Download Challenging issues in Stroke

Challenging issues in Stroke Rehabilitation
Alireza Ashraf, M.D.
Professor of Physical Medicine & Rehabilitation
Shiraz Medical school
The effect of timing on rehabilitation
- Fewer days between the onset of stroke and admission to inpatient
rehabilitation :
* Better functional outcome regardless of initial severity
* shorter stay in hospital
- Transfer of patients to rehabilitation before they are medically stable.
(Horn SD etal,2005)
- Earlier gait activities: significant association with outcome, regardless of how
much additional therapy or admission functional level (Horn SD et al, 2005)
Intensity of rehabilitation
- Weakly correlated with improved functional outcome.
(cifu Dx et al , 1999 ), ( Duncan pw et al , 2005)
- Less intense (30-45 min/day ) task-specific training regimens with the more
affected
limb:
produce cortical reorganization and meaningful functional improvements
( page SJ, 2003)
- Too much or the wrong type of activity early in the rehabilitation of the
upper
limb:
worse outcome & increasing spasticity .
(Turton A et al, 2002)
--Massed versus Distributed practice schedules:
Less rest between performance epochs has a detrimental effect on learning
so , “ massed practice” may be impractical. (Dobkin BH , 2004)
- Intensity of Training: Total time of practicing is less important than the
nature
of practice
(Bell KR et al, 2005)
- Contents of Training : * Enriched environments better than standard one
* Low evidence in humans.
Stroke unit VS General ward
* lesser cost
* more favorable outcome
* shorter stay in hospital ( kalra L, 1994)
Age
* Although age has a significant impact , it is a poor predictor of individual
functional recovery and can not be as a limiting factor in rehabilitation
( kugler c et al , 2003) , (Bagg S et al , 2002)
Ashworth scale VS Tardieu scale
* Ashworth and Modified scales: * low intra-rater and inter-rater
reliability
middle grades
* “clustering” effect of the patients in the
* Tardieu scale: * Not only quantifies the muscles reaction to stretch, but it
controls the velocity of the stretch and measures the angle
at which catch or clonus
occurs.
* spasticity angle: Difference between the angle at the end of passive range
of
motion at slow speed and the angle of catch at fast
speed
This angle estimates contributation of spasticity and
mechanical restraint of soft tissues.
-Evidence
weak
- Due
for the use oral antispastic medications in stroke is
(Montane A, et al , 2004)
to complications : “ start low and go slow”
combination
better tolerated
* Rather than higher doses of one drug, a
of lower doses of 2 drugs may be
(Nance p , 2001)
* Taper slowly
- Higher doses of BTX-A : Greater hypertonia reduction without any
advantage in the duration of effect. (smith SJ et al ,2000)
-The incidence of antibody to BTX in the spastic hypertonia :
Less than 1%
(yablon SA et al, 2005) & (Turkel C et al ,
2002)
- Repeated injection:
- Amount
Effective& safe
(Nauman M et al , 2006)
of saline : *No difference for dilution of Botox
* Greater amount
(ie , 5 cc)
(Franisco GE et al , 2002)
is superior.
(Gracies JM et al,
2002)
- Role of adjunctive therapy modalities after BTX-A injection:
No any systematic review
Central post-stroke pain
- pain associated with vascular lesions of CNS.
- Following lesions at any level in the spino-thalamo-cortical pathway
(i.e., lateral medulla oblongata , thalamus, posterior limb of internal capsule ,
…)
- Incidence: 2%11%
- onset: 20% immediately.
50% within first month
30% until 3 years
-Affected area varies, ranging from the entire of the involved
side
-of body, to a small
anatomic area (Depends on the location of the lesion)
- The area with sensory loss > The area of pain
- Burning
sensation :
most common (60%)
- Even pruritis can be seen
- Most common abnormality in physical exam: Dysesthesia
- Hallmark : Allodynia (in about 50%)
- Hypoesthesia: Near all of them have to temperature
- similar lesion in the same area : Different pain symptoms
Treatment
- Antidepressants: * Amitriptyline is the most effective followed by
nortriptyline
* caution in patients older than 65
- antiepileptics: * Gabapentine: - High dose
- Just clinical experience
- opioid: Ineffective
Migraine: Is it an etiology?
- Controversial:
to
(change of definition of migraine, migraine- like features due
large vessel dissection, Difficulty to obtain true history)
-Migrainous infarction: - Fixed , focal neurologic deficit following an attack
- 0.5%- 1.5% of all ischemic strokes and 10-14% of
ischemic stroke in young patients (Bousser MG et al , 2005)
- More often in migraine with aura
- Mechanism: unusually severe cortical hypoperfusion.
- 30% of infarction in occipital lobe
- 2.7 times increased the risk of ischemic stroke in women.
- Rise in the risk who smokes or uses OCP.
(Lampl c et al , 2006)
(Etminan M et al , 2005)
“ OCP”
- No risk with current low- dose in women without Vascular risk
factors.
- Even low dose OCP with caution in : - Migraine
- smoker
- HTN
( American college of OB & Gyn, 2006)
Hypertension and stroke
- Important for an initial than a recurrent stroke
- stroke occurrence: Depends more on the duration of hypertension than on
the
current level of blood pressure
- Treatment of only severe hypertension in a patient with
stroke:
Reduces the rate of recurrence
significantly
- optimal drug regimen: * uncertain
* with history of MI:
Beta- blocker+ ACE inhibi .
Acupuncture and stroke
- In several systematic reviews the effect is weak or nonexistent .
(zhang SH et al, 2005) ( wu HM et al , 2006)
- Other outcomes rather than motor recovery: * postural control
* Improvement of walking
speed
* Improvement of dysphagia
( seki T et al , 2005)
- Conclusion:
In the absence of any specific medical contraindications , it is safe and welltolerated . So , in some situations try of this is recommended.
“Task- oriented Training to promote upper extremity
Recovery”
- A dominant approach to motor restoration.
- Definition: - As a Top- Down approach in “WHO” definition
on
- Motor learning , Goal- directed training
- patient as an active problem-solver and focus of rehabilitation
acquisition of skills.
- Task: * challenging to achieve, involve real objects and activities, goaldirected
and
in nature.
* Distinct from exercise- based movements that can be abstract
without functional goal
- skill: - Desired outcome of a task- oriented program
- Ability to achieve a goal (task) with consistency , flexibility and
efficiency.
(Q uinn L etal , 2003)
“Ottawa panel evidence-based clinical guidelines (EBCPG)”
- Dividing ADL into component parts
- practice of individual components then combine them
- NOT consistent with supporting evidence & misses the essential outcome of
Task-oriented approach (skill).
Task-oriented Training
VS.
Neuromuscular Re- education
- For example: Brunnstrom, Bobath, Rood, knott and Doman- Delgado.
- Their bases never externally validated.
- Very few outcome measures existed.
- Focus just on the impairment without attention to voluntary participatory
behaviors or quality of life.
What are the active ingredients?
1- Challenging : * should be enough to require new learning with attention to
solve
the motor problem
(plautz EJ et al , 2000)
2-Progressive and optimally adapted:
optimally adapted to the patient’s capability and the environmental
context ,
not too simple or repetitive to challenge and not too difficult to
cause a failure
of motor learning
(Lee TD et al , 2005)
3-Interesting enough to invoke active participation:
* to engage a “ particular type of repetition “ referred to as “problemsolving”
* Voluntary movement elicits motor learning more than passively induced
movement.
(Lotze M et al , 2003)