Title: PRIMARY ISSUES IN REHABILITATION OF STROKE
1PRIMARY ISSUES IN REHABILITATION OF STROKE
- Michael Saucier, M.D., M.S.
- Dept. of Physical Medicine Rehabilitation
1
2OBJECTIVES
- Review the role of rehabilitation in stroke
recovery - Functional effects of stroke
- Discuss salient aspects of rehabilitation of
stroke including CIMT, Robotics Virtual Reality - Challenges in delivery of Stroke Rehabilitation
2
3GENERAL CONSIDERATIONS
- Recurrence is greatest in first 6 months
- 10-16 recurrence in 1st year
- Gradual decline to usual risk by about year 5
- 10 of survivors recover almost completely
- 25 recover with minor impairments
- 40 experience moderate/severe impairments
- 10 require care in a nursing home or LTC
- 15 die shortly after the stroke
4CENTRAL REHABILITATION THEMES
- Role of behavior in rehabilitation
- Experience-dependent cortical plasticity
4
5CORTICAL PLASTICITY
- The motor cortex is a shared neural
substrate for motor control. The highly
overlapping and divergent architecture provide an
ideal substrate for flexibility in outputs to the
spinal cord that can be rearranged based on
behavioral demands. - ---- Randolph Nudo, M.D.
5
6EXPERIENCE-DEPENDENT CORTICAL PLASTICITY
- Behavioral experience as a potent modulator of
cortical structure and function - driven largely by repetition temporal
coincidence - thought to drive formation of discrete modules
where conjoint activity is expressed as a unit - plasticity is probably skill- or
learning-dependent rather than use-dependent
6
7ROLE OF BEHAVIOR IN MODULATING POST-STROKE
RECOVERY
- CENTRAL QUESTION How can we drive adaptive
plasticity in intact portions of the ipsilesional
hemisphere? - Cortical electrical stimulation does this
enhance excitability of intact ipsilat. areas? - CIMT Constraint Induced Movement Therapy
- Pharmacology
- Robotics
- What do these have in common?
- -- utilize repetitive behavioral tasks,
especially those with high skill demands
7
8EFFECTS OF STROKE
- Paresis/Plegia
- Speech Impairments
- dysarthria (slurred speech)
- aphasia
- Neglect
- Cognitive/Neurobehavioral Syndromes
- Apraxia
Ochsner Medical Center
9EFFECTS OF STROKE
- Dysphagia
- Sensory loss
- Depression
- Visual, oculomotor vestibular deficits
- Central post-stroke pain
- Deconditioning
- Urinary dysfunction
9
10EFFECTS OF STROKE
- DVT
- Contralesional edema
- Hemiparetic shoulder syndrome
- Spasticity
- Diminished endurance
- Poor arousal (somnolence)
10
11COGNITIVE IMPAIRMENT
- Quantitatively cumulative effects of location,
number volume - Executive function
- Dementia
11
12CHARACTERISTICS OF COGNITIVE IMPAIRMENT
- Executive Function
- Executive function ill-defined
- constellation of higher order skills used to
manipulate available information to plan
execute complex activities. - attention, mental flexibility, processing speed,
set maintenance, set shifting, working memory,
error correction - 337 stroke pts 40.6 with dysfunction 1.5 SD
below mean for elderly controls (mean age 70.2
/- 7.6)
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13COGNITIVE IMPAIRMENT
- Stroke is a potent risk factor for dementia
- 10X risk for dementia with prevalence 20-25
- post-stroke dementia is a major risk factor for
mortality independent of age, Barthel index or
comorbid diseases. - improvement in post-stroke survival make this
important - comparison of 1984-1990 and 1991-2000 53
increase in all dementia types, 87 increase in
subjects with stroke. Stroke survival increased
53? 65.
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14CHARACTERISTICS OF COGNITIVE IMPAIRMENT
- CIND (vascular Cognitive Impairment/No Dementia)
- actually a diagnostic category (Rockwood,
Neurology, 2000) - reflects substantial cognitive deficits without
sufficient memory loss or other multi-domain
deficits to meet criteria for dementia. - CIND cognitive features are those related to
executive function sequencing, attention,
working memory, processing speed. - Using CIND even stroke survivors considered to
have NO cognitive deficits demonstrated worse
executive function than stroke-free controls.
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15MANAGEMENT OF COGNITIVE IMPAIRMENT
- Cognitive screening/followup fundamental to Rehab
- NON-PHARMACOLOGIC
- cognitive rehab via S.T. O.T.
- PHARMACOLOGIC disease modifying treatments vs
symptomatic treatments - Secondary prevention HTN control, glucose
control, aggressive dyslipidemia control
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16PHARMACOLOGY IN REHABILITATION
- Arousal Ritalin, Provigil
- Inattention Ritalin, Amantadine, Adderall
- Memory AD agents
- Spasticity Dantrium
- Functional
- Levodopa (Lancet, 2001)
- Reboxetine inhibits norepinephrine reuptake
may enhance learning of motor skills (Neurology,
2004)
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17NEW DIRECTIONS IN STROKE REHAB
18COMPARISON of CMS vs PRIVATE INSURANCE (PI)
CMS PI
Loss of function 1 extremity No Yes
Neuro disease 1 extrem cognitive/speech Yes Yes
Weakness 2 extremity weakness lt/ 2/5 Yes
Home disposition threatened (yes) Yes
Relapsing diseases MS, GBS No Yes
Hip fractures No (Yes)
1 TKA No (Yes)
2 TKAs Yes Yes
UE amputation No Yes
Spine surgery 2 extremity weakness lt/ 2/5 Yes