dr. sindhu pandit, md, mba ochsner pmr department · treatments such as acupuncture and oxygen...
TRANSCRIPT
Dr. Sindhu Pandit, MD, MBA
Ochsner PMR Department
None
Disclosures
Approximately 795,000 strokes are seen each year
10% of stroke survivors recover almost completely
25% recover with minor impairments
40% experience moderate to severe impairments requiring special care
10% require care in a nursing home or other long-term care facility
15% die shortly after the stroke
The Impact
- National Stroke Association
“There is increasing evidence that rehabilitation can have
a big impact on survivors’ quality of life, so the time is right to review the evidence in this complex field and highlight effective and important aspects of rehabilitation,”
- Carolee J. Winstein, Ph.D., lead author of the scientific statement published in the May 2016 issue of the American Heart Association journal Stroke
Prevent Complications
Minimize Impairments
Maximize Function
Goals of Rehabilitation
Depending on the severity of the stroke, rehabilitation
options can include:
Long term acute care
A skilled nursing facility/subacute care unit
A rehabilitation hospital with individualized inpatient therapy
Home therapy
Returning home with outpatient therapy
Post Acute Care
- National Stroke Association
Recovery
Resolution of edema surrounding the area of the infarct
Reperfusion of the ischemic penumbra
Diaschisis - state of low reactivity or depressed function as a result of a sudden interruption of major input to a part of the brain remote from the site of brain damage
With injury to one area of the brain, other areas of brain tissue are suddenly deprived of a major source of stimulation
Stroke Rehabilitation Clinician's Handbook –Canadian Partnership for Stroke Recovery
Later Recovery
Neuroplasticity - the ability of the central nervous system (CNS) to undergo structural and functional change in response to new experiences
Stroke Rehabilitation Clinician's Handbook –Canadian Partnership for Stroke Recovery
Timeline
Majority of neurological recovery occurs within the first 1- 3 months
Formal rehab continues for approximately 3-4 months after the event
Ongoing recovery for 6 months to a year
The two most important factors which predict motor
recovery are:
Stroke Severity: The most important predictive factor which reduces the capacity for brain reorganization
Age: Younger patients demonstrate greater neurological and functional recovery and hence have a better prognosis compared to older stroke patients
Predictors
Stroke Rehabilitation Clinician's Handbook –Canadian Partnership for Stroke RecoveryAdunsky et al. 1992; Hindfelt & Nilsson 1977; Marini et al. 2001; Nedeltchev et al. 2005
Stroke Rehabilitation: Strengthening Synapses to Achieve Optimal OutcomesBy MosunmolaOyawusi, MD; Uri Adler, MD; and A.M. Barrett, MDToday’s Geriatric Medicine, Vol. 7 No. 5 P. 12
Medical Management in the Rehab Setting
Prevention of Skin breakdown and Contractures
Prevention of DVT
Bowel and Bladder Management
Hemiplegic shoulder pain
Central Pain
Fall Prevention
Seizure Prevention
Poststroke Depression
Poststroke Osteoporosis
Functional Assessment
Motor Impairment
Mobility
Balance
Cognition and Memory
Communication
Hearing/Visual Impairments
Dysphagia
Traditional rehabilitation practice has often focused
on strengthening exercises and compensatory training
Emerging studies/approaches emphasize restorative treatments to re-establish lost functions through intensive task-based practice or direct brain stimulation
Approaches to Rehab
Stroke Rehabilitation: Strengthening Synapses to Achieve Optimal OutcomesBy MosunmolaOyawusi, MD; Uri Adler, MD; and A.M. Barrett, MDToday’s Geriatric Medicine, Vol. 7 No. 5 P. 12
Constraint-induced movement therapy (CIMT)
Immobilizing the unaffected limb restored competent, symmetric movements in the affected limb
Approaches to Rehab
Functional Electrical Stimulation (FES)
Paretic muscles can be made to contract by applying electrical currents to the intact peripheral motor nerves innervating them.
electrically elicited muscle contractions are coordinated in a manner that provides function
Approaches to Rehab
Body-Weight-Supported Gait Training
Allows the patient to practice complex gait cycles unweighted
Allows the patient to practice nearly normal gait patterns and to avoid developing compensatory walking habits, such as hip hiking and circumduction
Involves the patient being suspended in a harness system hanging from an overhead frame
Traditionally, the frame is situated over a treadmill or flat ground, with 1 to 2 physical therapists providing assistance for balance and advancement of the paretic limb
Approaches to Rehab
Rehabilitation—Emerging Technologies, Innovative Therapies, and Future Objectives Nneka L. Ifejika-Jones & Anna M. Barrett
Extensive research efforts have been dedicated to dynamic
exoskeletons for neurorehabilitation
Approaches to Rehab
Robotic hip–knee–ankle–foot exoskeletal orthoses have
become commercially available and may help poststroke
patients to stand and walk again
Exoskeletons incorporate the actuators that move the
patient’s legs during the gait cycle, through a
preprogrammed and near-normal gait cycle
Approaches to Rehab
Stimulation-Based Approaches
Transcranial magnetic stimulation (TMS)
- electromagnetic technology to create an electrical current that can depolarize neurons
Approaches to Rehab
Stroke Rehabilitation: Strengthening Synapses to Achieve Optimal OutcomesBy MosunmolaOyawusi, MD; Uri Adler, MD; and A.M. Barrett, MDToday’s Geriatric Medicine, Vol. 7 No. 5 P. 12
Stimulation-Based Approaches
Transcranial direct current stimulation (tDCS)
- electrical stimulation to enhance cortical excitability
- Saline-soaked pads placed on the scalp apply a very weak current in 10 - 30 minute sessions to modify rather than generate neuronal activity in cortical neurons by generating an electrical field that fosters neural network interaction
Approaches to Rehab
Stroke Rehabilitation: Strengthening Synapses to Achieve Optimal OutcomesBy MosunmolaOyawusi, MD; Uri Adler, MD; and A.M. Barrett, MDToday’s Geriatric Medicine, Vol. 7 No. 5 P. 12
Biological therapies –
ex. stem cells, are being investigated
Alternative or complementary medicine –
Treatments such as acupuncture and oxygen therapy are being evaluated
Virtual reality for stroke rehabilitation –
a Cochrane review showed Virtual reality may be beneficial in improving upper limb function and activities of daily living function when used as an adjunct to usual care (to increase overall therapy time)
Approaches to Rehab
The better we understand the choices we have been
making, either consciously or unconsciously, the more say we will have in the world we create. Neurocircuitry may be neurocircuitry, but we don't have to run on automatic.
- Jill Bolte Taylor
My Stroke Of Insight
Thank you!