PT for CVA I. Evaluation Brunnstrom stage, NIHSS

PT for CVA
I. Evaluation
Brunnstrom stage, NIHSS
神 經 物 理 治 療 學 及 實 習
胡 名 霞
1

Biomedical selection talk
• Teasell, R. (2008), "Stroke rehabilitation", in
Hachinski, V. (ed.), Cerebrovascular Disease:
Diagnosis, Treatment and Prevention - a
prioritized approach, The Biomedical & Life
Sciences Collection, Henry Stewart Talks Ltd,
London (online at http://hstalks.com/bio)
• Direct talk access link:
http://hstalks.com/lib.php?t=HST60.2024_1_2
&c=252
2

中 風 - 腦 血 管 阻 塞 或 出 血
(www.hmc.psu.edu/neurosu
rgery/aservices/
cerebralaneurysm.htm)
www.biomed2.man.ac.uk/bi
ology/ ns/njr/what2.html
(Time, 1996.9.16, p. 48.)
3

腦 中 風 ( 腦 血 管 病 變 )
• Stroke
• Cerebrovascular accident (CVA)
• Cerebrovascular disease (CVD)
• 突 然 發 生
• 局 部
• 非 進 行 性
• 出 血 (hemorrhage) 或 缺 血 (infarction)
• 腦 部 病 變
• http://www.med.harvard.edu/AANLIB/home.ht
ml
4

相 關 名 詞
• AVM: arteriovenous malformation
• TIA: transcient ischemic attack
• Young stroke:

PT diagnosis (preferred practice pattern)
• 5D
• Impaired motor function and sensory
integrity associated with nonprogressive
disorders of the central nervous
system – acquired in adolescence or
adulthood
• Guide to PT Practice, 2nd ed, 2001.
6

流 行 病 學 資 料
• Largest single cause of neurological disability
• 發 生 率 :
– 5.95/1000; >65 歲 ,50.7/1000 ( 黃 瑞 雄 , 1997)
– 55 歲 後 , 每 十 年 增 加 一 倍
– 男 : 女 =1.3:1 (1.17)
• 盛 行 率 : 約 15、16 萬 人
• 死 亡 率 :
– 我 國 第 二 大 死 因 ; >65 歲 之 第 一 死 因
– 急 性 期 死 亡 率 : 17-34%
– 第 一 年 死 亡 率 : 25-40%
7

Recurrent Strokes
• ~ 20%-40% of strokes are preceded by
a TIA or non disabling stroke (Rothwell et al.
Lancet Neurol 2006; 5: 323-331)
• Golden Opportunity for Stroke Prevention!
8

Epidemiology-etiology
Cerebral infarction
(thrombosis or
embolism
70%
hemorrhage 20%
(32% Taiwan,
佔 死 亡 60%)
unspecified 10%
9

Epidemiology - Risk factors
• High BP
• Diabetes mellitus
• Heart disease
• Cigarette smoking
• TIAs
• Prior stroke
• Cocaine use
• Physical inactivity
• Obesity
• Excessive alcohol
consumption
• Elevated blood
cholesterol and
lipids
10

Impact of Lifestyle Therapies on Blood
Pressure in Hypertensive Adults
Intervention Amount SBP/DBP
Reduce foods with
added sodium
1.8g or 78 mmol/d -5.1 / -2.7
Weight loss per kg lost -1.1 / -0.9
Alcohol intake - 3.6 drinks/day -3.9 / -2.4
Aerobic exercise 120-150 min/week -4.9 / -3.7
Dietary patterns
DASH diet
Hypertensive
Normotensive
-11.4 / -5.5
-3.6 / -1.8
Applying the 2005 Canadian Hypertension Education Program recommendations: 3. Lifestyle modifications to prevent and treat
hypertension Padwal R. et al. CMAJ ・ SEPT. 27, 2005; 173 (7) 749-751
Source: 2008 CHEP Recommendations
11

行 為 療 法 與 中 風 預 防 :
70 萬 名 中 風 患 者 中 , 有 多 少 人 可 被 預 防 ?
Hypertension
360,500
25,000
Cholesterol
146,000
10,000
Cigarettes
Atrial Fibrillation
89,500
68,500
5000
6400
Heavy Alcohol Use
34,500
2500
0 100,000 200,000 300,000 400,000
Number of Preventable Strokes*
*Based on estimated 700,000 annual strokes.
Gorelick PB. Arch Neurol. 1995;52:347-355.
Gorelick PB. Stroke. 2002;33:862-875.
12

大 腦 的 功 能
大 腦
思 考 學 習 動 作 感 覺
聽
脊 髓
周 圍 神 經
說
讀
寫
13

症 狀
Sensory (53%) Motor (88%)
hemianopia
Hemiplegia
Hemiparesis
mental Perceptual (32%)
Dementia
Hemi-neglect
Emotional lability
Language
Aphasia (30%)
Dysarthria (48%)
14

Grasp
reflex
Neglect
apraxia
Hemiplegia
Hemianopsia
Anosognosia
aphasia
Locked-in
syndrome
Drop
attacks
Thalamic
syndrome
Cortical
blindness
tremor
15

Framingham Heart Study 發 現 1974 年 後 , 死 亡 率 明 顯 降 低
後 遺 症
40%
死 亡
30%
復 原
30%
16

Epidemiology-outcome
• 美 國 四 百 萬 中 風 患 者 中 ,
– Need assistance: 31%
– Need help walking: 20%
– In long-term care facilities: 16%
– 7 年 後 仍 無 法 復 職 :71%
18

Percent of stroke patients with plateau in motor
recovery while receiving conventional rehabilitation.
N=804
95% get no
better after
11 weeks
with
routine
care.
19
Jorgenson et al. Arch Phys Med Rehabil 1995

腦 中 風 後 何 時 開 始 物 理 治 療 ?
• 視 個 別 狀 況 而 定
• 通 常 第 一 天 開 始 物 理 治 療 預 防 併 發 症 的
指 導 以 及 床 上 活 動
• 起 床 活 動 (British guideline, 較 為 保 守 )
– 腦 梗 塞 : 約 2-3 天
– 腦 出 血 : 約 7~10-14 天
20

ICF model- 動 作 障 礙 評 估
strength
Brunnstrom
stage
NIHSS
Fugl-Meyer
STREAM
21

肌 力 評 估
22

動 作 恢 復 分 期
Brunnstrom’s Stage
(Brunnstrom stage excel file available.)
24

Brunnstrom stage (now as part of
Chedoke-McMaster stroke assessment)
• Fractionation: the ability to move a single
joint without simultaneously producing
movements in other joints.
• Synergy pattern 協 同 動 作 形 式
• Associate movement 聯 合 動 作 ,
associated reaction 聯 合 反 應 :the
unintentional movement of one limb during the
intentional movement of another limb.
25

Brunnstrom stage
• I flaccidity
• II associated movement; spasticity
Typical
spastic
arm
posture
26

Resist
flexion
Resist
extension
27

Raimiste’s abduction/adduction
Test position
facilitation
28

Associated, synergy pattern
29

Extensor synergy of UE
碰 右 膝
30

Flexor synergy of UE
手 抓 耳 後
31

Flexor synergy of LE
腳 彎 到 胸 前
32

Extensor synergy of LE
腳 往 後 踢 直
33

Stage IV
• Hand to sacrum
• raise arm forward to
horizontal
• Pronation
• supination
• Hip unilateral
abduction
• Hip flexion, acute
angle
• knee flexion, acute
angle
• Ankle flexion, acute
angle
• Knee extension
34

Stage V
• raise arm to side
horizontal
• Supination
• Forward reach from
horizontal
• Raise arm over
head
• Ankle dorsi-plantar
flexion (with knee
extended)
• Ankle
supination/eversion
(with heel on floor)
• Isolated knee flexion
(with hip extend in
standing)
35

Wrist and hand assessment
36

Test with forearm supported
Or, for wrist flexion with
arm and hand supported in
neutral position
37

Speed test (for stages IV-VI)
• Lap to chin: 回 /5 秒
• Lap to knee: 回 /5 秒
38

NIHSS (National Institute of Health Stroke
Scale)(Baird et al., 2001; Brott et al., 1989)
• http://www.strokecenter.org/trials/scales/nihss
.html
• measured within 1 hour of the MRI scan
– Very severe: >25
– Severe: 15 – 25
– moderate: 5 – 15
– Mild: < 5 mild
39

Stroke strikes F.A.S.T.
• 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: go to the hospital
Every minute matters!