Cognitive Rehabilitation after Stroke

1
Cognitive Rehabilitation after Stroke

• Nadina Lincoln
• University of Nottingham

2
Stroke

• 1.5 2 per 1,000 population p.a.
• 300-500 admitted per year
• Mainly elderly
• Multiple pathologies
• Physical and cognitive
• Acute Rehab Nursing home - Community

3
Cognitive Impairments

• Language
• Perception
• Spatial attention
• Attention
• Memory
• Executive abilities
• Apraxia

4
Cognitive Impairments

• Language
• Perception
• Spatial attention
• Attention
• Memory
• Executive abilities
• Apraxia

5
Cognition ? Outcome

• Mercier et al 2001 (Stroke 32 2602-8)
• Motor , perceptual and cognitive factors related
  to functional autonomy
• Heruti et al 2002 (APMR 83 742-9)
• Cognitive scales relate to rehabilitation outcome
• Patel et al 2002 (JAGS 50 700-706)
• Cognitive impairment associated with poor long
  term outcome

6
Implications for Rehabilitation

• Need to be assessed to be recognised
• Ruchinskas 2002 (APMR 83609-12)
• 20 PT
• 8 OT
• rated 102 consecutively admitted elderly patients
• for presence of cognitive disorders
• Low rate of detection of cognitive problems as
  identified on MMSE

7
Identification of Impairment

• McKinney et al 2002 (Clin Rehab 16129-136 )
• Evaluation of effects of cognitive assessment

8
Trial Design
Screening and random allocation
Control Group Information not provided to staff
Assessment Group Screening and detailed
assessment information provided to staff, carer,
GP
3 month outcome assessment
6 month outcome assessment
9
Outcome

• No significant effect on
• independence in ADL (Barthel, EADL)
• mood (GHQ 28 patient and carer)
• satisfaction
• Reduction in
• Carer Strain

10
Carer Strain IndexOverall
11

• But
• Not followed by intervention
• Multi-site work
• Training of ward staff
• Low involvement with team

12
Implications for Rehabilitation

• Adjust rehabilitation according to nature of
  deficit
• Explanation vs demonstration
• Strategies to enable patients to participate in
  rehabilitation
• Automatic behaviours for apraxia
• Encouraging scanning for visual neglect
• Little evaluation

13
Effect of Stroke Unit

• Drummond Lincoln 2000 ( BJOT)

Stroke Unit
Conventional Wards
Outcome on Rey Copy
14
Dressing

• Walker, Walker and Sunderland (In press)
• Dressing errors and cognitive impairment
• Right hemisphere
• Failed to select correct sleeve
• Failed to cover paretic shoulder
• Left hemisphere
• Dressed non-paretic arm first
• Disorganised strategy

15
Cognitive Rehabilitation

• Cicerone et al 2000
• Evidence based cognitive rehabilitation
  recommendations for clinical practice
• (APMR 81 1596-1615)
• Stroke and TBI
• Included SCED and RCTs
• Selection procedure
• Support for effectiveness of cognitive
  rehabilitation
• Language and perception after stroke

16
Cochrane Reviews

• Cognitive rehabilitation for
• Attention
• Memory
• Spatial neglect
• after stroke

17
Cochrane Reviews

• Cognitive rehabilitation for
• Attention
• Memory
• Spatial neglect
• after stroke

18
Spatial Neglect

• Bowen, Lincoln Dewey 2002
• To determine the effects of rehabilitation on
• standardised assessments of scanning attention
  skills
• measures of disability
• discharge destination
• Whether any effects persist at follow-up

19
(No Transcript)
20
(No Transcript)
21
(No Transcript)
22
(No Transcript)
23
(No Transcript)
24
Summary of results

• Included 15 studies with 400 participants
• Only 6 studies included a measure of disability
• Only 4 investigated persisting effects
• Evidence of significant and persisting
  improvements in impairment level assessments -
  although this varied depending on test used
• Insufficient evidence to confirm or exclude an
  effect on disability or discharge destination

25
Advantage of Meta-analysis

• Extracts general message applicable to the group
  rather than the individual
• Uses evidence from all studies including small
  ones
• Facilitates planning services

26
Limitations of Meta-analysis

• Few trials
• Methodological weakness
• Lack of common outcome measures
• Impairment but not limitation in activity
• Situation specific

27
Limitations of Meta-analysis

• Few trials
• Methodological weakness
• Lack of common outcome measures
• Impairment but not limitation in activity
• Situation specific

28
Measures of Activities

• Independence in ADL (Barthel, EADL, FIM)
• Cognitive Activities
• Attentional Rating Scale (Ponsford Kinsella
  1991)
• Everyday Memory Questionnaire (Sunderland et al
  1983)
• Neglect rating scales (Azouvi et al 1996, Towle
  Lincoln 1991)
• Problem solving behaviours (von Cramon et al
  1991)

29
Limitations of Meta-analysis

• Few trials
• Methodological weakness
• Lack of common outcome measures
• Impairment but not limitation in activity
• Situation specific

30
Rehabilitation of Attention

• Sturm et al 1991
• Germany
• Intensive rehab
• Intensive training
• 14 sessions in 3 weeks
• Average age 51
• Neuropsychologists

• UK
• Low intensity rehab
• No specific training
• 0 sessions
• Average age 75
• Few psychologists

31
More trials are needed

• Plan services
• Effect on majority rather than individual
• Easier to do
• Outcome measures exist

32
Cognitive Rehabilitation after Stroke

• Depends on baseline of services
• Requires recognition of problems
• Advice and education require evaluation
• Specific training can be effective
• Evidence for effectiveness of services
• Trials are needed with outcomes assessed on
  measures of cognitive activity