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……