Upload
others
View
2
Download
0
Embed Size (px)
Citation preview
Understanding recovery of movement a2er stroke
Fact or Fiction
Presented by: Anne Burleigh Jacobs, PT, PhD www.sensomotor.com
Photos from website images
A few facts about Stroke Leading cause of long-‐term disability in the United States
Stroke occurs when blood flow to the brain is interrupted. Ø Ischemic = Clot = Approx 87% of all strokes
Cryptogenic = about 1 in 3 ischemic strokes of unknown cause Ø Hemorrhagic = Bleed = Approx 13% of all strokes Ø TIA = Transient Ischemic APack = short lasQng clot
A few facts about Stroke Treatment Emergency Medical Care is CriQcal to Recovery
Fewer than 10% of Americans know the signs of stroke. Ø Treatment with tPA improves recovery outcome.
Ø More hospitals are invesQng in tPA treatment, telemedicine and stent retrievers, but not enough stroke vicQms are geUng to the hospital in Qme.
Ø SomeQmes the family must educate the doctors/nurses.
We all have an obliga-on to educate people around us about stroke
Anne Burleigh Jacobs, PT, PhD – March 2017
Fact or Fiction
ì The majority of stroke survivors fail to thrive following a stroke.
MulQple studies try to develop tools to predict outcome / recovery
Ø Financially driven Ø O9en self-‐limi-ng
Ø Set false deadlines Ø O9en do not consider the pre-‐stroke person
Anne Burleigh Jacobs, PT, PhD – March 2017
“To Survive” versus “To Thrive”
ì To Survive = to succeed in keeping alive against the odds, to live a2er some event that has threatened one’s existence
25% of those who survive a stroke are left living with minor disability, approx 40% have more severe disabilities.
ì To Thrive = to succeed in being successful or happy in a parQcular situaQon, especially one that other people would not enjoy
Anne Burleigh Jacobs, PT, PhD – March 2017
Fact or Fiction
ì All of the cells in the area of brain injury are dead.
Photo courtesy of WebMD
Anne Burleigh Jacobs, PT, PhD – March 2017
“Silent Brain does not equal Dead Brain”
ì Cells that have been denied oxygen/glucose and have died
Different Zones of Injury
ì Cells that have reduced oxygen/glucose that reduce their cell funcQon in effort to survive
ì Cells that have lost communicaQon from the injured region of the brain
Anne Burleigh Jacobs, PT, PhD – March 2017
Fact or Fiction
ì Only older people suffer from stroke.
Anne Burleigh Jacobs, PT, PhD – March 2017
“Recovery differs from ReLearning”
ì Under the age of 55 Ø High blood pressure, smoking, diabetes Ø Women rapidly surpassing men Ø Family History
Approximately one in every four stroke vic-ms is under the age of 65. Of those nearly 200,000 people
ì Stroke in children Ø Heart defects , Vascular DissecQon Ø Sickle Cell Anemia Ø More recently diabetes and obesity related
Anne Burleigh Jacobs, PT, PhD – March 2017
Fact or Fiction
ì Most recovery from stroke has occurred in the first six months. AOer a year, people should not expect much more improvement.
Anne Burleigh Jacobs, PT, PhD – March 2017
“Recovery differs from ReLearning”
ì IniQal six weeks to six months, swelling and inflammaQon recede
“… data show that stroke does not just cause focal, circumscribed damage but reorganizes the basic physiology and output proper-es of a distributed set of brain areas.” (Carmichael, 2003)
ì Cells that have gone silent in effort to survive begin to turn back on – o2en without good corQcal regulaQon
ì ReLearning / NeuroplasQcity takes a long Qme.
Anne Burleigh Jacobs, PT, PhD – March 2017
Fact or Fiction
ì Recovery of is generally complete when the survivor is discharged from Therapy.
Photo courtesy of Duke Health Photo courtesy of John Hopkins
Anne Burleigh Jacobs, PT, PhD – March 2017
“Recovery is a Continuum”
ì In-‐paQent
Different Phases of ReLearning
ì Home-‐based
ì Community-‐Based Ø Community College Adap-ve Phys ED
Ø Personal Trainer / Private Therapist Ø Stroke survivor groups
Ø Emerging Technologies and Rehab Tools Ø ....
ì Out-‐PaQent
Anne Burleigh Jacobs, PT, PhD – March 2017
Fact or Fiction
Internet Source.mp3ringtone.info
ì No Pain, No Gain.
Anne Burleigh Jacobs, PT, PhD – March 2017
“Different types of pain post stroke”
ì SomeQmes the stroke damage to the brain can make even normal touch feel painful.
Central Pain
ì In other cases, pain is felt because of muscle Qghtness or shortening.
Pain Associated with Spasticity or HyperTonicity
Anne Burleigh Jacobs, PT, PhD – March 2017
“Different types of pain post stroke”
ì Pulling the flaccid arm or Overstretching the shoulder as tone is developing.
Pain Associated with Over-Stretching
ì A hand brace or ankle brace that does not fit properly can cause joint changes, skin breakdown, increased tone and pain.
Pain Associated with Poorly Fitting Orthotics
Anne Burleigh Jacobs, PT, PhD – March 2017
Photo courtesy of Saebo
Poorly fitting orthotics
Anne Burleigh Jacobs, PT, PhD – March 2017
Poorly fitting orthotics
NOT designed for walking
Anne Burleigh Jacobs, PT, PhD – March 2017
Fact or Fiction
ì Walking should be iniTated as soon as possible aOer a stroke.
Human walking is a complex coordinaQon of Ø Postural Orienta-on
Ø Balance Ø Strength
Ø Sensa-on Ø Timing
Anne Burleigh Jacobs, PT, PhD – March 2017
Postural Orientation
ì Eyes Open – Eyes Open with Head Turn
ì Eyes Closed -‐ Eyes Closed with Head Turn
Sitting – without any support
Standing – with a straight cane
ì Eyes Open – Eyes Open with Head Turn
ì Eyes Closed -‐ Eyes Closed with Head Turn
Anne Burleigh Jacobs, PT, PhD – March 2017
Learning to Walk ? Are these survivors ready to learn to walk?
Anne Burleigh Jacobs, PT, PhD – March 2017
Importance of the foot and ankle
Anne Burleigh Jacobs, PT, PhD – March 2017
Importance of the foot and ankle
Trulife AFO Phat Brace KickStart
Anne Burleigh Jacobs, PT, PhD – March 2017
Fact or Fiction
ì Most stroke survivors never recover funcTon of their affected arm or hand.
The en-re upper extremity is designed to help the hand func-on.
Anne Burleigh Jacobs, PT, PhD – March 2017
“Do not hurt the shoulder”
ì Post-‐stroke rehab o2en focuses on learning to live with one hand
Different Phases of ReLearning
ì The subluxed shoulder is painful – protect it! Ø Taping Ø Electrical SQmulaQon Ø Shoulder Slings (change as arm changes)
Anne Burleigh Jacobs, PT, PhD – March 2017
“Do not allow the hand to get fisted”
Different Phases of ReLearning
ì The hand no longer has sensory input – touch it!
ì Gentle range of moQon with rotaQon every day
ì Exercises for the arm should always start lying on your back with support to the elbow and hand
ì Change hand splints as the hand changes
Anne Burleigh Jacobs, PT, PhD – March 2017
Daily stimulation and stretch
Anne Burleigh Jacobs, PT, PhD – March 2017
Stage 1: No voluntary movement of limb can be initiated. No spasticity noted. The brain is in a state of “shock”
Stage 2: Basic limb synergies begin to appear. Spasticity is mild. Lower brain dominance as nervous system awakens
Stages of Recovery Brunnstrom 1966
Anne Burleigh Jacobs, PT, PhD – March 2017
Stage 3: Basic limb synergies seen with any effort to move. Spasticity is increased. Lower brain drives flexion of arm, extension of leg *
Stage 4: Some movements begin to deviate from synergies. Spasticity begins to decrease. Cortical areas begin to modulate the lower brain
Stages of Recovery Brunnstrom 1966
Anne Burleigh Jacobs, PT, PhD – March 2017
Stage 5: Relative independence from the limb synergies. Spasticity is mild. Cortical control of movement continues to develop
Stage 6: Individual, isolated joint movements are possible. Spasticity is negligible Movement appears normal
Stages of Recovery Brunnstrom 1966
Anne Burleigh Jacobs, PT, PhD – March 2017
Emerging Tools for Rehab
The landscape of tools for rehabilita-on post stroke is rapidly changing. Unfortunately, the average health care provider is not aware of the tools now available to stroke survivors. Insurance is slow to reimburse for many of these tools.
Presenta-on of products does not cons-tute endorsement of products
Anne Burleigh Jacobs, PT, PhD – March 2017
Tymo Therapy Plate www.tyromotion.com
v Visual feedback: Computer monitor v Standing v Sit <-‐> to <-‐> Stand v Weight-‐bearing thru Arms
Anne Burleigh Jacobs, PT, PhD – March 2017
The changing dynamics of AFOs
Ø Energy Storage and Release
Ø Dynamic Dorsiflex Assist
Ø Flexible Forefoot Plate
Ø AcQvates the calf muscles
Anne Burleigh Jacobs, PT, PhD – March 2017
Electronic Orthosis
Walk-Aide Bioness L-300
v SQmulaQon of Peroneal Nerve for Dorsiflexion
www.bioness.com
www.walkaide.com
Bionic Leg
www.alterg.com
v Sensors in Foot Plate v Motor-‐driven Knee v Auditory Feedback v Stance Stability v Extensor Assist v DecceleraQon Assist
Alter-‐G
www.alterg.com
v Air-‐filled Bladder v Reduces Weight Bearing v Sensory Drive to AmbulaQon v Therapist Facilitated v Reduced fear of falling
KickStart by Cadence
www.cadencebiomedical.com v External Orthosis v Spring Tensioner v Assist Hip Flexion v Facilitates Heel Strike v Plantar flexion Block v Stance Stability
Anne Burleigh Jacobs, PT, PhD – March 2017
TyroMotion
www.tyromoQon.com
Myomo
www.myomo.com
v External Orthosis v Biofeedback driven v Motor Actuator v Elbow Flexion v Elbow Extension v MyoPro has hand posiQoner
Saebo Therapies
SaeboFlex
SaeboGlove
www.saebo.com
v Exercise Devise /FuncQonal Tone Management v AcQve Flexion of Digits v Turn Off v Assisted Extension of Digits
Saebo MicroStim
Anne Burleigh Jacobs, PT, PhD – March 2017
Photo from Braintree Rehab
v External Orthosis v Five Electrodes: Thumb Extension Wrist Extension Finger Flexion / Extension v BioFeedback Driven NMES
Bioness H-‐200 www.bioness.com
Anne Burleigh Jacobs, PT, PhD – March 2017
Leap Motion www.leapmoQon.com
Anne Burleigh Jacobs, PT, PhD – March 2017
www.flintrehab.com
Music Glove
Anne Burleigh Jacobs, PT, PhD – March 2017
Is there a fixed time frame for ReLearning ?