PRIMARY ISSUES IN REHABILITATION OF STROKE

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PRIMARY ISSUES IN REHABILITATION OF STROKE

• Michael Saucier, M.D., M.S.
• Dept. of Physical Medicine Rehabilitation

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OBJECTIVES

• Review the role of rehabilitation in stroke
  recovery
• Functional effects of stroke
• Discuss salient aspects of rehabilitation of
  stroke including CIMT, Robotics Virtual Reality
• Challenges in delivery of Stroke Rehabilitation

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GENERAL CONSIDERATIONS

• Recurrence is greatest in first 6 months
• 10-16 recurrence in 1st year
• Gradual decline to usual risk by about year 5
• 10 of survivors recover almost completely
• 25 recover with minor impairments
• 40 experience moderate/severe impairments
• 10 require care in a nursing home or LTC
• 15 die shortly after the stroke

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CENTRAL REHABILITATION THEMES

• Role of behavior in rehabilitation
• Experience-dependent cortical plasticity

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CORTICAL PLASTICITY

• The motor cortex is a shared neural
  substrate for motor control. The highly
  overlapping and divergent architecture provide an
  ideal substrate for flexibility in outputs to the
  spinal cord that can be rearranged based on
  behavioral demands.
• ---- Randolph Nudo, M.D.

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EXPERIENCE-DEPENDENT CORTICAL PLASTICITY

• Behavioral experience as a potent modulator of
  cortical structure and function
• driven largely by repetition temporal
  coincidence
• thought to drive formation of discrete modules
  where conjoint activity is expressed as a unit
• plasticity is probably skill- or
  learning-dependent rather than use-dependent

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ROLE OF BEHAVIOR IN MODULATING POST-STROKE
RECOVERY

• CENTRAL QUESTION How can we drive adaptive
  plasticity in intact portions of the ipsilesional
  hemisphere?
• Cortical electrical stimulation does this
  enhance excitability of intact ipsilat. areas?
• CIMT Constraint Induced Movement Therapy
• Pharmacology
• Robotics
• What do these have in common?
• -- utilize repetitive behavioral tasks,
  especially those with high skill demands

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EFFECTS OF STROKE

• Paresis/Plegia
• Speech Impairments
• dysarthria (slurred speech)
• aphasia
• Neglect
• Cognitive/Neurobehavioral Syndromes
• Apraxia

Ochsner Medical Center
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EFFECTS OF STROKE

• Dysphagia
• Sensory loss
• Depression
• Visual, oculomotor vestibular deficits
• Central post-stroke pain
• Deconditioning
• Urinary dysfunction

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EFFECTS OF STROKE

• DVT
• Contralesional edema
• Hemiparetic shoulder syndrome
• Spasticity
• Diminished endurance
• Poor arousal (somnolence)

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COGNITIVE IMPAIRMENT

• Quantitatively cumulative effects of location,
  number volume
• Executive function
• Dementia

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CHARACTERISTICS OF COGNITIVE IMPAIRMENT

• Executive Function
• Executive function ill-defined
• constellation of higher order skills used to
  manipulate available information to plan
  execute complex activities.
• attention, mental flexibility, processing speed,
  set maintenance, set shifting, working memory,
  error correction
• 337 stroke pts 40.6 with dysfunction 1.5 SD
  below mean for elderly controls (mean age 70.2
  /- 7.6)

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COGNITIVE IMPAIRMENT

• Stroke is a potent risk factor for dementia
• 10X risk for dementia with prevalence 20-25
• post-stroke dementia is a major risk factor for
  mortality independent of age, Barthel index or
  comorbid diseases.
• improvement in post-stroke survival make this
  important
• comparison of 1984-1990 and 1991-2000 53
  increase in all dementia types, 87 increase in
  subjects with stroke. Stroke survival increased
  53? 65.

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CHARACTERISTICS OF COGNITIVE IMPAIRMENT

• CIND (vascular Cognitive Impairment/No Dementia)
• actually a diagnostic category (Rockwood,
  Neurology, 2000)
• reflects substantial cognitive deficits without
  sufficient memory loss or other multi-domain
  deficits to meet criteria for dementia.
• CIND cognitive features are those related to
  executive function sequencing, attention,
  working memory, processing speed.
• Using CIND even stroke survivors considered to
  have NO cognitive deficits demonstrated worse
  executive function than stroke-free controls.

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MANAGEMENT OF COGNITIVE IMPAIRMENT

• Cognitive screening/followup fundamental to Rehab
• NON-PHARMACOLOGIC
• cognitive rehab via S.T. O.T.
• PHARMACOLOGIC disease modifying treatments vs
  symptomatic treatments
• Secondary prevention HTN control, glucose
  control, aggressive dyslipidemia control

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PHARMACOLOGY IN REHABILITATION

• Arousal Ritalin, Provigil
• Inattention Ritalin, Amantadine, Adderall
• Memory AD agents
• Spasticity Dantrium
• Functional
• Levodopa (Lancet, 2001)
• Reboxetine inhibits norepinephrine reuptake
  may enhance learning of motor skills (Neurology,
  2004)

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NEW DIRECTIONS IN STROKE REHAB

• ROBOTICS
• VIRTUAL REALITY

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COMPARISON of CMS vs PRIVATE INSURANCE (PI)
CMS PI
Loss of function 1 extremity No Yes
Neuro disease 1 extrem cognitive/speech Yes Yes
Weakness 2 extremity weakness lt/ 2/5 Yes
Home disposition threatened (yes) Yes
Relapsing diseases MS, GBS No Yes
Hip fractures No (Yes)
1 TKA No (Yes)
2 TKAs Yes Yes
UE amputation No Yes
Spine surgery 2 extremity weakness lt/ 2/5 Yes