Recovery and Rehabilitation after Stroke

Recovery and Rehabilitation after Stroke NICK WARD UCL INSTITUTE OF NEUROLOGY QUEEN SQUARE n.ward@ucl.ac.uk Follow us on Twitter @WardLab For more information go to http://www.ucl.ac.uk/ion/departments/sobell/research/nward

Plan 1. Why? 2. When? 3. How? 4. Compensation vs Recovery 5. Upper Limb 6. Language 7. Prediction

Rehabilitation why? http://wellcometrust.wordpress.com/category/series/focus-on-stroke-series/

Where is rehabilitation on the treatment path? 1 Prevention Acute 2 Prevention Therapy Rehabilitation

Rehabilitation what is it? Rehabilitation is a process of active change by which a person who has become disabled acquires the knowledge and skills needed for optimum physical, psychological and social function. Rehabilitation is the application of all measures aimed at reducing the impact of disability and handicap and improving quality of life.

Rehabilitation - structure A rehabilitation service comprises a multidisciplinary team of people who: 1. Work together towards common goals for each patient 2. Involve and educate the patient and family 3. Have relevant knowledge and skills 4. Can resolve most of the common problems faced by their patients

Rehabilitation is a reiterative, active, educational, problem solving process focused on a patient's behaviour (disability), with the following components: 1. Assessment the identification of the nature and extent of the patient's problems and the factors relevant to their resolution 2. Goal setting Rehabilitation - process 3. Intervention, which may include either or both of (a) treatments, which affect the process of change; (b) support, which maintains the patient's quality of life and his or her safety 4. Evaluation to check on the effects of any intervention

Rehabilitation - outcome The rehabilitation process aims to: 1. Maximise the participation of the patient in his or her social setting 2. Minimise the pain and distress experienced by the patient 3. Minimise the distress of and stress on the patient's family and carers

Neuro-rehabilitation: iterative process 1. Avoid complications 2. Assessment - MDT 3. Measurement 4. Planning 5. Treatment 6. Evaluation 7. Reassessment

Avoid complications after stroke painful shoulders pressure sores contractures incontinence malnutrition aspiration pneumonia

Avoid complications after stroke

Avoid complications after stroke Don t pull on the hemiparetic arm get the patient to squeeze your fingers leave the patient in one position catheterise if possible

Avoid complications after stroke Do sit the patient out use pressure relieving mattresses ask/check for pressure sores check the swallow check the mouth care ensure adequate nutrition toilet regularly assess orientation assess mood talk.make a difference

Planning Goal setting A process of discussion and negotiation in which the patient and staff determine the key priorities for rehabilitation for that individual, and agree the performance level to be attained by the patient for defined activities within a specified time frame. A key element in the rehabilitation process. Commonly employed as a technique to actively engage patients in their rehabilitation programme. Occupational/organisational literature 1970s

Planning short term goals To wash my face and clean my teeth standing at the sink with an upright posture To wash myself in sitting, reaching down to my feet To dress my top half, following written prompts To move independently from sitting to lying in the gym

Planning long term goals To return home able to Walk indoors with my frame feeling more confident Participate in personal care and light domestic tasks incorporating standing Able to turn myself in bed Able to complete car transfers independently With advice on: Exercise programme Bladder and bowel management Standing programme/tone management

Who should be referred? In-patient or out-patient Patients who are medically stable (-ish) with multiple interacting problems who need input from two or more disciplines with potential to make functional gains Before you refer identify any previous input and its outcome

Compensation versus Recovery it is useful to divide neurorehabilitation into (1) measures primarily aimed at assisting adaptation to (or compensating for) impairment, and (2) those primarily aimed at reducing impairments The latter address underlying neurological deficits more directly but are relatively poorly understood.. and are based on advances in our neuroscientific understanding of how the brain is organised

Niell et al., Nat Neurosci 2004; 7: 254-260 What is brain plasticity? Dendritic growth in vivo Axon arborisation in vivo Hua et al., Nature 2005; 434: 1022-1026 dendrites axon

What is brain plasticity? A affected side infarct 10 days post stroke 17 days post stroke 24 days post stroke 31 days post stroke 3 months post stroke B affected side OUTCOMES Barthel ARAT GRIP NHPT Patient A 20/20 57/57 98.7% 78.9% Patient B 20/20 57/57 64.2% 14.9%

When is best to treat? 1. EARLY helps avoid complications 2. Natural history of recovery may be misleading 3. Can late treatment change impairment? This patient made 90% improvement 20 years after stroke

Treating upper limb impairment Task specific training is better than general exercise motor learning? Works better in patients with reasonable residual motor control Optimal dose is important but not clear Motor practice/ Motor learning Constraint induced therapy Robotic assisted devices Virtual environments

Treating upper limb impairment

Does it work - Dose Treating language impairment Problem: average amount of out-patient speech therapy ~ 12 hours

Predicting recovery after stroke

Predicting recovery after stroke Stinear, C. M. et al. Brain 2007 130:170-180

Predicting recovery after stroke

Recovery and rehabilitation after stroke Rehabilitation required by everyone (motor, language, cognitive) Rehabilitation starts on day 1 through MDT Avoid complications Goal setting is done for patients benefit Intensity and dose of intervention mahes a difference Never too late.. As long as complications are avoided