stroke rehab
DESCRIPTION
TRANSCRIPT
Stroke
Rehabilitation
Dr Deshan KumarAssociate Consultant
TTSH Rehabilitation Centre
Why Important ?
• 3rd leading cause of death
• 2nd leading cause of disability
• Most common cause of severe disability
• Mortality rates 22% to 37% in the first 30 days 25% to 50% in the first year
Types of Stroke
Ischaemic (~83%) Intracerebral
hemorrhage(~17%)
30 day survival 73-81% 30 day survival 36%
Mechanism of Recovery
• 1st mechanism- Early phase
• Resolution of harmful local factors • Edema• Hemorrhage• Blood pressure- improvement of local circulation• Resorption of local toxins • Recovery of partially damaged ischaemic neurons
• 2nd mechanism of recovery = Neuroplasticity• Ability of nervous system to modify structural and functional
organisation• Collateral sprouting of new synaptic connections • Unmasking of previously latent functional pathways
• Other mechanisms• Assumption of function by undamaged redundant neural
pathways• Reversibility from diaschisis• Denervation supersensitivity• Regenerative proximal sprouting of transected neuronal
axons
Stroke RehabilitationDefinition
• Multidisciplinary • Maximise physical, psychological, social and
vocational potential consistent with physiologic and environmental limitations
Stroke Rehabilitation
• Goals:• Prevention, recognition and management of
co-morbidities and medical complications• Promote cortical reorganisation• Training for maximal functional independence• Facilitating psychosocial coping and
adaptation by patient and family• Community reintegration• Improve quality of life
Stroke Rehabilitation
• ~ 10% of patients have complete spontaneous recovery
• ~10% do not benefit from rehab due to severity of lesion
• Remaining ~80% will benefit from rehabilitation
Criteria for Admission to a Rehab Programme• Stable neurological status
• Significant persisting neurologic deficit
• Identified disability affecting at least 2 of the following:• Mobility• Self- care• Communication• Bowel/bladder control• Swallowing
• Sufficient cognition to learn
• Sufficient communicative ability to engage with therapists
• Physical ability to tolerate the active program
• Achievable therapeutic goals
Medical/Rehab Diagnosis
• Medical diagnosis:• Pathology: cerebral infarct• Neurological deficit: hemiparesis
• Rehabilitation diagnosis:• Impairment: Problem at tissue/organ level
ie. Hemiparesis• Activity limitation: Problem at whole-
person level ie. inability to walk• Participation barrier: Problem at
environmental/societal level ie. unable to work
Motor Recovery
• Motor control returns proximally before distally
• Lower extremity function recovers earlier and more completely than upper extremity
Brunstromm Stages of Motor Recovery I Flaccid limb
II Some spasticity with weak flexor and extensor synergies
III Prominent spasticty; voluntary motion occurs within synergy patterns
IV Some selective activation of muscles outside of synergy patterns.
Spasticity reduced
V Most limb movement independent from limb synergy;
spasticity further reduced but still present with rapid movements
VI Near normal coordination with isolated movements
VII Restoration to normal
Stroke- Awareness of Self
Stroke: Improving Mobility and Balance
Body Weight Supported Treadmill Training
• Patient titrated effort
• Postural retraining
• Repetitive training for neuromuscular re-education
• More effective at establishing independent walking than current physical therapy intervention
Neuromuscular Electrical Stimulation
• EMG triggered neuromuscular stimulation
• Useful to improve wrist and finger extension
• Important movements to train for functional use of hand
Stroke: Improving Upper Limb Function
Functional electrical Functional electrical stimulation (FES)stimulation (FES)
Bioness Arm Unit
• Neuroprosthesis
• Functional aid for performing ADL
• Therapeutic device to aid motor recovery post stroke
Stroke- Upper Limb Function
CIMT
• Constraint Induced Movement Therapy
• Splint applied to intact hand 90% of the day
• Combined with “shaping“
• No benefit in early phase of stroke (VECTORS study)
Bilateral Arm Trainer
• Bilateral coordination improtant
• Improved spatiotemporal control of affected arm
• Greater gains in proximal upper limb
Stroke- Improving self care
Stroke- Dysphagia therapy
Stroke- Improving Communication
Stroke- Higher ADLS
Virtual Reality
• Multisensory approach
• Interactive, 3D environment
• Parameters and application can be adjusted to individual patient
• Helps improve velocity and walking distance in conjuction with robot based gait training
• Improve speed, precision and timing in robot based hand training
Virtual Reality
Electrical Brain Stimulation
• Intrahemispheric inhibition ( from cortical tissue surrounding the damaged area)
• Interhemispheric inhibition
• These influences affect skilled motor performance
Electrical Brain Stimulation
• Transcranial magnetic stimulation
• Transcranial direct cortical stimulation
• Beneficial effects on motor performance
Robotics
• Significant development in robot rehabilitation over last 15 years
• Task oriented training
• Higher volume practice
• Precisely guides training of skilled movements
• Consistency of therapy over time
MIT Manus
• Retrograde stimulation to aid in neuroplasticity
• Significant effect on upper limb motor function (Fugl-Meyer)
• Significant effect on quality of life ( Stroke Impact Scale)
• Effects seen 6 months after active therapy completed
Lokomat
• Robot assisted gait therapy
• Directed repetitive practice
• Retrain motor coordination
Robot Assisted Gait Training (RAGT)
• Evidence of RAGT and physiotherapy vs conventional physiotherapy is mixed
• RAGT and PT effective for patients less than 3 months post stroke for improving Functional Ambulatory Category
• Effective for patients with low FAC
• RAGT alone not superior to PT
Combining Techniques
• Interfacing virtual reality with robotic training
• VR games improve attention, speed, precision and timing in robotic hand based training
• Movement tracking and sensing gloves can be coupled to fMRI images, providing modified visual feedback
Late Rehabilitation Issues
• Psychological maladjustment
• Depression
• Sexuality
• Vocational
• Driving
• Equipment needs
• Hemiplegic shoulder pain• Spasticity• Shoulder- hand
syndrome
• Central post stroke pain
Shoulder Pain - Spasticity
Shoulder Pain- Spasticity
Neurolysis Serial casting
Shoulder pain- Subluxation
SUBLUXATION ( 30 – 50 % )
Proper positioning Arm trough/lapboard
Slings, straps, supports
Functional electrical stimulation
Shoulder pain- Subacromial Impingement
Post-stroke DepressionMay present early or late (40%)
Negative impact on function
Difficult diagnosis: Aphasia/Dysarthria Cognitive impairment Neglect
Treatment:
Restoration of function
Drugs : SSRI, TCA, Methylphenidate
Psychosocial support
Cognitive behavioural therapy
Driving
• Driving Assessment and Rehabilitation Programme (DARP)
• Neuropsychological testing for persons with cognitive or behavioural disorders • impulsivity• poor attention span• slowed decision making
• Simulated driving test
• Adaptive driving instruction program
Return to Work
• Important determinant of the quality of life
• “Work hardening” therapy
• Greatest opportunities to support vocational reintegration are in the areas of education and advocacy
Functional Outcome following Stroke
• ~1 in 10 functionally independent at time of stroke and nearly one-half are independent at 6 months
• Most improvements in ADLs occurs during the 1st 6 months- up to 5% of patients may show continued measurable improvement at 12 months post- stroke
Copenhagen Stroke Study
(community based, 1991-93)
Initially:
• mortality: 21%
• very severe: 19%
• severe: 14%
• moderate: 26%
• mild: 41%
Residual functional Residual functional
disability after rehab :disability after rehab :
• very severe: 14%very severe: 14%
• severe: 6%severe: 6%
• moderate: 8%moderate: 8%
• mild: 26%mild: 26%
• no disability: 46%no disability: 46%
Prognosis
• Best neurological recovery is seen by 11 weeks for 95% of patients
• Most ADL recovery (Barthel Index) is by 12.5 weeks with daily PT/OT
• But recovery could take 2 years or more
• Prognosis in patients with mild or moderate stroke is usually excellent - periodic rehabilitation interventions may be neccessary to maintain function
Typical Disabilities
• Typical disabilities in some specific activities at 6 months post- stroke• Unable to walk (15%)• Needs assistance for transfer (20%)• Needs assistance to bathe (50%)• Needs assistance to dress (30%)
Poor Prognostic Indicators for UE Recovery
• Severe proximal spasticity
• Prolonged flaccid period
• Absence of voluntary hand movement at 4-6 weeks
• Onset of movement at >2-4 weeks
• Full recovery is usually complete within 3 months of onset
Stroke rehab: Where?
Inpatient rehab unit: Neuro Rehab Unit
- Community Hospital
Non acute hospital setting –TTSH rehabNon acute hospital setting –TTSH rehab
Outpatient rehab:
- Hospital based
- Community based
- Social daycare
Domiciliary rehabilitation
- Community Rehab program
Nursing Home
• Patients need extended care
• Medically stable
• Group type therapy
• Limited one on one attention
• Direct involvement by nursing home doctor is variable
THE END……
THANK YOU……