Stroke Rehabilitation DR. RANI HALEY LINDBERG, M.D. UAMS DEPT. OF PHYSICAL MEDICINE AND 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 Physicians Rehabilitation Nurses Physical Therapists Occupational Therapists Care Coordinators/Social Workers Respiratory Therapists Speech-Language Pathologists Registered Dietitians Therapeutic Recreation Specialists Driver Rehabilitation Instructors Neuropsychologists Chaplains
Stroke Rehabilitation: Team Approach Patient and family Physician Physical Therapist Occupational Therapist Speech Language Pathologist Rehab Neuropsychologist Rehab Nursing and Aides Rehab Case Coordinator Recreational Therapist Chaplain Nutritionist Orthotist Vocational 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 control Cognitive: Communication, psychosocial
Motor Impairment and Recovery due to Stroke Up to 88% of stroke patients have hemiparesis Most recovery in 1 st 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 spasticity 2) Prolonged flaccidity period 3) Late return of proprioceptive response >9 days 4) 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 exercises 2. Mobilization 3. Compensatory techniques 4. 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 Approach Rood/Sensorimotor approach Motor Relearning program Behavioral 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
Complications after Stroke PROBLEMS ENCOUNTERED BEFORE, DURING, AND AFTER REHAB
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 exercises Elevation of limb Compression stockings or gloves SCDs Massage 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 LMWH SCDs TED hose
Bladder Dysfunction 50-75% of stroke patient have urinary incontinence during the 1 st 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 1 st 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 swallow Dysphonia Dysarthria Abnormal gag reflex Voice 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 Tracheostomy Emesis Reflux NGT feeding Dysphagia
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. AphasiaLonger rehabilitation length of stay AphasiaDecreased 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 depressiondelayed 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 3 rd 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 testing Functional Capacity Evaluation Return 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. 3 rd 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.