Rehabilitation in Cerebrovascular Disease and Traumatic Brain Injury

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Rehabilitation in Cerebrovascular Disease and
Traumatic Brain Injury

• Prawit Rungcharoensak M.D.
• Dept. of Rehabilitation Medicine
• BMA Medical College Vajira Hospital

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Cerebrovascular disease / stroke

• Prevalence 690 / 100,000
• Risk factors
• 1. Age (lt45 yr 60/100,000 45-65 yr 998
  gt65 yr 5063)
• 2. Hypertension
• 3. Valvular heart disease, arrhythmia (AF)
• 4. D.M.
• 5. Previous stroke / TIA
• 6. Race

• 7. Sex
• 8. Smoking
• 9. Family Hx.
• 10. DM
• 11. Elevated fibrinogen
• 12. Erythrocytosis
• 13. LDL

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• Pathology
• 1. Ischemic stroke (80-90 of CVD)
• Thrombotic (40) previous stroke, large vv.
• Embolic small vv., younger age, heart
  disease
• Lacunar penetrating artery in basal ganglion,
  
• internal capsule, brainstem (good
  recovery)
• 2. Hemorrhagic stroke mortality 50-70
• Lesion putamen, thalamus

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• Pattern of neurological recovery
• Hypotonia / flaccidity (48 hr)
• Flexion / extension synergies (2-30 d.)
• Isolated movement (6-33 d.)
• Full recovery (10 of Pt.)
• Prognosis 12 weeks

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Rehabilitation

• Goal Independence
• Candidate able to perceive, understand, follow
  command (verbal/gesture)
• Assessment
• pathology
• site of lesion
• symptoms signs
• risk factors
• stage of neurological recovery
• functional performance

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Positive predictors

• 1. Bladder control (within 1-2 wk)
• 2. Recovery of trunk, hip, shoulder muscles
  within 2-4 wk (proximal muscle)
• 3. Recovery of each muscles 4-6 wk (Isolate
  muscles)
• 4. Family support
• 5. No depression
• 6. Good perception

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Negative predictors

• 1. Prolonged coma
• 2. Prolonged flaccid (gt 2 months)
• 3. Severe proximal muscles spasticity
• 4. Inability to control bladder bowel (within
  2-3 wk)
• 5. Severe unilateral neglect
• 6. Severe intellectual / memory impairment
• 7. Visuospatial deficit / hearing deficit
• 8. Previous stroke
• 9. Severe depression
• 10. Associated diseases (CAD, CHF, PVD)

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Deficits

• 1. Cognitive problems
• Left hemiplegia perceptual deficit, neglect,
  poor insight judgement
• Right hemiplegia aphasia
• 2. Behavioral / emotional problems
• Depression (25-60) 6 m- 2 yr, 70 of right
  hemiplegia
• Undue cheerfulness (anxiety, lability) right
  frontal lobe
• Apathy right frontal lobe
• Denial

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Deficits

• 3. Communication disorder
• Language aphasia (spontaneous recovery 3-6 m)
• Articulation apraxia, dysarthria, dysphonia
• 4. Sensory deficits
• Visual field deficit
• Visual perceptual deficit (right hemisphere)
  body image, special related disorder
• Peripheral sensory deficit (propioception)

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Deficits

• 5. Motor deficits
• Spasticity
• Incoordination
• Weakness
• Motor apraxia
• 6. Bladder, bowel, sexual deficits
• Bladder 70 of Pt. can control (PC exercise,
  CIC)
• Bowel diet (75 of Pt. can control,
  incontinence in bed ridden)
• Sexual in 70 of cases

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Rehabilitation program

• 1. Mobility
• Bed positioning
• Therapeutic exercise (ROM)
• Bed mobility
• Sitting balance / trunk control training
• Transfer training
• Wheelchair management
• Standing / progressive ambulation (ROM,
  propioception, sitting balance, cognition, hip
  extensor power)
• 2. Activities of daily living
• UE function, good sitting balance, no sensory
  deficits

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Complications

• 1. Shoulder subluxation (50-80)
• Causes - paralysis of shoulder M., flaccid
  stage
• - laxity of joint capsule
• Treatment shoulder support / sling, ES, proper
  bed sitting position
• 2. Shoulder hand syndrome (RSD) (12.5, Mo 2-4)
• Causes ANS disorder, increased sympathetic tone
• Stage 1 pain on ROM, swelling of wrist
  fingers, cold skin
• Stage 2 swelling, joint stiffness,
  osteoporosis
• Stage 3 skin dystrophy, osteoporosis
• Treatment ROM, wrist hand splint, pain
  reduction (TENS, drug)

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Complications

• 3. Seizure (10-15)
• Early seizure (2 wk) brain swelling, cytotoxic
  metabolite, embolic gt thrombotic stroke, no
  treatment
• Late seizure (6 m - 2 yr) hemorrhagic stroke,
  medication
• 4. Aspiration Pneumonia (50)
• Causes - swallowing disorder, dysphagia
  (brainstem lesion)
• - cognitive function
• Treatment oral hygiene, proper eating position,
  proper diet, swallowing training

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Traumatic Brain Injury (TBI)

• Traffic accident 60
• Risk factors
• 1. Age 15-24 yr, 0-5 yr, gt65 yr
• 2. Sex male gt female
• 3. Alcohol
• 4. Other psychological, personality

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Classification of TBI

• 1. Severity Glasgow Coma Scale (GCS)
• Severe 3-8
• Moderate 9-12
• Mild gt 13

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Classification of TBI

• 2. Pathology
• 2.1 Focal
• Focal cortical contusion (FCC)
• Deep hemorrhage
• Focal hypoxic-ischemic injury (FHII)
• 2.2 Diffuse
• Diffuse axonal injury (DAI)
• Diffuse hypoxic-ischemic injury (DHII)
• 2.3 Indirect pathological condition secondary
  phenomena
• extracerebral hematoma, herniation syndrome,
  hydrocephalus, chronic subdural hematoma,
  hygroma, posttraumatic seizure

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• FCC
• frontal polar, orbital frontal apathy,
  disinhibition, IQ
• anterior inferior temporal aphasia, agnosia
• Deep hemorrhage
• basal ganglion hemiparesis, discordination,
  hypertonia, movement disorder, aphasia / neglect
• FHII
• posterior cerebral artery hemianopia, amnesia
• DAI
• corpus collosum coma (without lucid interval),
  confusional state, residual attention, cognitive
  behavioral impairments

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Recovery of diffuse TBI

• DAI
• Coma
• Vegetative state
• Mute / low level responsiveness
• Confusional state attention deficit, abn.
  behavior
• Evolving independence
• Intellectual / social competence
• FHII prolonged coma confusion, poor prognosis

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Specific impairments after TBI

• Physical
• 1. Movement control
• 2. Abnormal tone, spasticity
• 3. Cerebellar incoordination
• 4. Involuntary movement
• 5. Seizure
• Neuropsychological
• 1. Neurological arousal, attention (memory),
  behavior
• 2. Postconcussion syndrome headache, dizziness,
  insomnia, depression, fatigue
• 3. Psychological depression, anxiety,
  posttraumatic stress

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Rehabilitation program

• Acute neurosurgery
• Acute rehabilitation phase
• Coma
• prevention of complications
• coma stimulation (sensory stimulation, sitting)
• Confused
• rehab team approaching
• medication
• behavioral management

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Rehabilitation program

• Postacute rehabilitation phase (post discharge)
• Day care
• Day treatment
• Transitional living center
• Cognitive rehabilitation
• Functional skill training (ADL)
• Process oriented rehabilitation (attention,
  executive function)

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Outcome

• 1. Severe TBI (GCS 3-7)
• dead 35-50, cognitive impair 21, abn
  behavior 24
• 2. Mild TBI (GCS 12-15)
• postconcussion syndrome
• 3. Focal pathology
• multiple, mass effect, abn pupil poor
  prognosis
• 4. Diffuse pathology
• GCS, length of coma posttraumatic amnesia
  (PTA)
• 5. Recovery rate