1. Stroke/Brain Injury Jacob Pellegrino

2. What is a Stroke? The loss of blood flow to a region of the brain (Ehrman, J. pg. 559) 1.Build up of plaque in cerebrovascular arteries- Ischemic Stroke 2.Excessive bleeding and swelling in brain, which prevents blood flow to brain cells-Hemorrhagic stroke A stroke causes neurons in the brain to die, this causes the disability and impairment of skeletal muscles, speech, vision, and judgment Illustration copyright 2000 by Nucleus Communications, Inc. All rights reserved. http://www.nucleusinc.com

3. Ischemic Strokes Also known as Thrombotic or Embolic strokes Thrombotic- damaged or diseased brain arteries become blocked from a blood clot 1.Large-vessel thrombosis- blockage within the carotid or middle cerebral artery 2.Small-vessel thrombosis- blockage within the brains smaller arteries Embolic- stroke occurs outside of the brain, usually the clot will be sent from the heart and travel through the bloodstream until it becomes stuck

4. Hemorrhagic Strokes Hemorrhagic Intracerebral Strokes are bleeding within the brain Hemorrhagic Subarachnoid Strokes are bleeding in and around the spaces around the brain Hemorrhagic strokes can be caused by aneurysm, drug use, brain tumor, congenital arteriovenous malformations, and anticoagulant medication (Ehrman, J. pg. 561)

5. Diagnosing a Stroke A non-contrast CT scan is the main diagnostic tool to determine a hemorrhagic stroke Ultrasound, MRI, and angiography are the main diagnostic tools to assess possible blockages which lead to an ischemic stroke

6. Signs and Symptoms The most consistent symptoms are memory loss and paralysis Paralysis- the side of the brain which has damage causes the opposite side of the body to become paralyzed Right brain damage creates vision issues and strange behavior Left brain damage causes speech problems and slow behavior Other issues are weakness in face, arm, or leg, confusion, speech problems, cognitive issues, impaired vision, impaired coordination, and headaches

7. Genetics Gender plays a main role in stroke incidence, between the age of 55-64, women have a 1.25 greater chance for stroke (Ehrman, J. 560) With increase in age, the difference becomes smaller, but women over 85 have a higher chance The reason women have a higher chance of a stroke is a longer life expectancy and increased cardiovascular disease risk with menopause and estrogen replacement therapy African American’s also have a higher risk for coronary heart disease and hypertension (Munter, n.d.) “Black women were three times more likely to have an ischemic stroke compared with white women.” (Sevush-Garcy, J, pg.19)

8. Common Medications (Ehrman, J. pg. 563) Warfarin- anticoagulant No exercise effects Ticlopidine, Clopidogrel, Aspirin- antiplatelet No exercise effects Ramipril, enalapril- ACE inhibitor No exercise effects, but decreases resting and exercise blood pressure Nimodipine- calcium channel blocker Increased exercise capacity in patients with angina; may have an increase in resting and exercise heart rate, and decrease in resting and exercise blood pressure Hydrochlorothiazide- diuretic No exercise effects, but decreases resting and exercise blood pressure

9. Case Study Patient/Client Details- 56 year old African American male, smoker, weight 172lbs and height 6’0. He started to feel weakness in his right side, he was experiencing aphasia and a blood pressure of 190/85 mmHG. His LDL is 140 mg/dl and HDL is 30 mg/dl. Risk Stratification- A blood pressure above 130/85 mmHG this is a risk factor. He also is above the age of 45 which is a risk factor. He is a smoker which is a risk factor. His BMI is 23.3kg/m 2 which is a normal BMI, not a risk factor. With his LDL level being above 100mg/dl, this is a risk factor. Since her HDL levels are below 60mg/dl, this is not a negative risk factor. Risk Group- High Risk- A stroke is a cardiovascular disease Goals- Med management-ACE inhibitors to decrease hypertension and calcium channel blockers to decrease the force which muscles produce and dilate blood arteries which decreases blood pressure Cardiovascular exercise- treadmill or bicycle, 40-80% HRR, 3 to 5 days/week for 15-30 minutes Any special considerations with regards to the exercise response- Being a high risk individual means there should be a medical exam, an exercise test, and a medical doctor present during the exercise test all prior to exercise.

10. Exercise Testing Cardiovascular Treadmill- Self-selected speed with a 2% increase in slope every 2 minutes If patient is unable to reach 0.5mph, use cycle ergometer Cycle Ergometer- Start at 20 W and increase by 10 W each minute Strength- Patient should be assessed for function ability to perform test on affected side prior to testing Free weights, machines- 10RM test Dynamometry- Handgrip Range of Motion Goniometer Sit and Reach

11. Exercise Prescription Aerobic- Treadmill walking, cycle ergometer, water exercise 40-80% HRR 3 to 5 days/week for 15-30 minutes Progress from low to high intensity and longer durations, patient should be supervised by RPE scale Resistance- Machines, water exercise, resistance bands ≤80% 1RM 3 to 5 days/week for 30-45 minutes Progress as tolerated Flexibility- Passive movement, PNF Below slight discomfort 3 to 5 days/week for 10-20 minutes Progress as tolerated, focus stretching muscles on affected side (Ehrman; pg. 656)

12. Conclusion Stroke is a major risk of death and disability, behind cardiovascular diseases Exercise after a stroke is vital, especially when there is a loss in motor function Exercise is medicine!

13. References Anvekar, B. (2012, September 24). Neuroradiology Cases. Retrieved January 3, 2016, from http://www.neuroradiologycases.com/2012/09/ischemic-stroke-and-vascular.html Ehrman, J. Clinical exercise physiology (3 rd ed., p. 559-567) Flack, J, et al. (2010. Management of high blood pressure in blacks. Hypertension, 56. Retrieved from hyper.ahajournals.org/content/56/5/780 Intracerebral hemorrhage. (n.d.). Retrieved January 3, 2016, from http://www.uwmedicine.org/health-library/Pages/intracerebral- hemorrhage.aspxhttp://www.uwmedicine.org/health-library/Pages/intracerebral- Munter, P., He, J., Roccella, E., & Whelton, P. (n.d.). The Impact of JNC-VI Guidelines on Treatment Recommendations in the US Population. Retrieved January 4, 2016, from http://hyper.ahajournals.org/content/39/4/897.long Sevush-Garcy, J., & Gutierrez, J. (2015). An Epidemiological Perspective on Race/Ethnicity and Stroke. Current Cardiovascular Risk Reports Curr Cardiovasc Risk Rep. Retrieved January 4, 2016, from Springer Link. The Internet Stroke Center. (n.d.). Retrieved January 3, 2016, from http://www.strokecenter.org/patients/about-stroke/ischemic-stroke/http://www.strokecenter.org/patients/about- Wedner, D. (2015, September 11). New Guidelines for Women's Stroke Prevention. Retrieved January 3, 2016, from http://www.lifescript.com/health/centers/stroke/articles/new_guidelines_for_womens_stroke_prevention.aspx http://www.lifescript.com/health/centers/stroke/articles/new_gu Widar, M., & Ahlstrom, G. (2002). Disability after a stroke and the influence of long-term pain on everyday life. Scandinavian Journal of Caring Sciences Scand J Caring Sci, 302-310. Retrieved January 3, 2016, from Scandinavian Journal of Caring Sciences.