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Stroke Rehab What can we do?

Stroke Rehab What can we do?. Dr. Russell O’Connor Physiatry and Electromyography Associate Professor Division of Physical Medicine and Rehab University of British Columbia. Russ O’Connor MD, FRCPC. Physiatrist – Physical Medicine and Rehab.

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Stroke Rehab What can we do?

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  1. Stroke RehabWhat can we do? Dr. Russell O’Connor Physiatry and Electromyography Associate Professor Division of Physical Medicine and Rehab University of British Columbia

  2. Russ O’Connor MD, FRCPC • Physiatrist – Physical Medicine and Rehab Nerve Testing carpal tunnel, entrapment neuropathies, radiculopathies, plexopathies, diabetic and other peripheral neuropathies Work, sports and motor vehicle injury rehab Rehabilitation after stroke, brain injury, spinal cord, cardiac, immobility, burns, multitrauma, myopathies, other neuromuscular conditions Exercise prescription obesity, diabetes, patients with chronic Acute and Chronic pain management diagnosis and treatment of muscle, bone, joint and nerve pain

  3. Objectives By the end of the session the participant will be able to: • Know about a great source of information for the clinician treating stroke patients -  The Evidence-Based Review of Stroke Rehabilitation (EBRSR) at  - www.ebrsr.com • Understand the importance of functional recovery over and above neurological recovery • Importance of prevention of post stroke complications • Outline the secondary post stroke prevention strategies • Reason why the best care model for acute and subacute stroke care involves an interdisciplinary team approach.

  4. Stroke- Types • Ischemic 80% • TIA’s • Thrombotic • Embolic • Hemorrhagic 20% • Subarachnoid • Intracerebral

  5. Stroke demographics • #3 cause of death • Leading cause of serious, long-term disability in the United States. • 800,000 strokes in the US ¾ are new ¼ • 75% occur in those over 65 • Every 40 sec someone has a stroke in the US

  6. Effects of Stroke • Of every 100 people who have a stroke • 15% die • 10% recover completely • 25% minor impairment or disability • 40% moderate to severe impairment • 10% severely disabled they require long-term care

  7. www.ebrsr.com   • Stroke rehab evidence based review • Techniques, therapies, devices, procedures, medications used in stroke rehab • Purpose – maintaining timely and accurate information of effective stroke rehab, identifying research areas, and improving evidence based practice. • 11th revision now including articles up to Aug 2010 and 1078 RCT

  8. www.ebrsr.com   • Level of evidence ranked • Strong – metaanalysis or two RCT of at least fair quality • Moderate – supported by single RCT of at least fair quality • Limited – supported by one RC trial with > 10 pts in each arm • Consensus – group expert opinion • Conflicting – disagreement between two RCT’s

  9. Stroke Rehab is a TEAM approach • Need to develop of maintain skills in staff • Be formally coordinated and organized and geographically distinct with dedicated staffing • Weekly team meeting rounds • Clinicians should use standardized, valid assessment tools to evaluate the patient's stroke- impairments, disability and progress- Level B

  10. Job of Physiatrist • Make the diagnosis • Identify impairments, disability and handicap and then tailor rehab program to address these items • Treat underlying condition and prevent Cx’s • Rehabilitate – Requires team of rehab professionals • Prognosticate • Re- educate patient and family • Reintegrate back to the community

  11. Stroke and Disability

  12. Stroke Triage • 3 clusters • Mild – usually discharged home with outpatient follow-up • Moderate – most likely to benefit from inpatient Rehab • Severe- Placement typical with reassessment showing progress Triage according to – AGE and Severity of Stroke

  13. Case • A 52 year old male is referred for rehabilitation • Stroke 5d ago – moderate infarct left hemisphere • Afib • Right Hemiplegia – some leg control no arm control. • Expressive aphasia

  14. How do you determine he would benefit from rehab? • Consult stroke team • Detailed history, medical comorbidities – medical stability • Physical exam and assessment of level of disability • Motor • Sensory • Cognitive • Language • Bowel bladder • Ambulation / transfers • Ability to learn • Social support and discharge planning assessment

  15. Why are we talking about stroke rehab?

  16. Stroke Recovery • Neurological recovery • Early • Resolution of edema • Resolution of ischemic penumbra • Resolution of remote functional depression- DIASCHISIS • Late • CNS reorganization • Change in neurotransmitter levels • Unmasking latent pathways • Synaptogensis – development of new pathways

  17. Ischemic penumbra Infarct

  18. Stroke Recovery • Functional recovery • Can occur with or without neurological recovery • Results from improvements in self care and mobility • Dependent on • Motivation • Ability to learn and adapt • Type, quality and intensity of therapy REHAB

  19. Stroke severity and recovery Time 13wks 15 wks 10 wks 6 wks Percentage Jorgensen et al. Outcome and time course of recovery in stroke. Part I: Outcome. The Copenhagen Stroke Study. Arch Phys Med Rehabil 1995;76:399-405 (b).

  20. Stroke unit Evidence • Specialized stroke rehab units with interdisciplinary teams are associated with • improved functional outcomes, • reduced mortality • shorter lengths of hospital stay • reduced need for institutionalization in moderate to severe stroke patients. The Stroke Unit Trialists’ Collaboration (2007)

  21. Stroke units • Decreased risk of death – • OR 0.86, 95% CI 0.76-0.98,p=0.02 • Decreased risk of death and institutional care • OR 0.82, 95% CI 0.73- 0.92, p=0.0006 • NNT to prevent one death = 33 • NNT to prevent on patient from being institutionalized = 20 The Stroke Unit Trialists’ Collaboration (2007)

  22. Stroke Unit efficacy in ST and LTerm Indredavik et al. Benefit of a stroke unit: a randomized controlled trial. Stroke 1991;22:1026-1031. Indredavik et al. Stroke unit treatment. Long- term effects. Stroke 1997;28:1861-1866.

  23. Mobile Stroke team vs.. Stroke unit Kalra L et al. Alternative strategies for stroke care: a prospective randomised controlled trial. Lancet 2000;356:894-899.

  24. Is it safe to start exercising patients after a stroke • Evidence shows the more intense the therapy the better the functional recovery • Level 1a evidence

  25. Therapy intensity • Improve functional recovery occurs with more intense - more is better • I.e. more hours and increased frequency 6 vs. 5 days a week • But follows the law of diminishing returns • Doubling therapy doesn’t lead to doubling recovery Kwakkel et al. 1999, Langhorne et al. 1996, Kwakkel et al. 1997, Teasell et al. 2004 EBRSR – Teasell et al 2008.

  26. In the first week isn’t it too early to start therapy?

  27. Therapy timing • Early therapy shown to improve recovery of function in animal studies- earlier is better (first week) • Paolucci investigated the timing of rehab in a prospective comparative trial – limited evidence of early admission to rehab leads to improved functional outcomes.

  28. Motor Cortex plasticity and recovery • Repetitive task of previous skill has shown to increase motor cortex representation area on fMRI • Failure to practice tasks leads to shrinkage of cortical representation • Due to combination of motor learning and motor cortex plasticity Karni A, et al. The acquisition of skilled motor performance: fast and slow experience-driven changes in primary motor cortex. Proc Natl Acad Sci U S A. 1998;95(3):861-868.

  29. Brain reorganization • Relearning occurs on affected hemisphere • Re-organization occurs along the cortical rim of the infarct or damaged brain with increased activity in surrounding association areas and premotor cortex on the affected cortex • Ipsilateral (unaffected side) cortical activity occurs early and if persistent suggest poorer prognosis as affected brain not able to compensate

  30. Complications post stroke • Dysphagia • DVT • Pain • Hemiplegia shoulder • Bladder incontinence • Seizures • Depression

  31. Depression post stroke How common is it? • 1) 5% • 2) 20% • 3) 33% • 4) 60%

  32. Depression post stroke • Common • Mean prevalence raged for 31.8% in community and 35.5% in rehab hospital studies * • No association with stroke location^ * Robinson et al. Biol Psychiatry 2003;54:376-387. ^Carson et al. Lancet 2000;356:122- 126.

  33. Depression symptoms after stroke

  34. Depression post stoke • Risk Factors post stroke • Female • PHx of depression – mental illness Dx • Functional limitations (burden of disease) • Cognitive impairment • Risk increases dramatically with more than one risk factor • CONSIDER– Treatment prophylactically if two or more RF’s

  35. Depression post stroke • Strong evidence (1a) pharmacotherapy improves functional outcome • Both TCA’s and SSRI’s and methylphenidate • RECOMMENDATION- screening for depression and early aggressive treatment shown to improve functional outcome.

  36. Depression treatment and improved survival • Early treatment depression post stroke shown to decrease mortality • Jorge et al in 2003 • 104 pts within 6 months post stroke • RCT – placebo / nortrip / fluoxetine • Fu 3/6/9/12 wks and mortality data at 9 yrs • 48% deceased at 9 y • Intention to treat analysis showed treatment with antidepressant improved mortality and was even more significant in those who completed 12 wk course • Further research indicated but level 2 moderate evidence that treatment with antidepressant improves mortality

  37. Dysphagia • 30-65% pts in acute stroke setting • Associated with increased pneumonia, dehydration, and malnutrition • Assessment and treatment strategies for dysphagia decrease rates of pneumonia and health expenditures • Pneumonia number two cause of death in first year post stroke • Up to 1/3 are silent aspirators

  38. Dysphagia Case A 68-year old man presents with a stroke involving the territory of the left lateral medulla. This is due to an infarct of the posterior inferior cerebellar artery. The patient presents to the Emergency Room with significant ataxia, dizziness and dysarthria. Patient is given drink in AE by nurse and chokes and develops persistent cough. • What should be done?

  39. Dysphagia Case • Brain stem and bilateral strokes are at highest risk • NPO till formally assessed by trained staff at bedside • If deemed at risk then formal oromotor assessment recommended • Assessment should include water swallow test – • 1-2 tsp of water - if well tolerated • Small cup of water • If fails then NPO or NG and Video MBS

  40. DVT • 50 % acute stroke patients develop DVT off prophylaxis • Peak onset D2-7 (first week) • Most are below the knee and these don’t lead to PE • ½ DVTs are silent • 10-15% patients have a PE – usually from proximal DVTs • 1-2 % die

  41. DVT • D Dimer sensitive but not specific • Doppler US • Sensitivity – 95% for prox DVTs • Sensitivity – 73% for distal DVTs • Strong evidence (level 1a) • LMWH prophylaxis more effective than Un Heparin • Less risk of bleeding with LMWH

  42. Management of stroke RF’s critical to improved outcomes • TIA’s – investigation and treatment decreases 90d risk of stroke • HTN –diuretic / ACE (not captopril though) decrease future stroke risk • Cholesterol- weak causal relationship but treatment does reduce risk of future stroke • Smoking- decreases risk of future stroke • Diabetes- aggressive BP/ Chol/ and sugar control • Lifestyle -

  43. Management of stroke RF’s critical to improved outcomes • Afib – Coumadin indicated and decreases risk by 2/3’s • Carotid stenosis • Symptomatic – TIA or stroke • High Grade - 70-99% - CEA recommended • Mod Grade – 50-69% - CEA may be recommended • In surgeon with surgical Cx rate < 6% • Asymptomatic • 60-99% - CEA should be considered ARR – 17%+- 3.5% at 2 y – NNT 8

  44. Antiplatlet therapy • ASA – 81 mg /d decreases recurrent stroke 23% • NNT 111 in acute stroke and 28 over 3 y to to prevent 1 stroke • Plavix- Second line – increased GI and skin SE’s • ASA/Plavix – very little added benefit for increased rates of hemorrhage/ GI and other side effects

  45. Alternative therapies • Massage helps pain and anxiety post stroke • Moderate evidence acupuncture help painful hemiplegic shoulder • Repetitive transcranial Magnetic stimulation – strong evidence help short term motor recovery in the chronic stage of stroke in the upper extremity • There is moderate evidence motor cortex stimulation can improve upper limb function following stroke.

  46. What doesn’t work • Reiki • Hyperbaric oxygen post stroke • Mobile stroke teams

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