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PRIMARY ISSUES IN REHABILITATION OF STROKE

PRIMARY ISSUES IN REHABILITATION OF STROKE. Michael Saucier, M.D., M.S. Dept. of Physical Medicine & Rehabilitation. 1. OBJECTIVES. Review the role of rehabilitation in stroke recovery Functional effects of stroke

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PRIMARY ISSUES IN REHABILITATION OF STROKE

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  1. PRIMARY ISSUES IN REHABILITATION OF STROKE Michael Saucier, M.D., M.S. Dept. of Physical Medicine & Rehabilitation 1

  2. OBJECTIVES • Review the role of rehabilitation in stroke recovery • Functional effects of stroke • Discuss salient aspects of rehabilitation of stroke including CIMT, Robotics & Virtual Reality • Challenges in delivery of Stroke Rehabilitation 2

  3. GENERAL CONSIDERATIONS Recurrence is greatest in first 6 months 10-16% recurrence in 1st year Gradual decline to usual risk by about year 5 10% of survivors recover almost completely 25% recover with minor impairments 40% experience moderate/severe impairments 10% require care in a nursing home or LTC 15% die shortly after the stroke

  4. CENTRAL REHABILITATION THEMES Role of behavior in rehabilitation Experience-dependent cortical plasticity 4

  5. CORTICAL PLASTICITY “The motor cortex [is a shared neural substrate] for motor control. The highly overlapping and divergent architecture provide an ideal substrate for flexibility in outputs to the spinal cord that can be rearranged based on behavioral demands.” ---- Randolph Nudo, M.D. 5

  6. EXPERIENCE-DEPENDENT CORTICAL PLASTICITY • Behavioral experience as a potent modulator of cortical structure and function • driven largely by repetition & temporal coincidence • thought to drive formation of discrete modules where conjoint activity is expressed as a unit • plasticity is probably skill- or learning-dependent rather than use-dependent 6

  7. ROLE OF BEHAVIOR IN MODULATING POST-STROKE RECOVERY • CENTRAL QUESTION:How can we drive adaptive plasticity in intact portions of the ipsilesional hemisphere? • Cortical electrical stimulation: does this enhance excitability of intact ipsilat. areas? • CIMT: Constraint Induced Movement Therapy • Pharmacology • Robotics • What do these have in common? -- utilize repetitive behavioral tasks, especially those with high skill demands 7

  8. EFFECTS OF STROKE Paresis/Plegia Speech Impairments dysarthria (slurred speech) aphasia Neglect Cognitive/Neurobehavioral Syndromes Apraxia Ochsner Medical Center

  9. EFFECTS OF STROKE Dysphagia Sensory loss Depression Visual, oculomotor & vestibular deficits Central post-stroke pain Deconditioning Urinary dysfunction 9

  10. EFFECTS OF STROKE DVT Contralesional edema Hemiparetic shoulder syndrome Spasticity Diminished endurance Poor arousal (somnolence) 10

  11. COGNITIVE IMPAIRMENT Quantitatively: cumulative effects of location, number & volume: Executive function Dementia 11

  12. CHARACTERISTICS OF COGNITIVE IMPAIRMENT • Executive Function • Executive function: ill-defined • constellation of higher order skills used to manipulate available information to plan & execute complex activities. • attention, mental flexibility, processing speed, set maintenance, set shifting, working memory, error correction • 337 stroke pts: 40.6% with dysfunction 1.5 SD below mean for elderly controls (mean age 70.2 +/- 7.6) 12

  13. COGNITIVE IMPAIRMENT • Stroke is a potent risk factor for dementia: • 10X risk for dementia with prevalence 20-25% • post-stroke dementia is a major risk factor for mortality independent of age, Barthel index or comorbid diseases. • improvement in post-stroke survival make this important • comparison of 1984-1990 and 1991-2000: 53% increase in all dementia types, 87% increase in subjects with stroke. Stroke survival increased 53% 65%. 13

  14. CHARACTERISTICS OF COGNITIVE IMPAIRMENT • CIND (vascular Cognitive Impairment/No Dementia): • actually a diagnostic category (Rockwood, Neurology, 2000) • reflects substantial cognitive deficits without sufficient memory loss or other multi-domain deficits to meet criteria for dementia. • CIND cognitive features are those related to executive function: sequencing, attention, working memory, processing speed. • Using CIND: even stroke survivors considered to have NO cognitive deficits demonstrated worse executive function than stroke-free controls. 14

  15. MANAGEMENT OF COGNITIVE IMPAIRMENT • Cognitive screening/followup fundamental to Rehab • NON-PHARMACOLOGIC: • cognitive rehab via S.T. & O.T. • PHARMACOLOGIC: disease modifying treatments vs symptomatic treatments • Secondary prevention: HTN control, glucose control, aggressive dyslipidemia control 15

  16. PHARMACOLOGY IN REHABILITATION • Arousal: Ritalin, Provigil • Inattention: Ritalin, Amantadine, Adderall • Memory: AD agents • Spasticity: Dantrium • Functional: • Levodopa (Lancet, 2001) • Reboxetine – inhibits norepinephrine reuptake; may enhance learning of motor skills (Neurology, 2004) 16

  17. NEW DIRECTIONS IN STROKE REHAB • ROBOTICS • VIRTUAL REALITY

  18. COMPARISON of CMS vs PRIVATE INSURANCE (PI)

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