that with physical therapy it can help improve walking speed/functional mobility in post-stroke spastic hemiplegia</td>
</tr>
<tr>
<td>Surgery</td>
<td>may be useful in selected cases to improve function, hygiene, pain</td>
</tr>
</tbody>
</table>
</div>
<p> Note: side effects of medications (baclofen, benzodiazepines, clonidine, tizanidine) usually limit their usefulness in stroke patients</p>
</div>
</div>
</div>
</li>
<li class="accordion-item">
<a href="#" class="item-content item-link">
<div class="item-inner">
<div class="item-title">Dysphagia</div>
</div>
</a>
<div class="accordion-item-content">
<div class="content-block">
<div class="content-block-inner">
<h3>Diagnostics</h3>
<div class="buttons-row">
<!-- Link to 1st tab, active -->
<a href="#tab1" class="button active tab-link">Bedside</a>
<!-- Link to 2nd tab -->
<a href="#tab2" class="button tab-link">VFSS (MBS)</a>
<!-- Link to 3rd tab -->
<a href="#tab3" class="button tab-link">FEES</a>
</div>
<div class="tabs-swipeable-wrap">
<!-- Tabs, tabs wrapper -->
<div class="tabs">
<!-- Tab 1, active by default -->
<div id="tab1" class="tab active">
<div class="content-block">
<h3>Bedside Swallow Evaluation (BSE)</h3>
<img class="swallow" src="img/bedside_swallow.jpg" />
<p>minimally invasive, looking for overt cough or difficulty during swallowing trials, may evaluate gag reflex/pharyngeal sensation</p>
<p>Aspiration is missed on BSE 40-60% of the time (silent aspiration)</p>
<p>Predictors on BSE: abnormal cough, cough after swallow, dysphonia, dysarthria, abnormal gag reflex, voice change after swallow </p>
</div>
</div>
<!-- Tab 2 -->
<div id="tab2" class="tab">
<div class="content-block">
<h3>Videofluoroscopic swallow study (VFSS)</h3>
<img class="swallow" src="img/vfss.png" />
<p>aka modified barium swallow (MBS), gold standard for evaluation and treatment of dysphagia</p>
<p>Different amounts and consistencies of solids/liquids mixed with barium are swallowed while fluoroscopically visualizing the patient’s swallowing anatomy</p>
<p>Aspiration can be reliably diagnosed on a VFSS</p>
<p>Predictors of aspiration on VFSS: delayed initiation of swallow reflex or pharyngeal peristalsis</p>
</div>
</div>
<!-- Tab 3 -->
<div id="tab3" class="tab">
<div class="content-block">
<h3>Fiberoptic endoscopic evaluation of swallowing (FEES)</h3>
<img class="swallow" src="img/fees.jpg" />
<p>a more comprehensive evaluation of the pharyngeal stage of swallowing</p>
<p>Observes natural bolus flow and containment vs potential bolus obstruction; reaction to presence of residue, penetration, aspiration; effectiveness of cough</p>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</li>
<li class="accordion-item">
<a href="#" class="item-content item-link">
<div class="item-inner">
<div class="item-title">Aphasia</div>
</div>
</a>
<div class="accordion-item-content">
<div class="content-block">
<div class="data-table">
<table>
<thead>
<th>Speech Component</th>
<th>Impaired?</th>
</thead>
<tbody>
<tr>
<td>Fluency</td>
<td>
<div class="item-content">
<div class="item-inner">
<div class="item-input">
<label class="label-switch">
<input type="checkbox" id="fluency_switch">
<div class="checkbox"></div>
</label>
</div>
</div>
</div>
</td>
</tr>
<tr>
<td>Comprehension</td>
<td>
<div class="item-content">
<div class="item-inner">
<div class="item-input">
<label class="label-switch">
<input type="checkbox" id="comprehension_switch">
<div class="checkbox"></div>
</label>
</div>
</div>
</div>
</td>
</tr>
<tr>
<td>Repetition</td>
<td>
<div class="item-content">
<div class="item-inner">
<div class="item-input">
<label class="label-switch">
<input type="checkbox" id="repetition_switch">
<div class="checkbox"></div>
</label>
</div>
</div>
</div>
</td>
</tr>
<tr>
<td colspan=2>This describes:<span id="aphasia_label">Global</span></td>
</tr>
</tbody>
</table>
<h3>Aphasias List</h3>
<div class="data-table">
<table>
<thead>
<th>Type</th>
<th>Description</th>
</thead>
<tbody>
<tr>
<td>Anomic</td>
<td>temporoparietal injury, angular gyrus; may also see alexia or agraphia</td>
</tr>
<tr>
<td>Conduction</td>
<td>injury to parietal operculum (arcuate fasciculus), insula or deep to supramarginal gyrus (usually left side); literal paraphasias, targeting of words</td>
</tr>
<tr>
<td>Transcortical sensory</td>
<td>watershed lesion isolating Broca’s/Wernicke’s areas from posterior brain, angular gyrus or posterior-inferior temporal lobe; echolalia, neologisms</td>
</tr>
<tr>
<td>Wernicke’s</td>
<td>posterior superior temporal gyrus of dominant (usually left) hemisphere; marked paraphasias, neologisms, alexia and agraphia</td>
</tr>
<tr>
<td>Transcortical motor</td>
<td>frontal lobe, anterior/superior to Broca’s area or in the subcortical area deep to Broca’s area; reduced rate, initiation, organization of speech</td>
</tr>
<tr>
<td>Broca’s</td>
<td>posterior-inferior frontal lobe of dominant (usually left) hemisphere; telegraphic speech, paraphasias, articulatory errors or struggling</td>
</tr>
<tr>
<td>Mixed transcortical<br />
<td>aka. isolation aphasia, lesions in borders of frontal, parietal, and temporal areas; decreased rate and initiation of speech, echolalia</td>
</tr>
<tr>
<td>Global</td>
<td>various sizes and locations but usually involves left MCA distribution; ranges from mutism to total repetitive jargon or neologistic output</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
</div>
</li>
</ul>
</div>
<!-- REFERENCES -->
<div class="list-block accordion-list">
<ul>
<li class="accordion-item">
<a href="#" class="item-content item-link">
<div class="item-inner">
<div class="item-title">References</div>
</div>
</a>
<div class="accordion-item-content">
<div class="content-block">
<p>Zorowitz RD, Baerga E, Cuccurullo SJ. Physical Medicine and Rehabilitation Board Review. 3rd ed. New York, NY: Demos Medical; 2015. Chapter 1, Stroke. P.41-95.</p>
<p>Harvey RL, Roth EJ, Yu DT, Celnik P, Braddom RL. Physical Medicine and Rehabilitation. 4th ed. Philadelphia, PA: W.B. Saunders Company; 2011. Chapter 50, Stroke Syndromes. P.1177-1222.</p>
<p>Twitchell TE. The restoration of motor function following hemiplegia in man. Brain. 1951;74:443–480.</p>
<p>Brunnstrom S. Motor testing procedures in hemiplegia: based on sequential recovery stages. Phys Ther. 1966;46:357–375.</p>
<p>Zhang J, Zhou Y, Wei N, Yang B, Wang A, Zhou H, et al. (2016) Laryngeal Elevation Velocity and Aspiration in Acute Ischemic Stroke Patients. PLoS ONE 11(9): e0162257. https://doi.org/10.1371/journal.pone.0162257</p>
</div>
</div>
</li>
</ul>
</div>
<!-- END REFERENCES -->
</div>
</div>
</div>