dr. rani haley lindberg, m.d. uams dept. of physical medicine and
TRANSCRIPT
D R . R A N I H A L E Y L I N D B E R G , M . D .
U A M S D E P T . O F P H Y S I C A L M E D I C I N E A N D R E H A B I L I T A T I O N
Stroke Rehabilitation
Goals and Objectives
Describe the field of Physical Medicine and Rehabilitation
Discuss qualifications for inpatient rehabilitation Review goals of Stroke Rehabilitation Review complications related to stroke and their
effects on rehabilitation of a stroke patient
Physical Medicine and Rehabilitation: What is it?
ABMS 1947�Physical Medicine (Thermal, E-stim, U/S)�Rehabilitation (WWII)
Physiatry / Physiatrist � Diagnosis, treatment, and rehabilitation of primarily
neuromusculoskeletal and cardiopulmonary disorders, that may produce temporary or permanent impairment.
� PM&R
PM&R: What do they do?
Focus: Maximize Function / Quality of life� Physiatry: area of expertise is the functioning of the
whole patient, as compared with focusing on a specific organ system or systems.
� Prescribe Medications and Therapy
� Team Approach (e.g., Physical / Occupational Therapy)
The Physiatric Approach
Chief complaint Baseline level of function Current level of function
What are the current barriers that are preventing the patient from reaching their desired level of function?
Who “qualifies” for inpatient rehabilitation?
Qualifying Diagnoses for Inpatient Rehab
• Stroke• Spinal cord injury• Congenital deformity• Amputation• Major multiple trauma• Hip fracture• Brain injury• Neurological disorders (e.g., Multiple Sclerosis, Parkinson’s)• Burns• 3 different arthritis conditions for which appropriate, aggressive, and
sustained outpatient therapy has failed, and• Joint replacement
Theory Behind Early Stroke Rehab
Neuroplasticity:Modifications in neural networks are use
dependent
Need stimulation from:-Active rehabilitation-The environment
Timing for Inpatient Rehabilitation after Stroke?
Studies show fewer days between onset of stroke rehab and initiation of rehabilitation is associated with improved functional outcome at discharge and
shorter rehabilitation length of stay.
Stroke Rehabilitation: Goals
Functional enhancement by maximizing each patient’s:
-Independence-Lifestyle-Dignity
Focus on physical, behavioral, cognitive, social, vocational, adaptive, and re-educational points of view.
Programs for Patients After Stroke
Speech, Language and Cognitive Training Mobility Training Self-Care Training Peer Support Outpatient Family Stroke Education Group Specialized Feeding and Swallowing Program Driver Rehabilitation Outpatient Therapy
Rehabilitation Team Members
Physiatrists Consulting PhysiciansRehabilitation Nurses
Physical TherapistsOccupational Therapists
Care Coordinators/Social WorkersRespiratory Therapists
Speech-Language PathologistsRegistered Dietitians
Therapeutic Recreation SpecialistsDriver Rehabilitation Instructors
NeuropsychologistsChaplains
Stroke Rehabilitation: Team Approach
Patient and familyPhysician
Physical TherapistOccupational Therapist
Speech Language PathologistRehab NeuropsychologistRehab Nursing and AidesRehab Case CoordinatorRecreational Therapist
ChaplainNutritionist
OrthotistVocational Therapist
Functional Independent Measures
Global measure of functional independence. The total FIM rating ranges from 18-126 (i.e., 18
items rated on a 1-7 ordinal scale) FIM component subscores:
Self-care: bathing, eating, grooming, dressing upper/lower body, toileting
Mobility: Transfers (toilet; bed, chair, and wheelchair; tub and shower transfers) and locomotion (stairs, walk and wheelchair locomotion)
Sphincter: Bladder and bowel controlCognitive: Communication, psychosocial
Motor Impairment and Recovery due to Stroke
Up to 88% of stroke patients have hemiparesis
Most recovery in 1st three months with minor recovery after six months
Typically, leg recovers before arm-Lower extremity pattern:
flexor synergy �extensor synergy-Upper extremity pattern:
flexor synergy �extensor synergy
Predictors of Motor Recovery Post-Stroke
Severity of arm weakness� 9% with good recovery of hand function
Timing of motor return in hand� If some return by 4 wks, 70% chance of full to good recovery
Poor Prognostic indicators:1) Severe proximal spasticity2) Prolonged “flaccidity” period3) Late return of proprioceptive response >9 days4) Late return of proximal traction response>13 days
Brunnstrom Stages of Stroke Recovery
1. Flaccidity
2. Spasticity appears
3. Increased spasticity, basic synergy pattern appears, minimal voluntary movements
4. Decreased spasticity, some movements out of synergy patterns
5. Further decrease in spasticity, more complex movement combinations, synergy patterns no longer dominate
6. Disappearance of spasticity, able to move individual joints, coordination near normal
7. Normal function is returned
Rehabilitation Methods for Motor Deficits
Traditional therapies consist of:1. Positioning and ROM exercises2. Mobilization3. Compensatory techniques4. Strengthening and endurance training
For stroke rehabilitation, these exercises emphasize repetition of movements, importance of sensation to control movement, and developing basic movements and postures to improve motor control and coordination
Major Theories of Rehabilitation Training
Proprioceptive Neuromuscular Facilitation (Voss)Neurodevelopmental Technique (Bobath)
Brunnstrom/Movement ApproachRood/Sensorimotor approach
Motor Relearning programBehavioral approach
Special therapies and modalities
Functional Electrical Stimulation
• Mirror Therapy for Hemiplegia/Neglect• Dynamic Splinting• Constraint-induced Movement Therapy• Assistive devices and bracing for ambulation
P R O B L E M S E N C O U N T E R E D B E F O R E , D U R I N G , A N D A F T E R R E H A B
Complications after Stroke
Hemispatial Neglect
Deficit in attention to and awareness of one side of space defined by the inability of a person to process stimuli on one side of the body or environment
• Three quarters of patients with acute stroke have signs of neglect
•Unawareness of deficit in 20% to 58% of patients
•Pts with neglect took longer to recover than other stroke patients with similar stroke pathology and impairment.
•Pts with neglect required more therapy input and have longer rehab LOS
Neglect Treatment
Scanning Trunk rotation therapy Eye Patching, Prism
glasses Constraint-Induced
Therapy Mirror Therapy Neurostimulation
medications
http://blogs.discovermagazine.com/loom/2010/09/
Falls
Risk factors for in Hospital falls:� R>L Hemispheric stroke; Neglect and visuospatial deficits;
Impulsivity; bilateral strokes; confusion; male; poor ADL; urinary incontinence; use of sedatives and diuretics.
Preventive measures:� Adequate staffing; education; patient strength training;
balance training; cognitive remediation; restraints with monitoring; bed/chair alarms; timed voiding; minimize use of sedatives and diuretics.
*Moroz A, et al. Arch Phys Med Rehabil 2004;85(3 Suppl):S11-14.
Stroke: Shoulder Pain
Subluxation
Traction neuropathy
Bicipital tendinitis
RTC/Impingement
Frozen shoulder
Complex Regional Pain Syndrome
Treatment for Shoulder Pain
•Proper positioning and arm awareness
•Bracing/sling
•Estim
•Armboard/trough for wheelchair
•ROM excercises
•Injections
Dependent Edema
Treatment includes:ROM exercisesElevation of limbCompression stockings or glovesSCDsMassage
http://www.foot-pain-explained.com/edema.html
Spasticity after Stroke
Onset: days to weeks Upper extremity- flexion, lower extremity- extension Velocity dependent resistance to passive movement
of affected limb
www.informahealthcare.com
Spasticity after Stroke: Treatment
Slow, sustained stretching program Splinting Serial casting Cold modalities Medications: Baclofen, Zanaflex, Benzos Injections: Botox, Phenol Intrathecal Baclofen Pumps Surgery
www.rehabmart.com
DVT after Stroke
Occurs in 20-75% of untreated Stroke survivors 60-75% of DVTs occur in hemiplegic limb PE occurs in 1-2% of cases
Prophylaxis:Subcutaneous heparin or LMWHSCDsTED hose
Bladder Dysfunction
50-75% of stroke patient have urinary incontinence during the 1st month post stroke, 15% after 6 mths
Etiology is multifactorial Voiding disorders: areflexia, uninhibited spastic
bladder, outlet obstruction Treatment: tx underlying cause, regulate fluid intake,
timed voiding, education, and medication
When removing foley caths: remember to check PVRs!
Bowel Dysfunction
Incidence of incontinence: 31% of stroke patients Typically resolves after the 1st two weeks s/p stroke Decreased continence usually related to decreased
mobility or communication impairments Treatment includes transfer training and timed
toileting. Constipation is common and treated by improved
fluid intake, diet modification, stool softeners and stimulants.
Dysphagia
Overall incidence ~30-45% of stroke survivors
Signs of abnormal swallow:Abnormal and/or weak cough
Cough after swallowDysphoniaDysarthria
Abnormal gag reflexVoice change after swallow
Difficulty handling secretions
Aspiration
Missed on bedside swallow study in 40-60% of pts!! FEES and VFSS better at detected silent aspiration
Aspiration pneumonia risk factors:DECREASED LEVEL OF CONCIOUSNESS
TracheostomyEmesisReflux
NGT feedingDysphagia
Treating Dysphagia and Prevention Aspiration
Changing head position/posture
Elevation of head of bed
Feeding in the upright position
Using chin tuck technique
Turning head toward plegic/paretic side
Diet modification
Oral/motor exercises by Speech therapist
Aphasia
Impairment of the ability to utilize language due to brain injury
Can also include impairment in reading, writing, and problem solving.
Aphasia�Longer rehabilitation length of stay Aphasia�Decreased rehabilitation efficiency
Depression
Prevalence: ~40% of stroke patients
May be related to neurotransmitter depletion from stroke lesions and psychological response to physical/personal losses associated with stroke
Risk factors: female, prior psych hx, severe impairment, nonfluent aphasia, lack of social support
Persistent depression�delayed recovery and poor functional outcome
Treatment: Neuropsychology, medications
Seizures
Classification: at stroke onset, early after stroke, late after stroke
Early seizures usually due to metabolic derangement from acute ischemic/hemorrhagic injury and often do not recur
Stroke patients requiring inpatient rehab have higher probability of having seizure
If seizure occurs 2 wks after stroke, increased likelihood of recurrence
Treatment: Seizure precautions, anticonvulsants
Outcomes and Return to Work
Outcomes
The most reliable predictor of functional outcome during Rehab is the patient’s functional ability on admission. An admission FIM score >60 is a good indicator.*
Persistant urinary or fecal incontinence and the presence of a social support system is the key determinate in the ultimate discharge destination.**
* Ween JE, et al. Neurology. 1996;46:388-392.* *Brandstater M. In DeLisa ed. Rehabilitation Medicine 3rd ed. 1998;1165-
1189.
Predicting Outcomes
Age Severity of stroke Prior stroke Persistant urinary
incontinence Bowel incontinence Visuospatial deficits Unilateral hemineglect Coma at onset Poor cognitive function
Multiple neruologic deficits Impaired sitting balance Poor social supports Limitations in ADLs Depression Severe aphasia Severe comorbid medical
conditions Cerebral metabolic rate
(PET scan)
Ambulation Potential
Copenhagen Stroke study: 63% presented with impaired walking. Those who survived - 22% did not regain the ability to walk; 66% achieved independent walking, and 95% reached their maximum walking function at 11 months.*
Most common lower extremity is an ankle-foot orthosis (AFO) – both speed of gait and energy consumption can be improved using an AFO. **
*Jorgensen HS, et al. Stroke 1999;10(4):887-906.**Fowler PT, et al. J Orthop Res 1993;11:416-421.
Return to Work
Negative factors that effect return to work:� Low score on the Barthel Index� Prolonged rehabilitation length of stay� Aphasia� Prior EtOH abuse
Neuropsychological testingFunctional Capacity EvaluationReturn to work with restrictions
How to prepare a patient for inpatient rehabilitation
Initiate early rehab therapies: PT, OT, Speech, PM&R Prevent complications:
-Early ROM, stretching, and splinting to prevent contractures-Shoulder slings and proper arm position in bed-High suspicion for dysphagia and close monitoring for aspiration-DVT prophylaxis-Monitor nutrition- PEG tube placement early if delayed recovery expected- Monitor for neglect and help patient compensate for it!- Bladder/bowel: timed voids if possible. Check PVRs!
References
Braddom. Physical Medicine and Rehabilitation. 3rd edition. Cuccurullo. Physical Medicine and Rehabilitation Board Review. 2004 Maulden S.A. et al. Timing of Initiation of Rehabilitation After Stroke. Arch Phys
Med Rehabil. 2005. 86 (Suppl 2): S34-40. Bryan J. et al. Stroke and Neurodegenerative Disorders. 1. Acute Stroke Evaluation,
Management, Risks, Prevention, and Prognosis. Arch Phys Med Rehabil. 2004. 85 (Suppl 1): S3-9.
Ross A. Bogey et al. Stroke and Neurodegenerative Disorders. 3. Stroke: Rehabilitation Management. Arch Phys Med Rehabil. 2004. 85 (Suppl 1): S15-20.
Page et al. Efficacy of Modified Constraint-Induced Movement Therapy in Chronic Stroke: A Single-Blinded Randomized Controlled Trial. Arch Phys Med Rehabil . 2004. 85: 14-18.
Sütbeyaz et al. Mirror Therapy Enhances Lower-Extremity Motor Recovery and Motor Functioning After Stroke: A Randomized Controlled Trial. Arch Phys Med Rehabil. 2007. 88: 555-559.
Gialanella et al. Rehabilitation Length of Stay in Patients Suffering from Aphasia After Stroke. Topics in Stroke Rehabilitation. Nov/Dec 2009. 437-444.
Pierce and Buxbaum. Treatments of Unilateral Neglect: A Review. Arch Phys Med Rehabil. 2002. 83: 256-268.