1. Stroke and its effects
Physical, cognitive, swallowing difficulties

2. What we are learning today
The warning signs of a stroke, types of stroke
Effects of stroke
physical changes
thinking changes
vision and perception changes
swallowing changes
These are the effects being covered today. The emotional effects of stroke will be covered in another session.

3. How many strokes occur in Canada each year?
More than 50,000 strokes occur in Canada each year.
1 stroke / 10 minutes.
More than 50,000 strokes occur in Canada each year. That’s one stroke every 10 minutes.

4. What is a Stroke?
Interruption of blood flow to the brain = damage to the brain
Brain attack vs
Heart Attack
Blood traveling to the brain supplies oxygen and nutrients.
A clot can block an artery or an artery can burst. Without oxygen and nutrients the brain cells will become damaged and this may be irreversible.
Specific parts of the brain control specific body functions.
When part of the brain becomes damaged the part of the body that it controls is affected.
The symptoms of stroke occur suddenly.
It is often referred to as a “brain attack”. You can make the analogy between brain attack and heart attack to enhance understanding.

5. Ischemic Stroke Blockage in an artery. Most common
80% of all strokes are Ischemic.
Cerebral Thrombosis: A blood clot forms locally in the artery of the brain. This occurs gradually from cholesterol deposits, and eventually cuts off blood supply.
Embolism: A blood clot forms somewhere else in the body, dislodges and travels to the brain and cuts of blood supply to that part of the brain. (Emboli often arise from the heart especially in atrial fibrillation but may originate elsewhere in the body).
Reproduced with permission from the HSFO.

6. Hemorrhagic Stroke Bleeding when a blood vessel bursts.
20% of all strokes are hemorrhagic. A hemorrhagic stroke occurs when there is a sudden rupture of an artery.
Intracerebral Hemorrhage: The artery bursts, bleeding into the brain causing pressure in the brain.
Subarachnoid Hemorrhage: The artery bursts on the surface on the brain. The bleeding occurs in the area between the brain and the skull, and this causes pressure on the brain.
Reproduced with permission from the HSFO.

7. Signs and Symptoms of a Stroke or TIA • sudden Vision Problems
• sudden Weakness/Numbness
- loss of strength or numbness
- one side of body
• sudden Trouble Speaking
- difficulty speaking or understanding,
Or confusion
• sudden Vision Problems
- trouble with seeing things the right way
Not everyone experiences stroke symptoms in the same way. Often only some of the 5 symptoms are experienced during a stroke. The type of signs and symptoms that a person has during a stroke depends on:
• Which side of the brain the stroke occurred (each part of the brain controls different functions)
• How much damage occurred in the brain (size of the stroke and damage to brain tissue)
Key word is this happens all of a sudden
Re: Headache – usually a sharp/ severe/ usual headache that has not been experienced before

8. Signs and Symptoms of a Stroke or TIA - severe and unusual headache
• sudden Headache
- severe and unusual headache
• sudden Dizziness
- loss of balance, difficulty walking
The participants may ask questions about how to differentiate some of the symptoms such as headache as a sign of stroke vs a regular headache.
Emphasize that the symptoms are:
• Sudden
• Severe (headache)
• Unusual
To the Facilitator:
You can ask the group if they were aware of these symptoms and if they are aware of all the signs and symptoms. People in the group may share the symptoms that they experienced. As people will likely have experienced different symptoms, you can reinforce that each persons experience is unique as are all strokes.

9. Things we can’t change that our risk of stroke
Risk Factors
Things we can’t change that our risk of stroke
Age (over 55)
Boy or girl, gender
Family history
Ethnicity or race
A previous stroke
- These risk factors can not be changed but can help us identify people who are at greater risk
As one ages, chances of stroke are doubled after the age of 55 – as it is for many other diseases
More men tend to have strokes, but more women die of strokes. For women it could be that they do not react the same way to medications used for heart disease and stroke. More research is required in this area
If you had a relative who has had a stroke – this increases your chances
Individuals of South Asian, Aboriginal and African American descent are more at risk for strokes
if you had a previous stroke – chances for another stroke is doubled

10. Risk factors we CAN control
Hypertension/ Heart Disease
Diabetes
Diet high in fat and salt
Weight / obesity
Lack of exercise
Drug alcohol use
Smoking
The good news is: there is treatment.If you have had a previous stroke or TIA, depending on the cause, your doctor may prescribe medication or other treatment to help control the condition (diabetes, cholesterol, hypertension etc). High blood pressure is the most important modifiable risk factor. The target BP for the prevention of first or recurrent stroke should be < 135/85 and < 130/80 for diabetics.
Cholesterol
LDL – lousy cholesterol HDL – healthy cholesterol LDL should be <2.0 mmol/L (this is the bad cholesterol). The total cholesterol should be <4.0 mmol/L. This is a ratio of good cholesterol & bad cholesterol. Cholesterol comes from what your body makes plus what you eat (dietary cholesterol). High blood cholesterol level contributes to heart attack, stroke, clogging of arteries and high blood pressure. Foods high in saturated and trans fats can raise blood cholesterol. Trans fats are often found in commercially prepared foods and in shortening (make food taste good, but cause plaque to build up in the arteries).Heart disease: Cardiac diseases can increase the risk of stroke. Patients with atrial fibrillation (rapid irregular twitching of the upper chambers of the heart) may take anticoagulants to prevent clots from forming in the atria
Diabetes: Patients with diabetes have an increased susceptibility to hardening of the arteries—a contributor to ischemic stroke.
It is important to be active. You should do some form of physically active most days of the week. You don’t have to jog or run. Walking for 30 – 45 minutes 3 times a week is a good form of exercise.
Obesity/inactivity: Obesity and inactivity increases the risk of stroke because it is associated with other risk factors, such as high blood pressure and atherosclerosis
Alcohol intake: Research finding suggest that moderate alcohol consumption may decrease the risk of stroke (one drink/day for women & two drinks/day for men), but high alcohol consumption increases the risk for brain hemorrhage. However, if you currently don’t drink, don’t start. You should discuss your alcohol intake with your doctor as certain medications can be affected by alcohol.
Smoking: Smoking increases the risk of ischemic stroke. Studies show that stopping smoking decreases the risk of stroke. Even if you have smoked for years you can still reduce your risk by quitting now. You may want to consult your doctor or consider a smoking cessation program.

11. Our Brain and what it controls

12. Two sides of the brain control different functions
Specific parts of the brain control specific body functions. When part of the brain becomes damaged the part of the body that it controls is affected.
If the right side of the brain is affected, it usually affects the left side of body
If left side of brain is affected, it usually affects the right side of body.
This is because our nerve pathways cross as they travel from the brain to the body and this cross happens at the brainstem level.

13. Physical Changes
What are some of the common physical changes people may experience after a stroke?
Have group share any stories/ strategies that worked with themselves

14. Left side or Right side weakness

15. Changes in posture/ balance
- A common posture or walking pattern we see after a stroke

16. High tone shoulder
High muscle tone can pull the upper arm toward the chest.
Can have high tone or low tone both in arm and leg

17. Fatigue/ Changes in Sleep
Increased fatigue and changes in sleep patterns common after a stroke. This is important to remember for those who will be doing visits in the initial days following stroke. You may notice that your visit may be short due to the person with stroke’s level of alertness.

18. Common Physical Changes
Motor Loss
Sensation
Fatigue
Muscle Tone
Balance
Posture
Spasticity/ High tone/ Low tone
Coordination
Pain/ Swelling
Sleeping
Control of bowel and bladder
Not always have their glasses, hearing aids, dentures in……so we talked about how it can be frustrating and your visit may not always be that optimal
BUT trying to build that capacity where the staff will expect you so they will get those things in place

19. What’s Wrong With This Picture?
What would you do if you walked into a person’s room and saw them like this?
Never move the person yourself. Ask for help from your facility contact
You may place yourself and the other person at risk of injury if you try to move them.
Make sure the person you are speaking with has their hearing aids/ glasses/ dentures on

20. Cognitive and Perceptual Skills
Examples
Driving a car OR using TTC
Performing activities of daily living

21. Common cognitive impairments?
↓ Attention (↑ distractibility)
↓ Orientation
↓ Memory
↓ Initiation
↓ Insight/Judgment
↓ Problem solving
Attention – difficulty focusing on one thing, easily distracted
Memory – I didn’t ask for a visit, will remember things from long ago
Initiation - slower to respond
Insight and judgement will be impaired so that is why we emphasize not to do things for them even if they say it is ok
Problem solving – knowing how to recognize a problem and find a good solution
Can encourage then to use their memory books/ memory aids if they have one. Have them enter information. You can share strategies that worked for you. Remember that everyone’s interest and abilities are different.

22. Cognitive Impairments
Tell us your stories of things to consider when:
You were being visited during your recovery
You are visiting a person with stroke who has some cognitive impairments
Popcorn responses, maybe put on flip chart

23. How you can help Simple, short sentences One question at a time
Allow time for response
Be an attentive listener
Include family, friends and caregivers

24. What are some common perceptual impairments?
Neglect
Inattention
Visual spatial
Depth/ Distance
Perseveration
Impulsivity
Apraxia
Neglect – patient has decreased awareness of one side of body or environment even when provided with cues to look to that side
Inattention – do ignore one side of body but can be directed to look to that side
Impulsivity – patient has difficulty controlling

25. Visual Spatial
Problem with seeing how objects relate to each other and how they relate to objects in the environment eg missing a chair when they sit down, knocking things over
Patient may not see this closet as organized nor neatly arranged as we would

26. Depth Perception
Would have difficulty managing stairs as depth perception is affected

27. Apraxia
Apraxia is difficulty making purposeful movement or sequencing the steps of the movement together, even though the patient has the physical ability and understanding to do the task.

28. Visual Neglect Examples
Women
Because
Examples of left visual neglect
Word is women but they see men
Word is because but they see cause

29. Copy Tasks
Examples of common assessment tools that therapist use that some of you may remember
Draw a clock – some patients with left neglect or inattention will only put numbers down on right hand side
Copy of house – miss left side of house

30. Things to remember Use simple, short sentences
Ask one question at a time
Allow time for the person to respond
Try to get their attention before speaking –
face them/ approach on side they are more aware of
Ask the health care provider if they are available

31. Swallowing Difficulties After Stroke

32. Swallowing problems after a stroke
Over 40% of people have difficulties with swallowing after stroke.
Over 40% of people have difficulties with swallowing after stroke.

33. Swallowing
Swallowing is moving food and liquid from the lips into the stomach.
50% recover by 6 months after their stroke
Difficulty with swallowing is called Dysphagia.

34. Swallowing Swallowing is a fast sequence of events
The airway is protected during the swallow
Feeding has large impact on swallowing:
Recognizing food & drinks
Moving food/liquid from the plate to the mouth
Difficulty with swallowing is called Dysphagia.

35. Consequences of Dysphagia
Social isolation
Reduced quality of life
Dehydration and Malnutrition
Pneumonia
people are embarrassed because they eat differently, or feel excluded from social situations because they can’t eat
because they can’t enjoy eating they way they used to. As a result of this, they may eat less, isolate themselves from social situations which in turn reduces their quality of life.
Dysphagia can cause pneumonia from material going into the lungs

36. Nasogastric (NG) Tube Feeding
If not able to swallow = tube through the nose and into the stomach.
Provides food, water and medication.
Don’t be taken aback re: tubes

37. Picture of a NG Tube

38. Gastrostomy Tube (G-Tube)
Needs to be fed by a tube for a longer period of time =
tube from abdomen and into the stomach.

39. Was there anything that surprised you???
Comments/ Questions
Thank you!!!