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Rehabilitation in Younger Strokes. Robert Teasell MD FRCPC Professor and Chair-Chief Department of Phys Med Rehab Schulich School of Medicine University of Western Ontario Lawson Health Research Institute St. Joseph’s Health Care London London, Ontario, Canada. Objectives.

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rehabilitation in younger strokes

Rehabilitation in Younger Strokes

Robert Teasell MD FRCPC

Professor and Chair-Chief

Department of Phys Med Rehab

Schulich School of Medicine

University of Western Ontario

Lawson Health Research Institute

St. Joseph’s Health Care London

London, Ontario, Canada

objectives
Objectives
  • Understand rehabilitation of young stroke patients has unique features
  • Appreciate role of social factors in the rehabilitation of younger stroke patients
  • Understand role of age in rehabilitation of more severe stroke patients
case study 1
Case Study 1
  • 26 y.o. separated woman
  • 3.5 wks ago sustained ruptured Rt MCA aneurysm 2 days post-partum
  • Rt frontotemporal craniotomy and evacuation of hematoma
  • Dense Lt hemiplegia, dysphagia, hypophonic voice, urinary retention, decreased sensation and neuropathic pain on Lt side, Lt homonymous hemianopsia and Terson’s syndrome
case study 1 cont
Case Study 1 (cont)

Transferred to Stroke Rehab Unit 3.5 weeks post stroke and discharged almost 4 months later

case study 1 cont5
Case Study 1 (cont)
  • Sensation on Lt side severely impaired
  • Able to transfer w/c to bed independently +/- hand support, using a standing pivot transfer
  • Ambulating 60 meters with single cane and supervision
  • Propel wheelchair up to 50 meters
  • Manage full flight of stairs with handrail and supervision
  • Left neglect and vision interfered with higher level IADLs
case study 1 cont6
Case Study 1 (cont)
  • Went to live with her parents
  • Stroke Rehab Pilot OP Program for 11 months
  • Cerebral angiogram showed a small AVM during that time and underwent resection of AVM
  • Began teaching piano, got a part-time retail job and moved into her own home less than 2 years post event with her young son
stroke in young patients
Stroke in Young Patients
  • Stroke is generally considered to be a condition that occurs in elderly individuals
  • For every 4 individuals experiencing a stroke, 1 is under the age of 65 and 3-4% of all strokes are under the age of 45
  • Disproportionate number of younger strokes admitted for rehabilitation
young stroke patients have unique issues
Young Stroke Patients Have Unique Issues
  • Employment is important
  • More likely to be responsible for childcare
  • Family stress and psychosocial consequences
  • Rehab strategies for elderly patients is not always applicable for younger stroke patients
  • Given they live a long time disproportionate amount of costs of stroke
  • Few studies have assessed the specific needs of young stroke patients
stroke etiology in young patients
Stroke Etiology in Young Patients
  • Stroke patients in younger populations, have a wider variety of etiologies than older stroke cohorts
  • In approximately one-third or more of young stroke patients a diagnosis is not made
  • Hemorrhagic strokes together constitute 30-35% of all strokes under the age of 50; 15-20% of all strokes over the age of 50
recovery and prognosis
Recovery and Prognosis
  • Young stroke patients demonstrate greater neurological and functional recovery and hence have a better prognosis
  • Older patients’ limitations include less physiological reserve for recovery (frailty), lesser opportunity for neurological reorganization and higher prevalence of co-morbid conditions, particularly cognitive impairment
case study 2
Case Study 2
  • 16 year old with Moya Moya disease undergoes a revascularization procedure
  • Infarction of Rt MCA, ACA and PCA total loss of hemisphere (underwent 3 lobectomies)
  • Rehabilitation went on for 5 months
  • Berg balance score went from 0 to 41/56
  • Wheelchair dependent on admission but on discharge able to walk with minimal assistance
prognosis
Prognosis
  • Young stroke patients are more likely to return home after stroke, and recovery was most dramatic with moderately severe strokes
  • Younger patients had relatively high scores for functional ability as measured by ADLs and independent ambulation
rehab of younger stroke patients
Rehab of Younger Stroke Patients
  • Rehabilitation of young stroke patients is the same process as that of older stroke patients
  • Make greater and more rapid neurological recovery and can tolerate more intense therapy
rehab of younger stroke patients14
Rehab of Younger Stroke Patients

Rehab of younger stroke patients has associated social issues:

  • Family supports
  • Presence of young dependents
  • Marital stress
  • Return to work
  • Less willigness to participate in adaptive behaviours
  • Need to live longer to live with a possible disability
rehab priorities of young stroke patients
Rehab Priorities of Young Stroke Patients
  • Hartke and Brashler (1994) reported on 100 young stroke survivors who responded to a questionnaire about rehabilitation
  • Patients and physicians were asked what programs they felt what would be most helpful during inpatient rehabilitation
rehab priorities of young stroke patients17
Rehab Priorities of Young Stroke Patients
  • Only high-functioning stroke survivors chose vocational counselling frequently
  • Low-functioning survivors ranked family counseling higher and “may have been expressing greater concern over family strain due to their dependence”
  • “Interventions concerning sexual functioning, parenting, and dating/interpersonal relationships were chosen relatively less frequently, although they might be developmentally salient at a younger age” (Hartke and Brashler 1994)
family stress
Family Stress
  • Stroke tends to affect all family members who themselves often have to make significant adjustments to deal with disability
  • Correlations found between amount of strain and level of depression in spouses of younger stroke patients
  • Initial assessment of spousal depression and quality of life 1 year post-stroke predicted by initial levels of stress
  • Partner distress was often due to emotional distress in children having difficulty coping
case 3
Case 3
  • 31 y.o. female decreased LOC, left hemiplegia, vomiting
  • MRI revealed infarcts Lt cerebellum, Rt thalamus, Rt hemi-pons due to mid-basilar artery thrombosis
  • Intubation with subsequent tracheostomy, ICU stay and a feeding tube
case 3 cont
Case 3 (cont)
  • Initial problems included a spastic Lt hemiparesis, Lt ataxia, dysarthria, dyphagia, diplopia and emotional lability
  • Acute care x 6 wks and rehab x 18 wks
case study 3 cont
Case Study 3 (cont)
  • At discharge able to ambulate with rollator walker and one-person assist and ADL-independent
  • Combination of ataxia and hemiparesis presented special challenges
  • By one year continuing to improve – ambulating with Rollator walker or cane – falling every day
  • Able to exercise for 2 hrs per day on elliptical treadmill
  • Back to work 3.5 years later part-time
case study 3 cont22
Case Study 3 (cont)
  • Lived with her husband – highly athletic and independent individuals
  • Husband initially very stressed and required extensive counselling; worried about coping at home, finances
  • Initially he claimed the stroke was a good thing because it brought them closer together
  • Sexual activity problematic because he felt more like a caregiver
  • Split up 3 years after the stroke
family stress23
Family Stress
  • Caregivers at highest risk of depression are reportedly the spouses of younger, more severely impaired patients with lower household incomes, smaller social networks with whom they visit frequently, and lower levels of future optimism and expectation (Tompkins et al. 1988)
family stress24
Family Stress
  • Teasell et al. (2000) found 38% of young stroke patients experienced conflict with their spouse while on rehab unit sufficient that inpatient rehabilitation staff charted it
  • One in seven couples separated within 3 months of the stroke
  • 22% of young stroke patients appeared to experience conflict with children during inpatient rehabilitation
family stress25
Family Stress
  • Visser-Meily et al. (2005) noted that the severity of stroke had an impact on the amount of support a family received from hospital rehabilitation staff
  • Longer hospitalization correlated with the amount of attention rehab staff gave children of young stroke patients
  • Inpatient rehab staff did not pay more attention to children with adjustment problems
role change
Role Change
  • With more typical older stroke patients, families often experience role reversal – children may become parents to their husband; wife may need to assume husband’s roles around the home, etc.
  • Less of an issue with young stroke patients whereby old roles may need to be resumed; parents may need to reparent a previously independent child
case study 4 cont
Case Study 4 (cont)
  • 15 y.o. female admitted with large Lt subcortical stroke – etiology unknown ? PFO – Rx t-PA
  • Very active in athletics, oldest of 3 siblings, honor student, part-time babysitter, normal kid beginning to develop her own independence
  • 10 days later admitted with Rt hemiparesis – 7 week stay in rehab – CMS 6/7 except for foot 4/7
  • Returned to part-time school after 6 months and resumed soccer
case study 4
Case Study 4
  • Able to run but could not stand on one foot
  • Neuropsychs later showed mild impairments with executive skills, mild word-finding difficulties, working memory, behavioural inhibitions, visual spational abilities and attention
  • Remained honor student but could no longer do mathematics – no science career
  • Had to deal with mom making all her decisions for her
institutionalization
Institutionalization
  • Black-Schaffer and Winston (2004) found young severe stroke patients often had longer hospitalizations than older stroke patients cohorts
  • Older patients are recognized as having less chance of functional recovery and are more promptly discharged to nursing homes or institutional care; longer rehab visits for younger stroke patients result in greater rehab gains and greater likelihood of going home
institutionalization30
Institutionalization
  • Teasell et al. (2000) reported institutionalization in only 4 of 83 stroke patients < 50 years of age admitted to stroke rehab units
  • The common feature to each of these 4 strokes was a severe disabling stroke(s) occurring in association with poor social support
institutionalization31
Institutionalization
  • Black-Schaffer and Winston (2004) and Adunsky et al. (1992) both noted that institutionalization of these patients was rare, that young patients tended to be in rehab longer and reached much higher levels of functioning than elderly stroke patients
  • Attributed in part to lack of coexisting medical problems and lack of organic intellectual impairment
return to work
Return to Work
  • Vocational issues are unique to younger stroke patients
  • Monga (1997) noted, “The rehabilitation community has devoted only limited effort to the task of defining what is meant by the phrase return to work, to develop measures of vocational function, to applying these measures to patient populations, and to tracking return to work as a measure of rehabilitation outcome.”
return to work33
Return to Work
  • Studies show few young stroke patients are able to return to previous or any full-time employment one-year post-stroke even if physical deficits are minimal (Glozier et al. 2008)
  • Consistently, young stroke patients reduced the number and/or complexity of tasks performed (Black-Schaffer and Osber 1990)
case study 5
Case Study 5
  • 35 y.o. married salesman with a Lt cerebellar and pontine infarct
  • 2 days later life-threatening cerebellar bleed and underwent Lt cerebellar resection
  • Etiology of stroke never established
  • Clinically Rt hemisensory loss, severe Lt ataxia, dysarthria, diplopia, urinary retention, extreme paresis, fatigue and some memory loss
  • Admitted to inpatient rehab for 4 mos and made slow steady improvements
case study 5 cont
Case Study 5 (cont)
  • Mobility hindered by severe Lt ataxia, and Rt hemisensory loss; severe dysarthria
  • Experienced mood swings with frustration which improved as disability declined
  • At discharge 3 months later he was able to ambulate slowly with a cane and was independent in ADLs
  • Still experiencing diminished balance, decreased coordination Lt side, Rt sensory deficits and numbness, fatigue and weight gain
  • 1.5 yrs post-stroke able to return gradually to his previous work but never as good as before
factors predicting return to work
Factors Predicting Return to Work
  • White collar work and education (sedentary, work autonomy, coworker coverage)
  • Full-time paid employment pre-stroke
  • Lack of psychiatric illness
  • Limited residual muscle weakness
  • Lack of apraxia
  • Lack of aphasia
  • Lack of cognitive difficulties
cognitive deficits and rtw
Cognitive Deficits and RTW
  • Cognitive deficits following stroke increasingly recognized as important factor in RTW
  • Many of the cognitive deficits are subtle
  • Neuropsychological testing may be required to accurately delineate the extent of cognitive problems and determine how they might impact patients’ eventual return to work post-stroke
  • Mercier et al. (1991) found neuropsychological testing to be predictive of better return to work outcomes
fatigue in young stroke patients
Fatigue in Young Stroke Patients
  • 51.3% of young stroke patient experience chronic fatigue which can negatively affect scholastic, vocational and social pursuits
  • Independently associated with unfavourable functional outcomes and unemployment at mean 6 months follow-up
  • Post-stroke depression is present in one-quarter of young strokes
support organizations
Support Organizations
  • Post rehabilitation, young stroke patients want to connect with others who share similar experiences
  • Patients need time to come to terms with changed physical abilities, work, family and social life
slide40

Rehabilitation of Severe Strokes

  • Cortical reorganization is dependent on adjacent or connected cortical areas taking over lost function
  • Given extent of brain damage in severe strokes, pts typically severely compromised for cortical reorganization and neurological recovery
rehab of severe strokes
Rehab of Severe Strokes
  • Several RCTs comparing specialized stroke rehab to generalized stroke rehab for severe stroke subsets more likely:
  • Be discharged home
  • Shorter length of hospital stay
  • Reduced mortality
  • Minimal functional gains
  • Concept of slow-stream stroke rehab remains unproven
case study 6
Case Study 6
  • 46 y.o. married female
  • Hemorrhage involving Rt pons, midbrain and basal ganglia
  • Resulting bilateral hemiparesis, Rt ataxia, dysphagia, dysarthria, bowel and bladder incontinence
  • Admitted to Parkwood Stroke Rehab Unit 55 days post-stroke
  • Kept in rehabilitation 5.5 mos
case study 6 cont46
Case Study 6 (cont)
  • At discharge pt. required moderate to maximum assistance with all ADLs due to ataxia, hemiparesis and limited shoulder movement
  • Dysphagia with G-J tube eventually removed at time of discharge and on minced diet
  • Required one to two person transfer
  • Ambulating 10 meters with moderate assistance and cueing
  • Discharged home with strong family, private insurance and Home Care support
case study 6 cont47
Case Study 6 (cont)
  • Pilot Interdisciplinary outpatient therapy Program: 3 mos
  • COVS 34 to 46; Berg 5 to 7
  • After 3 week break, Comprehensive Outpatient Rehab Program (CORP) x 5 months
  • 3.5 years after last therapy at home
case study 6 cont48
Case Study 6 (cont)
  • CORP readmit Nov 15, 2005 – Jan 27, 2006
  • Berg Balance 12/56; COVS 48/91
  • Feb 6, 2006 to March 14, 2006 admitted to hospital for AVM removal
  • Rehab March 14 – April 12, 2006 for deconditioning
rehab of young severe strokes
Rehab of Young Severe Strokes
  • Young stroke patients appear to do better than older stroke patients
  • Important consideration when deciding on whether younger stroke patients would benefit from stroke rehabilitation
  • Severe stroke patients are inevitably admitted if young; not necessarily the case with similar older stroke patients
summary
Summary
  • Young stroke patients have many unique rehabilitation issues
  • They make a more rapid and complete neuro-recovery
  • They have a number of unique social issues
  • More likely to benefit from stroke rehabilitation if they suffer a severe stroke