Evidence based stroke rehabilitation
This presentation is the property of its rightful owner.
Sponsored Links
1 / 49

Evidence Based Stroke Rehabilitation PowerPoint PPT Presentation


  • 266 Views
  • Uploaded on
  • Presentation posted in: General

Evidence Based Stroke Rehabilitation. Scott Hardin MD Medical Director of Rehabilitation Services, Aurora St. Luke’s Clinical Safety Officer, Aurora St Luke’s Vice Chief of Staff, Aurora St Luke’s. Evidence Based Stroke Rehabilitation. Disclosures None.

Download Presentation

Evidence Based Stroke Rehabilitation

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript


Evidence based stroke rehabilitation

Evidence Based Stroke Rehabilitation

Scott Hardin MD

Medical Director

of Rehabilitation Services, Aurora St. Luke’s

Clinical Safety Officer, Aurora St Luke’s

Vice Chief of Staff, Aurora St Luke’s


Evidence based stroke rehabilitation1

Evidence Based Stroke Rehabilitation

Disclosures

None


Evidence based stroke rehabilitation2

Evidence Based Stroke Rehabilitation

Goals

Briefly review the history of stroke

Learn the pertinent epidemiological facts of stroke now and into the future

Gain an appreciation that, despite there being almost 1000 RCT regarding stroke outcomes, we are still in the infancy of understanding why we do what we do


Evidence based stroke rehabilitation3

Evidence Based Stroke Rehabilitation

Goals

Review data from the excellent resource Evidence Based Review of Stroke Rehabilitation (EBRSR)


Evidence based stroke rehabilitation4

Evidence Based Stroke Rehabilitation

History

600 BC Hippocrates – 4 humours

160 AD Galen – advanced the humour theory

1599 “the stroke of God’s hand”

1732 Robinson described the typical apoplectic patient


Evidence based stroke rehabilitation5

Evidence Based Stroke Rehabilitation

History

Mid 1600s Jacob Wepfer

cerebral hemorrhage

blocked cerebral arteries

1920s cerebral angiography

1935 blood letting debunked


Evidence based stroke rehabilitation6

Evidence Based Stroke Rehabilitation

History

1950s first carotid endarterectomy

1960s Doppler ultrasound

1960s hypertension a modifiable risk

1970s aspirin

CT scanning

PET scanning


Evidence based stroke rehabilitation7

Evidence Based Stroke Rehabilitation

History

1980s

stroke prevention/risk modification

smoking identified as risk

1990s

endarterectomy proven to be effective

anticoagulants and a fib

blood pressure and cholesterol


Evidence based stroke rehabilitation8

Evidence Based Stroke Rehabilitation

History

1990s

tPA approved

combined dipyridimole and aspirin

2000s

acute cerebral artery thrombectomy

carotid artery stenting


Evidence based stroke rehabilitation9

Evidence Based Stroke Rehabilitation

Epidemiology

>700,000 total strokes per year in the US

Mortality is still about 50%

However, stroke mortality fell 12% between 1990 and 2000

Men 1.25 x risk of women

Blacks have 2x risk of stroke vs white; Hispanic is in between


Evidence based stroke rehabilitation10

Evidence Based Stroke Rehabilitation

Epidemiology

There are an estimated 5 million stroke survivors in the US

More than 1.1 million with some form of chronic disability

Baby boomers

Disability


Evidence based stroke rehabilitation11

Evidence Based Stroke Rehabilitation

Why does rehab work?

Neural Plasticity – the ability of the brain to reorganize and learn new functions


Evidence based stroke rehabilitation12

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data

In its toddlerhood

Will be important to show we matter

Soon, doing things because we think it works won’t fly


Evidence based stroke rehabilitation13

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data

Indredavik et al 1990

randomized 220 strokes to the IRF* unit or general medical unit

outcomes were home or not, mortality, BI at 6 and 52 weeks, 5 years and 10 years

*IRF = Inpatient Rehabilitation Facility


Evidence based stroke rehabilitation14

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data

Indredavik et al 1990

Across all time frames statistically significant:

lower mortality in the IRF group

lower institutionalization in the IRF group

higher home living in the IRF group

higher BI scores in the IRF group


Evidence based stroke rehabilitation15

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data

Ronning and Guldvog – 1998

randomized controlled trial

251 strokes

compared community care (no IRF) to IRF

outcome was dependence (BI<75) or death


Evidence based stroke rehabilitation16

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data

Ronning and Guldvog – 1998

7 month follow up

23% IRF patients dead or dependent vs 38% community care (p=.01)

39% reduction in worse outcomes with IRF care


Evidence based stroke rehabilitation17

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data

Foley, et al 2007 Meta analysis of IRF stroke unit trials

world wide

consistent statistical benefit of IRP units over other types of post stroke care in reductions in mortality and less dependency


Evidence based stroke rehabilitation18

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data

EBRSR – Evidence Based Review of Stroke Rehabilitation

2001

systematically reviews all outcomes based stroke literature, summarizes and grades itwww.ebrsr.com


Evidence based stroke rehabilitation19

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data

EBRSR reviews stroke literature relative to:

techniques

therapies

devices

procedures

medications


Evidence based stroke rehabilitation20

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data

EBRSR

extensive and comprehensive database search strategies

3407 studies reviewed

2000 in depth studies reviewed

956 RCT

Methodological quality assessed using the PEDro scale


Evidence based stroke rehabilitation21

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data

EBRSR

grading scale (based on the AHCPR)

Level 1a (strong)

Level 1b (moderate)

Level 2 (limited)

Level 3 (consensus)

Level 4 (conflicting)


Evidence based stroke rehabilitation22

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data

EBRSR

only the data from the 956 RCTs are used for determination of evidenced based recommendations


Evidence based stroke rehabilitation23

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data

EBRSR

Recommendations are broken into:

Efficacy of Stroke RehabElements of Stroke Rehab

Outpatient Stroke RehabSecondary Prevention

Mobility/Lower extremityUpper extremity

Painful hemiplegic shoulderCognitive/Apraxic disorders

Perceptual disordersAphasia

Dysphagia/AspirationNutritional interventions

Medical complicationsDepression

Community reintegrationMiscellaneous

Young strokeSevere Stroke

Outcome measuresStroke Triage


Evidence based stroke rehabilitation24

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data

EBRSR

Stroke Triage

early screening

early admission, but

patients with severe stroke better managed in a less acute setting

younger (<55) patients with moderate to severe strokes should always be admitted to IRFs


Evidence based stroke rehabilitation25

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data

EBRSR

Stroke Rehab Elements

care pathways don’t improve outcomes or reduce costs

greater intensities of PT and OT improve functional outcomes

unclear intensive language therapy

the greater functional improvements from IRF care are maintained long term


Evidence based stroke rehabilitation26

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data

EBRSR

Lower extremity and mobility

Bobath is as good but slower

focused balance training is beneficial

rhythmic auditory sensory stim helps

PBWS on treadmill questionable

strength training is beneficial


Evidence based stroke rehabilitation27

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data

EBRSR

Lower extremity and mobility

cardiovascular training is good

WC self propel does not help

using canes enhances mobility

e stim with gait training improves gait

EMG/biofeedback improves gait training


Evidence based stroke rehabilitation28

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data

EBRSR

Lower extremity and mobility

tilt table or night splinting prevent contracture

AFOs help

e stim and U/S reduce spasticity


Evidence based stroke rehabilitation29

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data

EBRSR

Upper extremity

initial degree of motor impairment is the best predictor of motor recovery

NDT is not superior

effects of enhanced therapy, task specific training, sensorimotor training and mental practiceunclear


Evidence based stroke rehabilitation30

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data

EBRSR

Upper extremity

hand splinting does not help

robots help a little

CIT helps

virtual reality helps

Botox helps tone/spasticity but maybe not function


Evidence based stroke rehabilitation31

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data

EBRSR

Upper extremity

PT may not reduce spasticity

IPC does not help edema

FES does improve function


Evidence based stroke rehabilitation32

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data

EBRSR

Cognition

1/3 of stroke patients develop dementia

Stroke patients have 10x risk of developing dementia

Depression contributes to cognitive impairment in stroke


Evidence based stroke rehabilitation33

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data

EBRSR

Cognition

treating hypertension in stroke patients reduces their dementia risk

gesture training is effective for treating ideomotor apraxia


Evidence based stroke rehabilitation34

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data

EBRSR

Language therapy

is efficacious in aphasia when provided intensely for the first three months

group therapy may improve communicative and linguistic abilities


Evidence based stroke rehabilitation35

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data

EBRSR

Language therapy

CPU-based aphasia therapy helps

forced use aphasia therapy helps

repetitive transcranial magnetic stimulation and polarity specific transcranial direct stimulation may help


Evidence based stroke rehabilitation36

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data

EBRSR

Language therapy

piracetam, levodopa, memantidine, dextroamphetamine and donezepil may improve language function

bromocriptine, cholinergics, dextran and moclobemide do not help


Evidence based stroke rehabilitation37

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data

EBRSR

Dysphagia

VBMS is the only sure way to diagnose dysphagia and aspiration

Aspiration rates are high

risk of developing pneumonia is related to aspiration severity


Evidence based stroke rehabilitation38

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data

EBRSR

Dysphagia

all stroke survivors should be npo until assessed

SLPs should see all patients who failed the swallow screen

dysphagic individuals should feed themselves


Evidence based stroke rehabilitation39

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data

EBRSR

Dysphagia

a variety of treatments can be used to improve swallowing function post stroke


Evidence based stroke rehabilitation40

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data

EBRSR

Medical complications

indwelling catheters should only be used in specific instances

timed voiding, biofeedback pelvic training, behavioral therapy and weekly in home visits reduce incontinence


Evidence based stroke rehabilitation41

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data

EBRSR

Medical complications

incidence of DVT is less than 10%

anticoagulation reduces DVT

LMW heparin is more effective than unfractionated heparin

compression devices don’t help reduce DVT


Evidence based stroke rehabilitation42

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data

EBRSR

Medical complications

10% of post stroke patients have seizures

osteoporosis is common after stroke and can be reduced with ipiflavone, vit D + Ca, vit B12 + folate, sunlight, and bisphosphonates


Evidence based stroke rehabilitation43

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data

EBRSR

Depression

1/3 develop depression

influence of stroke location and propensity to develop depression not understood

depression negatively impacts recovery


Evidence based stroke rehabilitation44

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data

EBRSR

Depression

depression is associated with cognitive impairment

early initiation of post stroke antidepressants is effective in preventing depression

various medication classes are effective in depression


Evidence based stroke rehabilitation45

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data

EBRSR

Depression

pharmacologic treatment improves functional recovery

treatment with antidepressants improves long term survival

ECT and TCMS are effective

music therapy helps


Evidence based stroke rehabilitation46

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data

EBRSR

Depression

exercise training does not help


Evidence based stroke rehabilitation47

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data

EBRSR

Miscellaneous

unclear if acupuncture helps

Reikki does not help

HBO does not help


Evidence based stroke rehabilitation48

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data

Summary

many of the treatments we provide stroke patients are proven to help them

many of the treatments we may be providing stroke patients have been shown not to help (and yet we do them anyway!)

the EBRSR is an excellent resource to obtain data regarding the latest RCT evidence based outcomes information


  • Login