Pre-Conference Workshop Evidence-Based Stroke Rehabilitation

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Pre-Conference Workshop Evidence-Based Stroke
Rehabilitation

• Resource Persons

• Emmanuel B. John, PT, PhD
• Associate Professor Director, Motor Control
  Neuromuscular Performance Laboratory, Department
  of Physical Therapy, Radford University, Roanoke,
  VA, USA
• Chair Stroke Interest Group, Neurology Section of
  the American Physical Therapy Association
• Abiodun E. Akinwuntan, PhD, MPH, DRS Associate
  Professor Director, Driving Simulation Lab,
  Department of Physical Therapy Interim Associate
  Dean for Research, College of Allied Health
  Sciences, Georgia Regents University, Augusta,
  GA, USA

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Resource Persons

• Abiodun E. Akinwuntan, PhD, MPH, DRS
• Emmanuel B. John, PT, PhD

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Pre-Workshop Quiz

• List one reliable and valid outcome measures for
• Physical functioning
• Neurological Status
• Gait Velocity
• Cardiovascular endurance
• Name the two (2) broad ICF classifications
• List three (3) common models of
  neuro-physiotherapy interventions

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Stroke Toolbox and Gentiles taxonomy

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Break
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Interactive Case Study Session 1

• A 53 year old surgeon with memory problems,
  slight weakness of the right arm, profound right
  leg weakness and impaired sensation of the right
  side of the body.
• History
• Patient woke up from sleep to discover that she
  could not move her right leg and difficulty using
  her right hand. She immediately called her
  physician who told her to call the EMS. Patient
  was immediately taken to the hospital. Patient
  has just been recently transferred to a
  rehabilitation hospital and requires PT.
• Things to know
• Patient has previous history of cigarette
  smoking, anxiety, peripheral vascular disease and
  hypertension.
• Patient is currently alert and oriented, but
  hardly comprehends or follows simple commands.
• Patient has difficulties remembering events or
  encounters that recently occurred but can relate
  old events with ease (always telling stories of
  the past).
• Muscle power of the right upper extremity is now
  3.5/5 and 1 for the lower extremity.
• Patients response to pin prick is inconsistent
  on the right side of the body, more evident in
  the lower extremity.
• Patient can sit and ambulate independently in a
  wheel chair.
• Patient wants to be discharged home as soon as
  possible and possibly return to his career.

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Debrief for Case Study 1

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Theories and Concepts
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Neurologic Treatment Patterns

• Neurologic interventions to improve, resolve
  and/or manage neurologic lesions were developed
  based on motor control theories

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Conventional Therapeutic Exercise Approach

• Range Of Motion (ROM) Exercises
• Muscle Strengthening Exercises
• Mobilization Activities
• Fitness training
• Compensatory Techniques

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Neurophysiological TherapeuticExercise Approaches

• Muscle Re-education Approach (1920s)
• Neurodevelopmental Approaches (1940-70s)
• Sensorimotor Approach (Rood, 1940s)
• Movement Therapy Approach (Brunnstrom, 1950s)
• NDT Approach (Bobath, 1960-70s)
• PNF Approach (Knot and Voss, 1960-70s)
• Other Neurophysiological Approaches
• Motor Control Relearning (1980s)
• Contemporary Task-Oriented Approach (1990s)

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Contemporary Task-Oriented Approach

• Based on systems model of motor control and
  contemporary motor learning theories
• Emphasizes that effective therapeutic
  intervention depends on identification of the
  system that is critical to controlling the
  occupational performance at a specific time

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Motor Control/Relearning Approaches

• Incorporates functional training for key motor
  tasks such as sitting, standing, standing up, or
  walking.
• The therapist analyses each task, determines
  which component of the task cannot be performed,
• trains the patient in those components of the
  task, and
• ensures carryover of this training during daily
  activities

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Interventions in Stroke
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Stages of Recovery Post Stroke

• Hyper-acute
• Time period Onset up to 6 hours post onset
• Rehab Environment ER, Neuro/Stroke Unit, acute
  care hospital
• Acute
• Time Period 1st 24 hours to 7 days (lt 1 month)
  post stroke
• Rehab Environment ACH, Acute/Inpatient Rehab
  hospital
• Sub-Acute
• Time Period 7 days to 3-4 months (1-6 months)
  post stroke
• Rehab Environment Acute/Inpatient Rehab, OPC,
  Community programs
• Chronic
• Time Period gt3-4 months (gt6 months) post stroke
• Rehab Environment Outpatient Clinic, Community
  programs
• Bader et al., 2006, Stroke Engine, OSullivan 2007

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Drivers of Neuroplasticity Changes Post Stroke

• Task-specific Training
• Aerobics
• Use it or Lose it Use it and Improve it
• Specificity
• Repetition
• Intensity
• Age
• Sleep
• Timing of Rehabilitation
• Imagery and Mental Practice (Remember mirror
  neurons?)

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Constraint-induced Movement Therapy
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Body weightsupported treadmill training
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Force-plate biofeedback training for postural
symmetry
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• Virtual Reality and Robotics Rehabilitation

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NDT Treatment facilitation of weight shifting in
standing
Application of slow reversals to weight shifting
in standing
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Task-oriented approach to improve ankle
dorsiflexion range of motion
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NDT treatment facilitation of bridging with key
points of control on the distal femurs
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Summary

• Review causes of stroke
• Description of Ischemic and Hemorrhagic strokes
• Description of deficits and postural control
  problems
• Stages of recovery
• Assessment tools
• Acute Care Intervensions

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Lunch Break
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Interactive Case Study Session 2

• A 64 year old left handed man with mild
  dysarthria, 4/5 strength in the left arm and
  occasional extinction on the left side to double
  simultaneous visual or tactile stimulation.
• History
• Patient called his daughter one day and
  complained of difficulty getting his arm through
  the left sleeve of his dress and slight tingling
  sensation on left side of his face. His daughter
  told him to stay where he is and she called
  emergency services. Patient has just been
  referred for out patient PT after 5 weeks of in
  patient stroke management.
• Things to know
• Patients goal is to get back as quickly as
  possible to pre-stroke routine of farming.
• Patient has previous history of diabetes,
  hypertension and a known fall risk.
• Patient is alert and oriented, communicates
  effectively and adequately follows command.
• Patient can raise left arm against moderate
  resistance but has difficulty holding medium
  sized objects in his left hand and signing his
  name.
• Patient is able to raise left leg against
  moderate resistance and ambulates independently
  but sometimes misses his steps.
• Patient lives in a two storey house with all
  bedrooms on the second floor.
• Patient is sometimes unaware of his left side of
  space (body and environment).

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Debrief for Case Study 2

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Break
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Theories and Concepts

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Post-Workshop Quiz

• List one reliable and valid outcome measures for
• Physical functioning
• Neurological Status
• Gait Velocity
• Cardiovascular endurance
• Name the two (2) broad ICF classifications
• List three (3) common models of
  neuro-physiotherapy interventions

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Discussions Current and Future Workshops