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WEEK 11 STROKE
WEEK 11 STROKE

WEEK 11 STROKE

WEEK 11 STROKE
• STROKE • It refers to a potentially fatal reduction or cutoff of the blood supply
• STROKE
• It refers to a potentially fatal reduction or cutoff of
the blood supply to part of the brain resulting in
brain cell damage & varying severities of impaired
neurological function
• TYPES: 1) Ischemic Strokes &
2) Hemorrhagic Strokes
1) Ischemic Strokes: most common (82% of all
strokes) & similar to that of IHD occurs due
to obstruction in an artery supplying
the
brain
2) Hemorrhagic Strokes : less common, but more deadly & occurs when an artery supplying the
2) Hemorrhagic Strokes : less common, but more
deadly & occurs when an artery supplying the brain
is burst
but
a
large
no.
of
pts.
Suffered
from neurologic
impairments
,
that
require
acute
&
long
term
rehabilitation programs
occurs due to U.M.N.L.
includes paresis , paralysis , spasticity & debilitating
secondary effects such as contractures & disuse
muscle atrophy

Although the survival rate for stroke is good (70%)

This disability includes impairment in language & perception as well as motor emotional , sensory &

cognitive functions stroke impairment that

• Therefore to combat the physical deceleration of the post stroke pts. Acute & long term
• Therefore to combat the physical deceleration of
the post stroke pts. Acute & long term exercise
,
improve functional status & optimize quality of life
programs
are
needed
to
enhance
recovery
of remainder of life
Stroke
and
loss
of
exercise
capacity:
A
stroke
and
resulting
hemiparesis
produce
physiologic changes that are similar to those that
occur
with
prolong
disuse
For e.g. paretic
muscle show a reduced muscle
blood flow when compared with non-paralyzed
extremities at the same level of physical activity i.e.
lactate ,
glycogen utilization & diminished
capacity to oxidize FFA
to initiate contraction , where as non paretic muscle recruit type I fibers capacity of oxidative
to initiate
contraction , where
as
non
paretic
muscle recruit type I fibers
capacity
of
oxidative
metabolism
&
diminished
exercise endurance
factors
that
complicate
exercise
training
program are muscle strain , spasticity , joint pain &
disturbance in gait thus imposing greater energy
expenditure during routine mobilization

The paretic muscle activate glycolytic type II fibres

Eventually this change in recruitment pattern leads to reduced proportion of type I fibers diminished

Other

Consequently the amount of O2 consumption at sub maximal work load in hemiparetic pts. Is greater than in normal subjects

• In addition , physical inactivity associated with hemiparesis results in disuse of non-affected muscles ,
• In
addition , physical inactivity associated with
hemiparesis results in disuse of non-affected
muscles , thus further
limiting aerobic capacity .
The diminish use of non-affected muscle enhances
the energy cost of movement of these muscles as
well
• In
addition
there
are
many
confounding
co-
morbidities common to stroke survivors including
obesity , HTN, type II DM , hyperlipidemia , stress ,
depression
that
negatively
impart
the
pt.
capabilities
to
comply
with
efforts
to
maintain
physical function
• The
overall goal
of long
term
exercise training
regardless of confounding influences , is regaining
& maintaining independence in basic activities of
daily living & quality of life
• CLASSIFICATION OF STROKE RISK FACTORS • MODFIABLE RISK FACTORS : • Smoking, HTN, Dyslipidemea ,
• CLASSIFICATION OF STROKE RISK FACTORS
• MODFIABLE RISK FACTORS :
• Smoking, HTN, Dyslipidemea , physical inactivity
(sedentary life style), Elevated cholesterol/lipids,
alcohol, oral contraceptives
• PARTIALLY MODFIABLE RISK FACTORS :
• DM,
MI,
Previous
stroke,
LVH,
Hypercoagulable
state, TIA
• NON-MODFIABLE RISK FACTORS :
• Age, Gender, Race , positive family history
a progressively lower risk of stroke , particularly the ischemic stroke
a progressively lower risk of stroke , particularly the
ischemic stroke

Daily caloric expenditure is strongly associated with

This physical inactivity constantly emerges as an independent risk factor for recurrent stroke

a progressively lower risk of stroke , particularly the ischemic stroke • Daily caloric expenditure is

Therefore , it appears that

activity (regardless the

type & intensity) has a protective effect against exercise result in significant in cerebral O2 saturation
type & intensity) has a protective effect against
exercise result in significant
in cerebral O2
saturation , cytochrome enzyme levels , enhanced
cerebral activation & initiation of auto regulatory
mechanism

stroke The

• EXERCISE TRAINING & TESTING OPTIONS • ENDURANCE & AEROBIC EXERCISE TARINING • Endurance training is

EXERCISE TRAINING & TESTING OPTIONS

• EXERCISE TRAINING & TESTING OPTIONS • ENDURANCE & AEROBIC EXERCISE TARINING • Endurance training is

ENDURANCE & AEROBIC EXERCISE TARINING

Endurance training is an important component in stroke rehabilitation program , particularly the long term & maintenance phase

• EXERCISE TRAINING & TESTING OPTIONS • ENDURANCE & AEROBIC EXERCISE TARINING • Endurance training is
• EXERCISE TRAINING & TESTING OPTIONS • ENDURANCE & AEROBIC EXERCISE TARINING • Endurance training is

RECOMMENDATION FOR ENDURANCE TRAINING FOR STROKE PROGRAM

Determine co-morbidities & their effects on pts. Functional capacity

Asses pts. Ability to walk in distance & minutes & his/her ability to use modified equipment

FREQUENCY & DURATION OF AEROBIC ACTIVITY

each session to 45
each session to 45

Start with 2-3 min sessions & min.

• FREQUENCY & DURATION OF AEROBIC ACTIVITY each session to 45 • Start with 2-3 min
• FREQUENCY & DURATION OF AEROBIC ACTIVITY each session to 45 • Start with 2-3 min

3 times / week , if pt. can walk for 15-20 min with or with out period of rest

• FREQUENCY & DURATION OF AEROBIC ACTIVITY each session to 45 • Start with 2-3 min
• FREQUENCY & DURATION OF AEROBIC ACTIVITY each session to 45 • Start with 2-3 min

5 times/ week , twice/day , if pt. can‘t tolerate 15 min of walking

• FREQUENCY & DURATION OF AEROBIC ACTIVITY each session to 45 • Start with 2-3 min
• IMPROVEMENT AS A RESULT OF ENDURANCE EXERCISE TRAINING • Increase gait speed • Reduction in
• IMPROVEMENT AS A RESULT OF ENDURANCE
EXERCISE TRAINING
• Increase gait speed
• Reduction in the energy requirement to perform
standardized walking task
• Improved stair climbing ability
• Improved lower extremity muscle tone
• Enhanced independent function
• Greater maximal exercise capacity
• Greater physical work capacity
HDL &
TGs
• Decreased fibrinolysis plt. Aggregation & increase • Decrease resting & sub maximal heart rate &
• Decreased
fibrinolysis
plt.
Aggregation
&
increase
• Decrease resting & sub maximal heart rate &
blood pressure
• Delay in onset of angina with exercise
• Enhanced
motor
recruitment
limiting
the
development of disuse atrophy
• Reduction in cardiovascular risk , including
better BP control
• IMPROVEMENTS IN PERCEPTION activity level at which pt. feels comfortable performing routinely or for an
• IMPROVEMENTS IN PERCEPTION
activity
level
at
which
pt.
feels
comfortable performing routinely or for an extended

Increased

period of time Enhanced quality of life

Improved self confidence & perceived functional abilities

Greater confidence of engaging in physical activities & an increased willingness to attempt physical task

• TASK RELATED TRAINING • Approximately 2/3 of the stroke survivors have chronic neurologic impairments that
• TASK RELATED TRAINING
• Approximately
2/3
of
the stroke
survivors have
chronic neurologic
impairments that affect their
morbidity & their ability to perform routine task of
daily living
• The inability
to perform
continue
task can
be
physically inconvenience & v. frustrating
• To promote long term improvement & maintenance
of specific task oriented function , activities that
incorporate specific task improvement must be
part of pts. Daily routine
• Muscle or muscle-group
specific strengthening
exercises are a central component
of
any
task
related –training program
, to improve walking , task related training involves strategies to strength co- ordination , wt.
,
to
improve
walking , task related
training involves strategies to strength co-
ordination , wt. bearing capacity of the affected
lower limb & flexibility & other strategies to provide
the opportunity for intensive repetitive practice such
as walking on a treadmill
related program can be performed during a
rehabilitation
program
as
well
as
independently at home & may include activities as

For instance

As a result of appropriately task related programs, walking speed & endurance , force of production , sit to stand , balance while standing & stepping all improve & in addition pts. Report that they feel better & are more confident

Task formal

Sit to stand from various chair heights Perform heel lift in standing position

• Sit to stand from various chair heights • Perform heel lift in standing position •

Doing reciprocal leg flexion & extension in standing position

Standing up from chair , walking a short distance & return to chair

• Sit to stand from various chair heights • Perform heel lift in standing position •

Walking on a treadmill Walking on various surfaces & obstacles Walking over slopes and stairs

• Sit to stand from various chair heights • Perform heel lift in standing position •
• Sit to stand from various chair heights • Perform heel lift in standing position •

HOME EXERCISE PROGRAM

For strokes pts. To be able to maintain the gains in physical function accrued during the acute & long term rehabilitation process , they must received

education & instructions for continued home exercise & activity enhancement . In addition to maintain the level physical functions

they have gained, pts. Will continue to improve if

enhance activity & skills training are adhered to after discharge from formal rehabilitation programs

The home exercise programs include:

Strength training: hand

weights, elastic bands,

home made weights , food cans, water filled bottles & bopoks

• ENDURANCE: 1) walking , walking & more walking • 2) home exercise equipments : cycles
• ENDURANCE: 1) walking , walking & more walking
• 2) home exercise equipments : cycles , steppers &
house steps
• Task related
activities: transition from sitting to
standing , wt. bearing activities etc, etc
• END OF WEEK 11
END OF WEEK 11
WEEK 12
WEEK 12
LIPID & LIPOPROTEIN DISORDERS
LIPID & LIPOPROTEIN DISORDERS
the last decades efforts have been done to identify & address the risk factors for the
the last decades efforts have been
done to identify & address the risk factors for
the development of ischemic heart diseases,
in an attempt to reduce the no. of cases &
improve the quality of life
Diet,
exercise
,
lifestyle
modification
&
pharmacological intervention have been
developed to reduce morbidity & mortality
aggravated by increase BP , smoking ,
obesity physical inactivity & increase plasma
cholesterol .

Over

presence of increase LDL-C.
presence of increase LDL-C.

Of these coronary heart disease risk factors increase cholesterol has the greatest population attributable risk

Elevated

plasma cholesterol especially

cholesterol from LDL C is strongly related to CHD.

On the other hand HDL-C provides protection against CVD & the cholesterol associated with these lipoproteins (HDL-C) is inversely related

to the development of CHD, even in the

• Research have been shown that treating plasma lipid disorders can reduce the incidence & severity
• Research have been shown that treating plasma lipid
disorders can reduce the incidence & severity of CHD
• COMPOSITION & FUNCTIONS OF LIPOPROTEIN
• Lipids serve many important biological functions in
the body
• Phospholipid
&
cholesterol
serve
as
a cellular
component & precursors of hormones
• Where as TG provides F.A which are source of energy
in metabolic active tissues
• Lipids because of their chemical compound are not
transported independently in blood therefore the
primary function of lipoprotein is to transport water
insoluble lipids from their site of absorption or
synthesis to target tissues
lipoprotein are heterogeneous group of size decreases the greater is the protein & lesser is the
lipoprotein
are
heterogeneous
group
of
size decreases the greater is the protein & lesser is
the lipid content

Plasma

aggregate molecules made up of various lipids & specialized proteins called apolipoproteins CLASSIFICATION They are classified according to their size & density

The larger the lipoprotein , the larger is the % of non-polar lipids (T.G. & cholesterol esters) & as the

All lipoprotein contains apolipoprotein , phospholipid, cholesterol & T.G. although in different proportion .

All

the proteins

surface

layer

of

apolipoprotein

of lipoprotein are

in

lipoprotein

.

They

the outer

are

called

They are special macromoecule complex of lipids & proteins specific

They are of 4 types CM VLDL LDL HDL.

CM: lowest in density(0.95-1 gm/ml) & largest in size. Highest % of lipid & lowest % of protein

VLDL: density 1.05- 1.10 gm/ml LDL: density 1.10-1.15 gm/ml

HDL: (density)1.15-1.20 gm/ml (inc. protein & dec. lipid)

Functions

CM: transport dietary lipid to body tissues

VLDL:

transport

endogenous

TG

from

liver

to

adipose tissue LDL: delivers cholesterol to the peripheral tissues

HDL: delivers cholesterol from tissues to liver for elimination

• Modification apolipoproteins, in the no. or functions of intravascular enzymes , lipids transfer proteins &
• Modification
apolipoproteins,
in
the
no.
or
functions
of
intravascular
enzymes
,
lipids
transfer proteins & lipoprotein receptors result in a
variety
of
plasma
lipid
disorders
termed
DYSLIPIDEMIAS
• PRIMARY DYSLIPIDEMIAS: excessive dietary intake
of saturated F.A. & cholesterol accounts for
approximately 80% of primary dyslipidemias .
• Familial dyslipidemias or inherited genetic disorders
that
also
constitutes
primary
plasma
lipid
&
lipoprotein disorders.
• SECONDARY DYSLIPIDIMIAS: occurs in metabolic
disorders such as D.M. , S.L.E., nephrotic syndrome ,
renal failure & acute hepatitis
• It also occurs due to drugs such as β- blockers , estrogen, anabolic steroids &
• It also occurs
due to drugs such as β- blockers ,
estrogen, anabolic steroids & corticosteroids.
• DEFINITION OF DYSLIPIDEMIAS
• HYPERCHOLESTEROLEMIA:
elevated
cholesterol
concentration ≥ 240mg/dl
• HYPERTRIGLYCERIDEMIA: elevated fasting
T.G. levels ≥ 200mg/dl
plasma
• HYPERLIPIDEMIA:
elevated
cholesterol
&
T.G.
concentrations.
• DYSLIPIDEMIA: general term used to identify many
abnormal blood lipid disorders.
• RELATIONSHIP B/W LIPID, LIPOPROTEIN & CFARDIOVASCULAR DISEASES & graded association between blood cholesterol , LDL-C
• RELATIONSHIP B/W LIPID, LIPOPROTEIN &
CFARDIOVASCULAR DISEASES
& graded
association between blood cholesterol ,
LDL-C & atherogenesis.
TG
levels also
may be an independent
predictor of CAD. , especially when accompanied by
low LDL-C values
The
level
of
HDL-C is
inversely
associated
with
incidence of CAD

Atherosclerosis affecting the coronary vessel , often referred to as coronary artery disease (C.A.D.)

Strong epidemiologic evidence supports a continuous

Elevated

optimal/above optimal: 2.59-3.34 mmol/L
optimal/above
optimal:
2.59-3.34
mmol/L

LDL-CHOLESTEROL Levels in terms of risk for coronary heart disease:

Adult levels:

Optimal: <2.59 mmol/L (<100 mg/dl).

Near

(100-129 mg/dl). Borderline high: 3.37-4.12 mmol/L (130-159 mg/dl). High: 4.14-4.89 mmol/L (160-189 mg/dl). Very high: > 4.92 mmol/L (>190 mg/dl).

optimal/above optimal: 2.59-3.34 mmol/L • LDL-CHOLESTEROL Levels in terms of risk for coronary heart disease: •
• HDL-CHOLESTEROL Expected values No risk Moderate risk High risk Men (mg/dl) > 55 35-55 <35

HDL-CHOLESTEROL

Expected values

 

No risk

Moderate risk

High risk

Men (mg/dl)

> 55

35-55

<35

mmol/L

>1.45

0.90-1.45

<0.90

Women (mg/dl)

> 65

45-65

<45

mmol/L

>1.68

1.15-1.68

<1.15

• SERUM TOTAL CHOLESTEROL • Desirable cholesterol level < (5.2 mmol/L or < 200 mg/dl). •

SERUM TOTAL CHOLESTEROL

Desirable cholesterol level < (5.2 mmol/L or < 200 mg/dl).

• SERUM TOTAL CHOLESTEROL • Desirable cholesterol level < (5.2 mmol/L or < 200 mg/dl). •

Borderline high cholesterol: 5.2-6.2 mmol/L (200-239 mg/dl). High cholesterol: > 6.2 mmol/L (≥240 mg/dl).

• SERUM TOTAL CHOLESTEROL • Desirable cholesterol level < (5.2 mmol/L or < 200 mg/dl). •
• SERUM TOTAL CHOLESTEROL • Desirable cholesterol level < (5.2 mmol/L or < 200 mg/dl). •
• SERUM TOTAL CHOLESTEROL • Desirable cholesterol level < (5.2 mmol/L or < 200 mg/dl). •
• The recommendations for lowering the lipid levels includes , dietary interventions , increase physical activity
• The recommendations for lowering the lipid levels
includes , dietary interventions , increase physical
activity & exercise , wt. loss & drug therapy
• Exercise
increases
the
caloric
expenditure by
oxidation of lipids (F.A.) & CHO.
• As a result HDL conc. Increases & TG decreases in
response to exercise .
• THE LIPID & LIPOPROTEIN REESPONSE TO FUNCTIONAL FOODS foods are those foods that impart medicinal
• THE LIPID & LIPOPROTEIN REESPONSE TO
FUNCTIONAL FOODS
foods
are
those
foods that impart
medicinal or health benefits beyond basic nutrition .
These foods contain biologically active components
that appears promising in the prevention &
treatment & treatment of C.V.D. & some forms of
cancer .
lower
the
CVD risk by lowering
LDL
cholesterol , slowing the plaque formation , reducing
clot formation by inhibiting platelet aggregation &
improving arterial compliance .

Functional

They are effective in reducing risk of CVD & includes soluble fiber , plant stanols & plant sterols .

These foods

fibers dissolve rapidly in aqueous solutions found in the digestive tract. sources such as oats, oat
fibers dissolve rapidly in
aqueous solutions found in the digestive tract.
sources such as oats, oat bran , psyllium , various
& beans
,
citrus
fruits , strawberry
&
STEROLS
&
STANOLS:
Margarine-like
spreads contains plant sterols & stanols.

Moreover , lipid lowering effects of drug therapy are augmented when combined with functional foods

SOLUBLE FIBER: these

Soluble fiber has been shown to have a direct effect on lowering LDL-C

Studies have shown that LDL-C can be lowered 5- 10% by ingesting 7-10g/day of soluble fibers from

legumes apples. PLANT

• They lowered LDL-C by incorporating more readily into micelles that form in small intestine during
• They lowered LDL-C by incorporating more readily
into micelles that form in small intestine during fat
digestion
• incorporation of plant sterols/ stenols into these
lipids transport molecules displaces cholesterol ,
thereby inhibiting intestinal absorption of dietary
cholesterol and cholesterol that re enters the
intestine through enterohepatic circulation

Any exercise that include large group of muscles &

rhythmic & dynamic

in

nature

,

sustained

for

several minutes preferred , because this type of

physical exertion expenditure .

enhances

the

rate

of caloric

Thus wt. bearing exercise that augment the rate of caloric expenditure would have an advantage over non-wt. bearing exercises.

Exercise

intensity

does

not seem

to influence

exercise induced blood lipid changes , so low to moderate intensities are just effective as high intensity as long as energy is expended . The

mode

or intensities

is

not

the

primary focus,

however , any exercise that results in significant is

likely to produce more favorable blood lipid profile.

EXERCISE PRESCRIPTION OPTIONS

MODE: Any mode that includes large group of muscles & is dynamic & rhythmic in nature. Wt. bearing exercise are preferred to increase the rate of caloric expenditure.

Example of wt. bearing exercises are : brisk walking , jogging, stair stepping & aerobic classes.

Example of non-wt. bearing exercises are cycling, rowing etc.

FREQUENCY: daily is preferred , however, at least every other day to maintain the transient benefit

of exercise on HDL C & TG concentration . Daily exercise may be most effective , esp. when other risk factors are present such as DM, HTN &

Obesity

DURATION:30-60 min. of moderate intensity exercise corresponds to an exercise energy

expenditure of 350 500 (depending on body mass & fitness level) . The total exercise time can be calculated through out the day

Progression: the total volume of exercise as it relates to energy expenditure is the primary focus of exercise for lipid profile management. The choice of

increase intensity or duration should be based on

pts. Tolerance & preference

OTHER CONSIDERATION: educate the pt. about the role of exercise so that reasonable goals are

achieved

Determine the type of medication that are being used for lipid lowering & beware the possible adverse effects of medications.