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Stroke Rehabilitation - managing physical impairment

Stroke rehabilitation
pmr refresher course

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Stroke Rehabilitation - managing physical impairment

  1. 1. Stroke Rehabilitation managing the Physical Impairments – an overview Dr George Zachariah Dept of PMR Govt Medical college , Thiruvanathapuram
  2. 2. Special acknowledgements • Dr Mrinal Joshi ( Rehabilitation Foundation society ) • Dr Abdul Gafoor , Prof & HOD • Our stroke patients and their family • My teachers, colleagues & Family • Almighty
  3. 3. Lesson plan • Definition • Importance of penumbra • Why early rehab • Phases of rehab • Rehab plan & team • Phases described • Newer rehab interventions supporting neuroplasticity • Conclusion ( if time permits – our experience)
  4. 4. Stroke / CVA • Stroke is an acute neurological deficit lasting more than 24 hours due to a focal disruption of cerebral circulation.
  5. 5. Definition • STROKE – previously known medically as CVA , is the rapidly developing loss of brain function due to disturbance in blood supply to the brain. Wikipedia 2010 • the term “stroke” is not consistently defined in clinical practice, in clinical research, or in assessments of the public health. The classic definition is mainly clinical and does not account for advances in science and technology. • Stroke 2013 AHA/ASA expert consensus ICD - 10 , Chapter VI , G 45 & 46
  6. 6. Stroke Rehabilitation • Stroke Rehabilitation is a progressive, dynamic, goal oriented process aimed at enabling a person. with impairment to reach their optimal physical, cognitive, emotional, communicative, and social functional level. – Heart & Stroke foundation, Canada • Rehabilitation helps stroke survivors relearn skills that are lost when part of the brain is damaged • NINDS.
  7. 7. Priorities in Stroke management • Stabilise the medical condition • Control life threatening complications • Improve blood flow • Limit secondary complications • Early Rehab • Prevent another stroke
  8. 8. Prevention • Exercises • Stop smoking • Control hypertension • Treat diabetes • Anti platelet drugs • Anticoagulation • Carotid end arterectomy
  9. 9. Prevention • S. cholestrol <200mg /d National cholestrol Edu Prgm RBS < 200mg% Davidson Txtbk
  10. 10. Penumbra
  11. 11. Current concept in stroke management • >20ml/100g/min of cerebral blood flow can sustain neural activity • <10ml/100g/min cellular death • 20-10ml/100g/min Na+ K+ pump fails • Basic cell intact but electrically silent • This rim “ischemic penumbra”
  12. 12. • Stroke intervention before 6 hrs saves the penumbra. National stroke association • Insulin & glucose control is Neuroprotective. • Antipatelet drugs + BP control
  13. 13. Penumbra • Longer ischemic time for reperfusion destroys the cells--------Neurology • Longer delay in activity also destroys the functions of this penumbra ---- rehab
  14. 14. Early Rehab saves the Penumbra
  15. 15. REHAB “ Consideration of a patients rehabilitation needs should commence at the same time as Acute Medical management. ” Pg 1207, Davidsons Principle & Practise of Medicine – 20e
  16. 16. Very Early Mobilisation (VEM) • Introduction – Very early rehab with emphasis on mobilization may contribute to improved functional outcome after stroke. – Greatest contributors to better outcome was better BP control and early mobilization.
  17. 17. A Very Early Rehabilitation Trial (AVERT) for Stroke phase II safety and feasibility • Julie Benhardt,Helen Dewey et al • National stroke Research Institute – Australia • 3 phases • Stroke 2008, 39:390 AHA
  18. 18. VEM • Study setting – 2 stroke units in teaching hospitals in Melbourne Australia • Study design – Prospective,open randomised controlled trial, blinded, outcome assessment design
  19. 19. VEM • Results – Mobilization VEM 18 hrs SC 30 hrs – Adverse events VEM 15 SC 14 – Falls VEM 19.7 SC 22.8/1000 – Disability at 3 months • Better outcome VEM 39.5% SC 30.3 % – Disability at 12 months • No significant difference – Case fatality at 3 months • 15.5% as compared to 20 % in population of stroke Pts
  20. 20. VEM • Summary – AVERT protocol in which mobilization occurs within 24 hrs is a safe and feasible approach • further – PHASE III AVERT is on 2104 patients multicenter study at 30 centers in 3 countries – Unblinded early reports • Death rates 5.8% n=170 C Cassel medscape 2008
  21. 21. Physical Impairments of Stroke -focal areas of brain Area Impairment remarks Primary motor area in the precentral gyrus( motor Homunculus )- Int capsule- pyramidal tract Hemiplegia in various proportions, motor weakness and poor voluntary control Synergy patterns Basal ganglia & extrapyramidal systems Poor trunk control, balance , rigidity Falls, poor transfers Anterior to precentral gyrus, in the frontal lobe with connections to IC, Basal ganglia, cerebellum Poor static & dynamic balance, motor planning, ataxia, chorea, hemiballismus, tremors Falls poor sitting & standing balance , ADLs affected UMN system of CNS, esp internal capsule Spasticity- increase in tonic & phasic spasticity Contractures, joint pains, loss of function ( ref- compiled from rehabilitation of stroke syndromes-Chap 51 PMR 3rd Ed Braddom)
  22. 22. Impairments in Stroke prevalence Framingham Study Enass, Catherine et al- Estimate of prevelance of A/c Stroke impairments in multi ethnic population ( South London stroke registry) n=1259 Stroke 2001 impairment percentage Gaze paresis 18.4 % Field defect 26.1 Visual neglect 19.8 Sensory inattention 19.4 LL motor deficit 27.2 UL motor deficit 77.4 Ataxia 7.2 UL sensory deficit 30.3 Dysphagia 44.7 Dysphasia 23 Urinary incontinence 48.2 %
  23. 23. Framingham Study only 1 in 10 strokes were completely independent Participation & Activity Percentage of patients No Vocation post stroke 63% Reduced socialisation 59% Reduced use of transport 44% Dependant in ADLs 32% Dependant with dressing 30% Transfer assistance 20% Unable to walk 15%
  24. 24. Strategies to manage -Stroke Impairments impairment problem intervention Upper limb involvement Spasticity Weakness Coordination Pain shoulder CRPS Drugs,BTx, splints, positioning, Halter, antagonistic muscle strengthening. CIMT, NMES, FES, Contrast bath, mirror therapy, Bobath, Task oriented Approach Lower limb involvement Spasticity, weakness, Poor control, stability contracture Prone lying, exercises, stretching & position AFO, Drugs, Injections, serial casting, tendon lengthening, FES, BWSTT, Robot Assisted training, Bobath, Trunk control & stability Rigidity, Balance, Transfers affected Bridging, trunkal exercises, BWSTT, Transfer training, railing, Tripod Apraxia & neglect Difficulty with ADLs esp Dressing& hygiene, Gait, siting balance,neglect is a disorder of Visual & spatial attention Sensory motor integration, sensory input from affected site, Mirror therapy,Transfer training, Standing balance training.
  25. 25. managing impairments • Restoration of Locomotion is one of the main goals in Stroke Rehab • Gait is affected due to • Muscle weakness • Spasticity • Sensory motor control loss • Impaired cognition • Shorter steps, longer stance phase
  26. 26. Managing Trunkal imbalance • Trunk biomechanics during hemiplegic gait after stroke – A systematic review, Vancriekinge T et al – Gait & Posture 2017 • Decreased trunkal coordination & Ltd strength • Pelvic step is influenced • Increased mediolateral trunk sway • Specific exercises, walking aid, orthosis help control these defects • Weight bearing Asymmetry associated with Postural instability – Systematic review- Kamphius J – Stroke Res Treatment 2013 • WBA – weight bearing asymmetry towards the non paretic side is common • WBA- poorer COP trajectory synchrony • Increase in WBA- increases postural sway • Training of weight bearing symmetry is a major focus of stroke rehab
  27. 27. Role of Ankle foot orthosis in improving locomotion & functional recovery in Patients with Stroke- a Prospective rehab study H Sankarnarayanan,Anupam Gupta et al- Journal of Neuroscience & rural Prac-2016 • N=26 • Outcome measures – 6 minute walk test, speed of 10 Mt walk, FIM • MCID in 6MWT ( 50 M) • 34.6% of Pts using AFO & 11.5% of Pts not using AFO • All Pts had subjective improvement while using AFO • Conclusion • Use of AFO in stroke = mixed response • 2/3rd of patients had no effect • AFO provided mediolateral stability & helped in swing Phase.
  28. 28. Stroke Rehabilitation Phases Phase purpose action remarks Phase I Evaluation Medical, functional & Life situation Phase II Rx, Arrest pathogenesis Drugs & interventions Phase III Enhancement Exercises, counselling & orrthosis Strengthening &balance Phase IV Task reacquisition ADL& gait training Phase V Environmental modification Home & Workplace modifications , Return to society
  29. 29. Phase I- Evaluation Personal details emphasis History Functional H/o & review of systems General Examination Vitals & deformities Systemic examination complications CNS Visual, aphasia, Neglect, spasticity Neuromusculoskeletal Exam Tone, voluntary control ,power ,synergy, contractures Functional evaluation ADLs, Balance, Transfers, Gait Scales & scores
  30. 30. Evaluation scale NIHSS National institute of health stroke scale FIM Functional Independence measure - ADLs Modified Rankin scale Disability Fugel Meyer Spastic hand function MAL or Wolf scale Hand function ( Motor activity Log) Hoffer & Bullock ambulation One minute walk test walking Get up & go test ambulation Star cancellation Visual neglect Gait Analysis
  31. 31. Enumeration of Impairments, Activity & participation, complications Sl no Medical issues complications impairment Activity participation remarks 1 diabetes Shoulder subluxation hemiplegia Walking affected Duty as driver for ambulance affected 2 infarct Ataxia Rt side Poor sitting Poor dynamic balance Regular attendance to community meet affected 3 Able to feed Parenting & decisions -fair 4 Good family interactions
  32. 32. Rehab planning – eg. Sl No Impairments Action Rehab team 1 spasticity Positioning, Baclofen, Injection, ortrhosis - -WHO, Articulated AFO Nursing, Physiatrist, Orthotist 2 Limb contracture Equinus Stretching, serial casting,, Physio, Physiatrist/ Ortho 3 Aspiration Pneumonia Ryles , Good mouth hygiene, antibiotics chest PT Nursing, PT 4 Shoulder subluxation ES to deltoid , Shoulder halter PT, Orthotist 5 Falls Counselling, balance training, tripod Nursing, OT, Orthotist 6 Aphasia Speech stimulation Speech therapist Body image & neglect Mirror therapy and sensory stroking OT Followed by an informed instruction to each member after the team meet
  33. 33. Stroke Rehab team • Physiatrist • Neuro Physician • Psychiatrist • Occupational therapist • Physiotherapist • Rehab nurse • Speech language pathologist • Orthotist • Social worker…….
  34. 34. Phase III-- Enhancement • Common rehab interventions in a classical hemiplegic Stroke with spasticity and equinus , for ambulation .. • ROM exercises, gentle stretching , distal to proximal stroking of the limb to improve sensory input, Bridging to improve trunk control, biofeedback balance training exercises, tilting table and standing frame for bedridden patients, standing weight shifts and , orthotics like AFO & cock up splints(WHO) and shoulder halter, walking Aids like tripod walking stick. Electrical stimulation & FES.
  35. 35. Phase IV -- Task Reacquisition • Once the person with Stroke has achieved adequate sitting balance and standing balance • he/she could be progressed to Task reacquisition like • Gait training, step climbing , ADL training- one hand dressing, toileting & feeding . • reach out to an over head shelf, open a door, • manage a computer/ laptop • later even driving a modified car.
  36. 36. Phase V--Environmental Modifications • railings on the better side • Grab bars in bathrooms • Water health faucet on the able side • Toilet chairs with arm rest • Railing on the bed for a confused patient • Chairs with high seats
  37. 37. Family • Take the patient & family into confidence • Explain the disease process • Its treatment options, impairments, prognosis for recovery • Focus on accepting the condition • Motivate for regular exercises and life style changes • Move focus from impairments to Activity & participation.
  38. 38. Neuroplasticity Neuroplasticity refers to the ability of the CNS to reorganise and remodel particularly after CNS injury
  39. 39. Functional recovery following stroke cellular level • Dentritic sprouting • New synapse formation • Long term potentiation and depression of cerebral cortex • Undamaged areas taking up lost function of infarcted areas • Prevention of Diaschisis
  40. 40. Peri infarct reorganisation • Alteration of cortical motor maps after primary motor cortex lesions – “ vicarious reorganisation”. • FMRI studies – Dorsal shift of cortical activation near areas of infarct – Eg : recovery of finger movements following small cortical lesions picked up in FMRI
  41. 41. Rehab interventions supporting Neuroplasticity • Distal to proximal stroking of the limbs affected • Active assisted & simulated ADLs • Task oriented approach – Carr & Shepperd • Simulated activities • Bobath approach
  42. 42. Rehab interventions supporting Neuroplasticity • Bodyweighted supported treadmill training –BWSTT • “ massed practice with progressive wt bearing” • Pamela et al – n=408 • NEJM-2011 • compared Home exs to BSTT • Fugel meyer, walking speed & Berg scale • After 6 months similar gains in walking speed
  43. 43. Rehab interventions supporting Neuroplasticity • Robotic devices can induce repetitive passive or assisted limb movement • Cortical excitability in FMRI was a good predictor for functional gains following Robot assisted training • Millot, Spencer & Chan
  44. 44. Rehab interventions supporting Neuroplasticity • Virtual reality • Adding imagery to movement , lit up additional brain regions in FMRI – Stewart & Crammer • studies
  45. 45. Rehab interventions supporting Neuroplasticity • Constrained induced movement Therapy • Proposed by Edward Taub & supported by Randolph • Improving function of impaired limb by blocking the good limb in a arm sling
  46. 46. Rehab interventions • Rythmic auditory stimulation- RAS • Can enhance gait function by improving the pace for walking • In gait velocity, stride length, & cadence • Rebecca Hayden , IJNs , 2009
  47. 47. Rehab interventions • Recent studies using FMRI & r TMS show that the adult brain is also capable of adaptive plasticity., with undamaged areas taking up lost function • EMG initiated FES- Menta move
  48. 48. Rehab intervention supporting Cortical remapping • Mirror therapy • form of Motor imagery where a mirror in the sagittal plane is used to convey visual stimuli of the normal limb movement when the affected limb is hidden • VS Ramachandran- Phantoms in the brain
  49. 49. Summary • Though there is a battery of rehab interventions to improve physical function of stroke impairments • Stand alone none can guarantee a complete recovery • Only a judicious combination of the same can bring better results
  50. 50. Role of the Physiatrist • Brain programmer … neuroplasticity, retrain • Engineer … biomechanics of gait • Team guide … coordinate, be aware • Friend • Doctor … help the patient take decisions.
  51. 51. Role of Physiatrist • A Friendly Doctor
  52. 52. conclusion • Save the penumbra • Evaluate well – function & risk factors • Enumerate- Impairment, activity, participation & complications • Rehab plan • Support team work • Help the person with stroke back into society.
  53. 53. Thank you
  54. 54. If Time Permits
  55. 55. Our experiences… • RajaLakshmi (name changed) • 60 yrs old Lady • CVA Lt Hemiplegia • Atrial Fibrillation (on Warf) • Hypertension & Dyslipidemia • Subclinical Hypothyroidism
  56. 56. • 60 yr old Rajalakshmi is a grand mother who had retd as a administrative staff. • Hypertensive last 4-5 yrs on drugs • 2 am she fell down after vomiting in the bathroom. • She was able to speak but could not walk after this • Noticed weakness of Lt UL & LL
  57. 57. RajaLakshmi • Referred to Our Dept at 2 wks. • P.R – 76/mt irreg, BP 150/100, RR – Temp 98 F • Hemineglect • Hemianopia and UMN Facial Palsy • Grade 0 power with Hypertonia Lt UL & LL.
  58. 58. At admission • FIM - 59/126 • NIHSS – 11/42 • m Rankin scale – 4/6 • She was unable to sit up and was dependent in all ADLs with significant neglect on lt side
  59. 59. Rajalakshmi • Put on early mobilisation program which included • Positioning of arm in Abd & ER • Positioning of leg in Abd & Ankle in Neutral • Distal to proximal stroking • TA, hamstring, add & finger flexor stretching.
  60. 60. Rajalakshmi • Bridging • Knee rolls • Sitting up on bed on Rt side • Caregiver was adviced to interact with patient only from the left side • Low intensity , 3-5 repetition of each set every 2 hrs was given by caregiver.
  61. 61. Rajalakshmi • Progressed from • tilting table to standing table to parallel bars over 2-3 weeks • OT for ADL training & sensory integration for Lt side • PT for gross motor skills • Wrist hand orthosis & Shoe insert AFO.
  62. 62. Rajalakshmi • She is now standing independently in parallel bars with an AFO • Independent in Feeding,brushing,toileting • Partially dependent in bathing,dressing • Vitals PR - 76/mt BP–140/90 Temp – 98F • Voluntary control better in the knee extensors • FIM – 73/126
  63. 63. On the flip side… • Shobana (name changed) • 65 yrs old housewife • Hypertension and dyslipidemia (on drugs) • Was referred to PMR on day 5 of the Stroke. • Rt Sided weakness and Global Aphasia. • CT scan – Lt Fronto-parietal infarct
  64. 64. Shobana • On day 2 in PMR • Progressive Drowsiness & unresponsive to stimuli ….. vitals were stable • Medicine Consultation • Rpt CT scan – Evolving Rt parietal infarct • Shifted to the ICU ….
  65. 65. Stroke spectrum Comatosed unstable patient to RIND
  66. 66. Prevention is always better than rehabilitation

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