Rehabilitation of the Stroke Patient

1. Rehabilitation of the Stroke Patient Presented by: Shawn Baker, PT, DPT Leslie Brady, PT, MPT Baylor Institute for Rehabilitation

2. Objectives • Discuss basic principles of neuroplasiticity after injury. • Review treatment approaches used in the inpatient rehabilitation setting with regards to the stroke population. • Discuss challenges with the stroke patient in the rehabilitation setting.

3. What is Neuroplasticity? • Neuro: Nerves and/or brain • Plasticity: Moldable or changeable in structure • Speaks to the adaptive capacity of the central nervous system • Brain is not a static organ • Brain changes throughout life and after injury

4. Neuroplasticity After Brain Damage • LEARNING1 • Best hope for remodeling the damaged brain • Reorganizes the damaged brain, even in the absence of rehabilitation • Brain damage changes the way the brain responds

5. Neuroplasticity After Injury1 • Use it or lose it • Use it and improve it • Specificity • Repetition matters • Intensity matters • Time matters • Salience matters • Age matters • Transference • Interference

6. What Exactly Are Patients Doing in Therapy? Treatment Approaches used in the Inpatient Rehabilitation Setting

7. Treatment Approaches • Body weight support treadmill training • Constraint induced therapy • Functional electrical stimulation • Mirror therapy • Use of tape

8. Body Weight Support Treadmill Training (BWSTT)2 • Characteristics of gait after stroke • BWSTT provides environment to relearn normative gait • Parameters to consider include: • Amount of weight supported • Speed • UE support • Use of brace • Findings

9. Videos!

10. Constraint Induced Therapy3 • Forced use of the affected extremity • Limiting use of non-affected extremity with constraining device • Parameters to consider include: • Amount of day constrained • Type of constraining device • Behavior contracts • Findings

11. Functional Electrical Stimulation4 • Electrical stimulation over affected muscle groups • Combined with practice/activity • Parameters to consider: • Amount of stimulation • Which activity • Contraindications/precautions • Findings

12. Mirror Therapy5,6 • Mirror placed in midsagittal plane • Reflecting movements of non-affected side as it were the affected side • Parameters to consider include: • Amount of time per day • Use of mirror box or upright mirror • Findings

13. Use of Tape • Uses for tape in rehabilitation setting: • Shoulder subluxation • Knee hyperextention • Edema • Types of tape used: • Kinesiology tape • Corrective tape • Findings

14. Challenges We Face With Stroke Patients

15. Inpatient Rehabilitation Challenges • CMS requirements and Three hour rule • Cognition • Communication • Dysphagia/pneumonia • Bowel/bladder incontinence • Pain • The “pusher”

16. Determination of IRF Stay7 • Based on assessment • Criteria must be met at time of admission: • Require active and ongoing intervention of multiple disciplines • Require an intensive rehabilitation therapy program • Reasonably be expected to actively participate and benefit from therapy program • Requires physician supervision • Requires intensive and coordinated interdisciplinary team approach

17. Intensive Rehabilitation Program7 • 3 hours of therapy per day, at least 5 days per week • Acceptable cancel reasons • Make up time if necessary • PT, OT, ST only count • In certain cases, 15 hours over a 7 consecutive day period • Must be well-documented • Order by physician

18. Cognition • How much is needed to cause impairment? • Greater than 10mL but less than 50mL which equals 1-4% of brain volume8 • Vascular Cognitive Impairment (VCI) • Affects in executive function9 • Cognitive deficits include: • Attention, language syntax, delayed recall and executive dysfunction affecting the ability to analyze, interpret, plan, organize, and execute complex information9 • Multicenter study found 56% of patients report confusion after CVA10

19. Cognition Continued • Safety10 • Pressure sore/skin break 21% • Fall, serious injury 5% • Fall, total 25% • Causes of falls in community dwelling stroke survivors11 • Difficulty stooping and kneeling • Getting up in night to urinate more than once

20. Communication • What is language?12 • Recognize and use words and sentences • Much of the capability resides in left hemisphere • Aphasia12-14 • 1 million people in the US have aphasia • Ability to use or comprehend words • Apraxia12-14 • Difficulty initiating and executing voluntary movement patterns necessary to produce speech when there is no paralysis or weakness of speech muscles • Dysarthria14-15 • Motor speech disorder

21. Dysphagia • Swallowing process disrupted • 65% of stroke survivors experience dysphagia16 • Aspiration can occur • Aspiration pneumonia17 • Dysphagia carries threefold to sevenfold increase increased risk • Patient has threefold increased risk of death if developing • Dysphagia is a predictor of mortality after stroke

22. Bowel/Bladder Incontinence18,19 • Affects 40-60% of patients admitted to hospital after CVA • 15% have ongoing problems one year after CVA • Can affect: • Equipment ordered for home use • Discharge placement • Incontinence associated with poorer functional outcomes • Increased institutionalization

23. Pain20 • Musculoskeletal • Spasticity • Shoulder/hand pain • Central Pain • Constant, moderate to severe pain • Brain registers even slight contact to skin as painful • Reported in approximately 8% • Onset more than a month after stroke

24. Pusher Syndrome21,22 • Distinctive disorder of actively pushing away from non-hemiparetic side • Present in approximately 10.4% of patients • Patient’s perceived “upright” orientation was tilted about 18 degrees toward ipsilesional side with eyes occluded • Patients with pusher syndrome take 3.6 weeks (63%) longer to reach same functional outcome level

25. Sitting on a tilting chair, patients with pusher syndrome were required to indicate when they reached “upright” body orientation.13 (a) With occluded eyes, the patients experienced their body as oriented “upright” when actually tilted 18 degrees to the side of the brain lesion. Karnath H , and Broetz D PHYS THER 2003;83:1119-1125 Physical Therapy

26. Questions? Thank you!

27. References • Kleim, J.A. (2008). Principles of Experience-Dependent Neural Plasticity: Implications for Rehabilitation After Brain Damage. Journal of Speech, Language, and Hearing Research. Vol 51 • McCain, K.J., et al. (2008). Locomotor Treadmill Training with Partial Body-Weight Support Before Overground Gait in Adults with Acute Stroke: A Pilot Study. Archives of Physical Medicine and Rehabilitation. Vol 89 • Wolf, S. et al. Effect of constraint-induced movement therapy on upper extremity function 3 to 9 months after stroke. Journal of the American Medical Association. 2006; 296:2095-2103 • Yan, T., et al. (2005). Functional Electrical Stimulation Improves Motor Recovery of the Lower Extremity and Walking Ability of Stroke Subjects With First Acute Stroke: A Randomized Placebo-Controlled Trial. Stroke. 2005;36:80-85. • Sutbeyaz, S., et al. (2007). Mirror Therapy Enhances Lower-Extremity Motor Recovery and Motor Functioning After Stroke: A Randomized Controlled Trial. Archives of Physical Medicine and Rehabilitation. Vol 88 • Thieme H., et al. (2012). Mirror therapy for improving motor function after stroke. Cochrane Database of Systematic Reviews 2012, Issue 3 • Inpatient Rehabilitation Therapy Services : Complying with Documentation Requirements. Retrieved from: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Inpatient_Rehab_Fact_Sheet_ICN905643.pdf

28. References Continued • Stroke and Cognitive Impairment. Retrieved from: http://www.preventad.com/pdf/support/article/Stroke_Cognitive_Impairment.pdf • Stroke: Challenges, Progress, and Promise. Retrieved from: http://stroke.nih.gov/materials/strokechallenges.htm#Basics3 • P.Langhorne, D.J., et al. (2000). Medical Complications After Stroke: A Multicenter Study. Stroke. 2000;31:1223-1229 • Mackintosh, S. F., et al. (2005). Falls incidence and factors associated with falling in older, community-dwelling, chronic stroke survivors (>1 year after stroke) and matched controls. Aging Clinical and Experimental Research. Vol 17, Issue 2 • Conditions Impacting Communication After Stroke. Retrieved from: http://www.strokeassociation.org/STROKEORG/LifeAfterStroke/RegainingIndependence/CommunicationChallenges/Conditions-Impacting-Communication-After-Stroke_UCM_310071_Article.jsp • Aphasia vsApraxia. Retrieved from: http://www.strokeassociation.org/STROKEORG/LifeAfterStroke/RegainingIndependence/CommunicationChallenges/Aphasia-vs-Apraxia_UCM_310079_Article.jsp • Speaking of Stroke: Why Speech May be Affected by Stroke. Retrieved from: http://www.nxtbook.com/nxtbooks/aha/strokeconnection_20100506/index.php#/16

29. References Continued • Dysarthria. Retrieved from: http://www.asha.org/public/speech/disorders/dysarthria/ • Difficulty Swallowing After Stroke. Retrieved from: http://www.strokeassociation.org/STROKEORG/LifeAfterStroke/RegainingIndependence/PhysicalChallenges/Difficulty-Swallowing-After-Stroke_UCM_310084_Article.jsp • Singh, S. and Hamdy, S. (2006). Dysphagia in Stroke Patients. Postgraduate Medical Journal. 82(968): 383–391 • Continence Problems After Stroke. Retrieved from: http://www.bladderandbowelfoundation.org/uploads/pdf/F12_Continence_problems_after_stroke,_March_2011[1].pdf • Mehdi, Z., Birns, J. and Bhalla, A. (2013), Post-stroke urinary incontinence. International Journal of Clinical Practice, 67: 1128–1137. • Pain. Retrieved from: http://www.stroke.org/site/PageServer?pagename=pain • 21. Karnath, H.O., et al. (2007). Pusher Syndrome-a frequent but little-known disturbance of body orientation perception. Journal of Neurology. 254:415-424 • 22. Karnath, H.O. and Broetz, D. (2003). Understanding and Treating “Pusher Syndrome”. Physical Therapy. Volume 23, Number 12