STROKE REHABILITATION

Transcription

1 STROKE REHABILITATION AISHWARYA PATIL, MD CHI-IMMANUEL REHAB INSTITUTE, OMAHA STROKE US > 700,000 Strokes per year 5.6 million Americans live with disability caused by previous Stroke (National Center for Health Statistics) Leading cause of permanent disability in adults 45% of stroke patients have moderate-severe disabilities requiring rehabilitation Reduces mobility > half of stroke survivors above 65 yrs 1

2 STROKE REHAB GOALS: Maintain, optimize medical mgt Maximize functional recovery Minimize disability Improve quality of life, participation in society Patient centered care: organized, specific, comprehensive REHAB TEAM : Physicians PT, OT, ST Nurses Psychologist Dietician Case manager Social worker Rec Therapist Chaplain ACUTE INPATIENT REHAB 3 hours of therapy per day : PT, OT, ST Medical acuity Daily Physician rounding Comprehensive care Assistive devices Home evaluation, modification Outpatient follow up Return to work, driving Disability 2

3 STRONGEST PREDICTORS OF OUTCOME: STROKE SEVERITY, AGE Large strokes, severe clinical deficits Age: >65 NIHSS score within 24 h of acute ischemic stroke onset: <6 : good recovery (able to live I, return to work/ school) 7-10 : 46% at 3m : 23% at 3m >16 : high probability of death, severe disability Canadian Neurological scale (CNS): < 6.5 increased 30 day mortality, poor outcome in 6m (NIHSS = 23-2 x CNS) NEUROIMAGING: INFARCT VOLUME, LOCATION Volume of ischemic tissue DWI MRI <36 hrs+ NIHSS + time from onset, predicts 3m outcome Large study with 1800 pts with CT/MRI <72 hrs: initial infarct vol independent predictor of stroke outcome at 90 days with age + NIHSS score ACA, MCA, supratentorial Acute occlusion of cervical ICA, basilar, large intracranial artery Diffusion perfusion mismatch, poor collaterals, edema 3

4 INFARCT LOCATION Strokes in insular region (MCA): increased mortality, autonomic dysregulation, early expansion Anterior choroidal artery infarctions: progress early Internal capsule: worst prognosis for recovery of hand motor function at 1 yr Lacunar infarcts, cryptogenic strokes: better prog upto1y Cardioembolic, large artery: worse prognosis PREDICTORS OF OUTCOMES Early neurological deterioration Extension of infarct, hemorrhagic conversion Progressive edema, raised ICP Seizures Delirium Depression 70-80% Integrity of ipsilesional CSP tract: motor recovery (MEP by TCM, DW MRI, DTI) 4

5 PRESTROKE CO MORBIDITIES : POOR OUTCOMES Anemia Afib Cancer CAD Dementia DM II Periventricular white matter BMI- underweight, normal; high mortality Hyperglycemia >110 mg/dl on admission Heart failure, MI Dependency Renal dysfun, HD Poor nutrition Postop: high short term morbidity Nonwhites, Socioeco, education Gender : no difference STROKE RECOVERY Affected: Arm > Leg, Recovery: Leg > Arm Proximal > distal Tone > voluntary movement Most recovery within 3months Early, intense rehab: A Very Early Rehabilitation Trial after stroke (AVERT): Phase III, multicenter, RCT 80% recovery in first year Flexor synergy pattern UEx, Extensor in LEx 5

6 PREDICTORS OF MOTOR RECOVERY : Severity of arm weakness at onset Complete arm paralysis : poor recovery of useful hand function 9% No grip strength at 4 weeks Severe proximal spasticity, prolonged flaccidity Some motor recovery of hand by 4 weeks: 70% chance of making full or good recovery Hemianopsia > 3 weeks GOOD RECOVERY: 6 M Return of arm, hand function Active finger extension Grasp release Shoulder shrug Shoulder abduction 6

7 STROKE REHAB 50-70% regain functional independence 15-30% permanently disabled 20% institutionalized 3 months post stroke IV tpa : Significant motor outcomes at 3 months Mechanical Thrombectomy: superior WILL I WALK AGAIN? 80% ambulate short distances without assistance < 50% limited community ambulation (150ft) 10-33% with Lower Extremity paresis ambulate with Mod I 78% - 85% walk with or without Assistive device 7

8 WHO WILL WALK? WANDELAPM&R 2000 Barthel index score >60 : walk with A Barthel index score 100: d/c to community I Barthel index < 20: 70 % Lower Extremity strength 3/5 in 1 week 48% - 58% regain independence with ADLs 2009 study: 50% return to work at 1 yr GLOBAL PROGNOSTIC SCALES OPS Reding 3 factor ASTRAL score DRAGON score iscore PLAN score Modified Rankin scale Barthel Index PREP algorithm predicts potential for UE recovery after stroke Function (voluntary activation)- SAFE (shoulder Abduction finger extension) 0-10 SAFE score >8 = complete recovery 8

9 APHASIA: RECOVERY, PROGNOSIS Incidence 25-33% Mild 300 pts with Aphasia at adm: time to max language recovery in 95% pts with mild, mod, sev aphasia was 2,6,10 wks % at 6 months Recovery slower, lasts longer Variable Depends on size of the lesion May occur beyond 1 year (Skilbeck) DYSPHAGIA 50% early after stroke Aspiration risk PEG: high NIHSS score, bi hemispheric infarcts Retrospective cohort study of 563 pts adm to stroke rehab: FT placed in 30% removed before discharge from rehab; rest by 1 yr 9

10 SENSORY LOSS 65-94% stroke survivors Reduced mobility, ADLs Thalamic stroke Debilitating post stroke pain syndrome Visuospatial neglect: 70-80% recover in 3m Hemianopsia: driving RISK FACTORS FOR DISABILITY Severe stroke (minimal motor recovery at 4 weeks) Low level of consciousness Diabetes mellitus Cardiac disease Electrocardiograph abnormalities Old age Delay in medical care Delay in rehabilitation Bilateral lesions Previous stroke Previous functional disability Poor sitting balance Global aphasia Severe neglect Sensory and visual deficits Impaired cognition Incontinence (>1 2 weeks) 10

11 PROBLEM LIST Medical issues Bladder- 50% at 1 week, 15% at 6 months Nutrition, Hydration, skin Aphasia, Dysphagia DVT, PE Pneumonia Seizures POST STROKE Shoulder pain 72% RTC tendonitis Brachial plexopathy Subluxation CRPS I ( RSD, shoulder- hand syndrome) Adhesive capsulitis Spasticity Fatigue 30-70% 11

12 DEPRESSION 40%- 80% Organic: catecholamine depletion through damage to frontal (NA, DA, 5HT) projections Reactive: Grief, psychological responses for physical, personal loss of control,severe disability Similar in caregivers (Flick 1999) 6 months - 2 years Left frontal lesions (controversial) Fluoxetine for motor recovery after acute ischaemic stroke (FLAME): a randomised placebo-controlled trial Lancet Neurology In ischemic stroke, mod to sev motor deficit, early prescription of fluoxetine with PT enhanced motor recovery after 3 months. STROKE RECOVERY 1. Cortical reorganization: Collateral sprouting Neuroplasticity: Repair, reconnect, recruit neuronal pathways; transform, renew and rewire, stimulated by PT, OT, ST 2. Unmasking of contralateral, ipsilateral pathways 3. Compensation 12

13 STROKE RECOVERY Therapies within 24 hours Intensity of Therapies Higher functional gains > 3 hours Therapy Organized inpatient stroke unit more likely to be alive, indep, living at home 1 year post stroke Encourage therapeutic value of non supervised activity to complement structured therapy Delay in Rehab: poor functional outcomes PT Walking speed predicts level of disability. Walking speed > 0.8 m/s: full mobility in community < 0.4 m/s limited to home 0.4 to 0.8 m/s short walks in community Improving functional walking capacity is primary goal of PT interventions 13

14 HOW TO INCREASE STEPS IN GAIT TRAINING Higher intensity and repetition lead to increased outcomes (Langhorne, French 2009, Moore2010) Number of repetitions of Lower extremity exercises predict time to independent walking and speed(scrivener 2012) Current: Avg 357 steps, 75 active LEx exercises (Lang 2009) steps possible (Moore 2010, Holleran 2013) HOW TO INCREASE STEPS IN GAIT TRAINING More repetitions of LEx exercise = Better recovery Higher intensity is better Aerobic conditioning improves gait endurance, speed (Pang 2003) Practicing functional activities improves functional tasks, motor control BP <200/100 and > 80/60 pre exercise Maintain <240/110 through exercise 14

15 TASK ORIENTED TREATMENT (TOT) The best way to promote functional recovery after Stroke Focuses on practice of skilled motor performance to facilitate neural reorganization, "rewiring" in CNS. Patient centered goals, focus to acquire skills, optimal challenge Repetition is the key CIMT: Effect of Constraint Induced Movement Therapy on upper extremity function 3 to 9 months after stroke: the EXCITE randomized clinical trial (JAMA 2006) Current: Average 32 functional reaches, 54 active Upper extremity exercises ( Lang 2009) 300 possible (Birkenmier 2010) MUSIC: EARLY POST STROKE ENHANCED COGNITIVE RECOVERY, MOOD 60 patients with left or right MCA infarct assigned randomly to music, language, control group x 2months listened daily to self selected music or audio books Control group- none Music group- Significantly improved verbal memory, focused attention, less depressed and confused Dr Oliver Sachs 15

16 FUTURE Brain computer interface: motor imagination, visual feedback, functional electrical muscle stim Virtual Reality Robotic exoskeleton Vagus nerve stimulator, Implanted Wearable devices with sensors: gait, balance 16

17 VIRTUAL REALITY (VR) Effect of a four-week virtual reality-based training versus conventional therapy on upper limb motor function after stroke: A multicenter parallel group randomized trial. Schuster-Amft C 1,2, Eng K 3, Suica Z 1, Virtual reality for stroke rehabilitation.laver KE 1, Lange B, George S, Deutsch JE, Saposnik G, Australia VR 17

18 TCDS Transcranial direct current stimulation (tdcs) for improving ADLs and physical and cognitive fun after stroke. Elsner B 1, Kugler J, Pohl M, Mehrholz J. OBJECTIVES: To assess the effects of tdcs on ADLs, arm and leg function, muscle strength and cognitive abilities (including spatial neglect), dropouts and adverse events in people after stroke. MIRROR THERAPY Visual feedback Improves UE motor function, ADLs, Pain Valuable adjunct 18

19 LITEGAIT: PARTIAL WEIGHT BEARING GAIT THERAPY Develops new function restoring neuronal networks Triggers spinal-cord s centralpattern generator, that can sustain lower-limb repetitive movements like walking, indep of direct brain control 19

20 LOKOMAT: ROBOT ASSISTED WALKING THERAPY Combines repetitive task specific training with stimulation of spinal stepping generators. FDA 2001 Exoskeleton Repetitive walking pattern helps the brain and spinal cord to reroute signals interrupted by injury strengthen muscles improve circulation strengthen bones at risk for osteoporosis Electromech assisted gait training + PT= more likely to achieve independent walking LOCOMOTOR EXPERIENCE APPLIED POST STROKE (LEAPS) TRIAL: DUNCAN ET AL, NEJM 2011 Compared 2 different therapeutic exercise programs provided by PT to improve ability to walk after stroke Task-specific walking program, stepping on treadmill with PBWS Exercise program targeted mc gait-relevant impairments after stroke: weakness and poor balance. Stroke survivors in community with marked limitations in walking, task-specific treadmill training with BWS (locomotor training) was not shown to be superior in improving the functional level of walking to home administered PT focused on less-intensive but progressive strength and balance training. 20

21 LEAPS TRIAL, NEJM % had an improved functional level of walking, improved walking speed, distance walked, steps taken in the community. Improvements in balance, ADLs, physical mobility, social participation were clinically significant. Changes in scores on (FMA) Fugl-Meyer Assessment of Motor Recovery in legs were modest. WII REHAB Effectiveness of Virtual Reality Exercises in Stroke Rehab (EVREST) Int Journal Stroke feb 2010, Toronto RCT assessing the feasibility, safety, and efficacy of virtual reality using Wii gaming Multicenter Trial 21

22 MIT MANUS Robotic therapy reps/ 30 mins( vs 36 reps) Robot-Assisted Therapy for Long-Term Upper-Limb Impairment after Stroke (NEJM, 5/13/2010 ARMEO Simulate arm movts used in real-life tasks Goal-oriented tasks Visual feedback Neuromuscular control exercise, strength Sensors, software Record arm movement at each joint, track improvement Customize training program 22

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24 THANK YOU! 24