STROKE CARE NOW NETWORK CONFERENCE MAY 22, 2014

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1 STROKE CARE NOW NETWORK CONFERENCE MAY 22, 2014

2 Rehabilitation Innovations in Post- Stroke Recovery Madhav Bhat, MD Fort Wayne Neurological Center

3 DISCLOSURE Paid speaker for TEVA Neuroscience Program.

4 OBJECTIVES Describe the current research and therapies utilized in stroke recovery. Discuss the neuroscience principles in assessment of prognosis of stroke.

5 INTRODUCTION EVOLVING FIELD OF NEUROREHABILITION Until the late 1960, researchers generally believed that once development was over, any regeneration in the adult CNS would be very limited and any recovery following insult was the result of substitution(training in compensatory techniques). Through 1970s and 1980s multiple animal studies demonstrated CNS structural changes and adaptive improvements in both normal

6 INTRODUCTION (CONT.) adult animals and adult animal given behaviorally specific training following injuries. In the current decade, research investigated neural stem cell therapy, nerve growth factors, enzymes which are favorable environmentally to neuronal and axonal growth. With advent of functional imaging and magnetic stimulation, the past decade witnessed

7 INTRODUCTION (CONT.) documentation in adult humans of neural network reorganization during recovery and response to behavioral therapy and pharmacologic manipulation. CNS plasticity involves neurogenesis, programmed cell death, dendritic and axonal sprouting, long term potentiation and long term depression of synaptic transmission, and recruitment of adjacent cortex and contralateral

8 INTRODUCTION (CONT.) hemisphere. As a concept, plasticity refers to changes in neural networks in response to injury, rehabilitation, pharmacotherapy, electrical and magnetic stimulation, and stem cell and gene therapy Although activity directed plasticity can be beneficial, left undirected it may be detrimental resulting in spasticity, aberrant movement, and neuropathic pain.

9 STROKE REHABILITATION Stroke is a common condition and comprises over half of neurologic admissions to community hospital. As C. Miller Fisher from Massachusetts General Hospital in Boston used to say resident learns neurology stroke by stroke. Stroke is the third leading cause of death in United States behind heart disease and cancer.

10 STROKE REHABILITATION (CONT) Significant cause of disability. The cost of care and earnings lost due to stroke in 2010 was estimated at $ 73.7 billion. Most neurologists are well versed with acute management of stroke however few are familiar with rehabilitative aspects of stroke. They are in a unique position to participate in complete stroke continuum of care from admission, rehabilitation, follow up, secondary prevention.

11 STROKE REHABILITATION (CONT.) Goal: To ensure that each person reaches the maximum physical, functional and psychosocial recovery possible within the limits of his or her impairment. Stroke rehabilitation should facilitate relearning skills that were possible before the stroke but in some cases focus of rehabilitation must be adaptation and compensation for deficits.

12 RECOVERY AFTER STROKE Most recovery of specific deficits (motor, sensory, speech) occurs during the first 3 to 6 months after stroke. Absence of finger extension in involved hand in 2 weeks or no measurable grip at 1 month after a stroke suggests a poor prognosis for recovery of functional arm use. An ability to move hip within a week after stroke suggests good prognosis for ambulation with an assistive device.

13 RECOVERY AFTER STROKE Motor recovery almost always occurs in proximal muscles of the upper and lower extremities. Inability to form words at 2 weeks after stroke suggests poor prognosis for recovery of meaningful functional language.

14 Brunnstrom Stages of Motor Recovery Stage 1 Flaccid paralysis Stage 2 Movements in synergy pattern, emergence of spasticity Stage 3 Voluntary synergy movements, producing movements across joints, increased spasticity Stage 4 Voluntary movements outside of synergy patterns, decreasing spasticity Stage 5 Developing control of individual or isolated movements Stage 6 Return to near-normal motor control

15 EMERGING THERAPIES Constraint-Induced movement therapy(cimt): Restraining the unaffected extremity during therapy sessions with affected extremity and for several hours or constantly at other times for period of several weeks to over a month. CIMT has been shown to produce clinical improvement and changes in fmri in both acute and chronic patients post-stroke.

16 EMERGING THERAPIES (CONT.) Disability is moderately improved immediately following intervention. Patients need 10 degrees of wrist and finger extension. Helps patients with mild to moderate stroke. Cognitively impaired patients may not be receptive to wearing a cast or restraint on the uninvolved extremity.

17 EMERGING THERAPIES Mirror Movements: (cont.) Involuntary movements of ipsilateral hand during voluntary movements of contralateral hand. Normal from the age of 4 years to 11 years due to immaturity of transcallosal inhibition from lack of myelination. Considered abnormal in adults and may be secondary to cerebral palsy, stroke, Parkinson s disease, cervicomedullary junction anomaly.

18 EMERGING THERAPIES (CONT.) Transcranial magnetic stimulation and transcranial direct current stimulation: Lateralization of neural activity during unimanual task is, in part related to interhemispheric inhibition between motor areas exerted via transcallosal connections which are disrupted following stroke. Persistent activation of unaffected hemisphere may limit activation of involved hemisphere, thus recovery.

19 EMERGING THERAPIES (CONT.) Concentration of activity in motor areas correlates with good recovery, while persistence of activation in the contralesional hemisphere correlates with less recovery. Stimulation of involved hemisphere and inhibition of uninvolved hemisphere with TMS and tdcs are beneficial and effects last minutes to hours after stimulus.

20 EMERGING THERAPIES (CONT.) Currently they are not part of therapeutic regimen following stroke or TBI as many questions still exist regarding these therapies, such as optimal frequency and intensity of stimulation, appropriate timing and duration of the program post-injury, patient selection.

21 EMERGING THERAPIES Robot-assisted therapy: (CONT.) Robotic devices are able to deliver high intensity, reproducible therapy and may be useful in those with little voluntary movement as well those with greater ability.

22 Robot assisted therapy

23 EMERGING THERAPIES (CONT.) Body weight-supported treadmill training(bwstt): Involves compensating for a percentage of the subject s body weight, usually via suspension with a harness over a treadmill. The subject then walks on the treadmill at varying speeds and with varying percentage of body weight support. In addition, One or more therapists may assist by advancing a paretic leg or providing tactile or verbal cues.

24 BWSTT

25 BWSTT Practical efficacy of BWSST has been limited by the physical and time demands placed on therapists. Working on a treadmill facilitates an even gait speed and provides more gait cycles and repetition than could occur over ground, while reducing the need for trunk control by displacing weight through the harness suspension.

26 EMERGING THERAPIES (CONT.) Peripheral stimulation techniques: Include muscle vibration, peripheral nerve stimulation. Functional electrical stimulation facilitate muscle contraction, alters the excitability of the corticospinal pathway via modulation of motor cortex activity. It remains unclear what frequency, intensity, duration, and timing post-injury produce best results.

27 EMERGING THERAPIES Mental Practice: (CONT.) Mental practice with motor imagery is used in athletic skill training. Mental practice may be useful in as an adjunct to CIMT or other repetitive therapies in improving motor skills. Mirror neurons found in the premotor and parietal cortex are activated during motor imagery. It can be carried out independent of therapy sessions by the patient.

28 EMERGING THERAPIES (CONT.) Constraint-induced language therapy(cilt); CILT uses a physical barrier between participants who are given tasks that require communication, thus forcing communication. No other means of communication like gestures are allowed.

29 CONCLUSION The past decade has seen an incredible leap in our understanding of how the injured nervous system responds to a variety of neuro-restorative therapies. A definitive conclusion remains elusive owing to heterogeneity in research design, subjects and timing. Clinical implementation lags because of lack of time, limited funding and reimbursement, limited communication and large effort needed.

30 REFERENCE Continuum. Volume 17, Number 3, June 2011, American Academy of Neurology.

31 THANK YOU

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