Challenging issues in Stroke Challenging issues in Stroke RehabilitationRehabilitation

Alireza Ashraf, M.D.Alireza Ashraf, M.D.

Professor of Physical Medicine & Rehabilitation Professor of Physical Medicine & Rehabilitation

Shiraz Medical schoolShiraz Medical school

The effect of timing on The effect of timing on rehabilitationrehabilitation- Fewer days between the onset of stroke and - Fewer days between the onset of stroke and admission to inpatient rehabilitation admission to inpatient rehabilitation : : * Better functional outcome regardless of * Better functional outcome regardless of initial severityinitial severity * shorter stay in hospital * shorter stay in hospital - Transfer of patients to rehabilitation- Transfer of patients to rehabilitation before before they they are medically stable.are medically stable. (Horn SD etal,2005) (Horn SD etal,2005)

- Earlier gait activities: - Earlier gait activities: significant association significant association with outcome, regardless of how much additional with outcome, regardless of how much additional therapy or admission functional level therapy or admission functional level (Horn SD et al, (Horn SD et al, 2005) 2005)

Intensity of rehabilitationIntensity of rehabilitation

- - WeaklyWeakly correlated with improved functional outcome. correlated with improved functional outcome. (cifu Dx et al , 1999 ), ( Duncan pw et al , 2005)(cifu Dx et al , 1999 ), ( Duncan pw et al , 2005)

- - Less intense Less intense (30-45 min/day )(30-45 min/day ) task-specific training regimens with the task-specific training regimens with the more affected limb:more affected limb: produce cortical reorganization and meaningful functional improvements produce cortical reorganization and meaningful functional improvements ( ( page SJ, 2003)page SJ, 2003)

- Too much or the wrong type of activity early in the rehabilitation of - Too much or the wrong type of activity early in the rehabilitation of the upper limb: the upper limb: worse outcome & increasing spasticity worse outcome & increasing spasticity . . (Turton A et al, 2002)(Turton A et al, 2002)

--Massed versus Distributed practice schedules:-Massed versus Distributed practice schedules: Less rest between performance epochs has a detrimental effect on Less rest between performance epochs has a detrimental effect on learning so , “ massed practice” may be impractical. learning so , “ massed practice” may be impractical. (Dobkin BH , (Dobkin BH ,

2004)2004)

- Intensity of Training- Intensity of Training: Total time of practicing is less important : Total time of practicing is less important than the nature of practice than the nature of practice (Bell KR et al, (Bell KR et al,

2005)2005)

- Contents of Training : - Contents of Training : * Enriched environments better than * Enriched environments better than standard one standard one * Low evidence in humans. * Low evidence in humans.

Stroke unit Stroke unit VSVS General General ward ward

* lesser cost * lesser cost * more favorable outcome * more favorable outcome * shorter stay in hospital * shorter stay in hospital ( kalra L, 1994)( kalra L, 1994)

Age Age

* Although age has a significant impact , it is a poor predictor of * Although age has a significant impact , it is a poor predictor of individual functional recovery and can not be as a limiting factor in individual functional recovery and can not be as a limiting factor in rehabilitation rehabilitation ( kugler c et al , 2003) , (Bagg S et al , 2002) ( kugler c et al , 2003) , (Bagg S et al , 2002)

Ashworth scale Ashworth scale VSVS Tardieu scale Tardieu scale

* * Ashworth and Modified scalesAshworth and Modified scales: * low intra-rater and inter-rater : * low intra-rater and inter-rater reliability reliability

* “clustering” effect of the * “clustering” effect of the patients in the middle patients in the middle grades grades

* * Tardieu scaleTardieu scale: * Not only quantifies the muscles reaction to : * Not only quantifies the muscles reaction to stretch, but it stretch, but it controls the velocity of the stretch and measures controls the velocity of the stretch and measures the angle at which catch or clonus occurs. the angle at which catch or clonus occurs. * * spasticity anglespasticity angle: Difference between the angle at the end of : Difference between the angle at the end of passive range of motion at slow speed and passive range of motion at slow speed and the angle of catch at fast speed the angle of catch at fast speed This angle estimates contributation of spasticity This angle estimates contributation of spasticity and mechanical restraint of soft and mechanical restraint of soft tissues.tissues.

--Evidence for the use oral antispastic medications in Evidence for the use oral antispastic medications in stroke is stroke is weakweak (Montane A, et al , 2004)(Montane A, et al , 2004)

- - Due to complications Due to complications : : “ start low and go slow”“ start low and go slow” * Rather than higher doses of one drug, * Rather than higher doses of one drug, a combination of lower doses of 2 a combination of lower doses of 2 drugs may be better tolerated drugs may be better tolerated (Nance p , 2001) (Nance p , 2001)

* Taper slowly * Taper slowly - - Higher doses of BTX-A Higher doses of BTX-A : Greater hypertonia reduction without : Greater hypertonia reduction without any advantage in the duration of effect. any advantage in the duration of effect. (smith SJ et al ,2000)(smith SJ et al ,2000)

-The incidence of antibody to BTX in the spastic The incidence of antibody to BTX in the spastic hypertonia hypertonia : : LessLess than 1% than 1% (yablon SA et al, 2005) & (yablon SA et al, 2005) & (Turkel C et al , 2002) (Turkel C et al , 2002)

- Repeated injection- Repeated injection: Effective& safe : Effective& safe (Nauman M et al , 2006) (Nauman M et al , 2006)

- - Amount of salineAmount of saline : * : *NoNo difference for dilution of Botox difference for dilution of Botox ((Franisco GE Franisco GE et al , 2002) et al , 2002)

* Greater amount * Greater amount (ie , 5 cc)(ie , 5 cc) is superior. is superior. (Gracies JM et al, 2002)(Gracies JM et al, 2002)

- Role of adjunctive therapy modalities after BTX-A - Role of adjunctive therapy modalities after BTX-A injection:injection:

No any systematic review No any systematic review

Central post-stroke painCentral post-stroke pain

- pain associated with vascular lesions of CNS. - pain associated with vascular lesions of CNS.

- Following lesions at any level in the spino-thalamo-cortical - Following lesions at any level in the spino-thalamo-cortical pathwaypathway (i.e., lateral medulla oblongata , thalamus, posterior limb of internal (i.e., lateral medulla oblongata , thalamus, posterior limb of internal

capsule , …)capsule , …)

- - Incidence: 2%- 11% Incidence: 2%- 11% - - onsetonset: 20% immediately.: 20% immediately. 50% within first month 50% within first month 30% until 3 years 30% until 3 years

-Affected area varies, ranging from the entire of the Affected area varies, ranging from the entire of the involved side involved side - - of body, to a small anatomic area of body, to a small anatomic area (Depends on the location (Depends on the location of the lesion)of the lesion)

- The area with sensory loss > The area of pain - The area with sensory loss > The area of pain

- - Burning sensation Burning sensation : most common (60%) : most common (60%)

- Even pruritis can be seen- Even pruritis can be seen - Most common abnormality in physical exam: - Most common abnormality in physical exam: DysesthesiaDysesthesia - Hallmark : Allodynia - Hallmark : Allodynia (in about 50%) (in about 50%)

- Hypoesthesia: - Hypoesthesia: Near Near all all of them have to temperatureof them have to temperature - similar lesion in the same area : - similar lesion in the same area : Different pain Different pain symptoms symptoms

TreatmentTreatment - Antidepressants- Antidepressants: * Amitriptyline is the most effective followed by : * Amitriptyline is the most effective followed by nortriptyline nortriptyline * caution in patients older than 65 * caution in patients older than 65

- antiepileptics- antiepileptics: * Gabapentine: - High dose : * Gabapentine: - High dose - Just clinical experience - Just clinical experience

- opioid- opioid: Ineffective: Ineffective

Migraine: Is it an etiology?Migraine: Is it an etiology? - - ControversialControversial:: (change of definition of migraine, migraine- like (change of definition of migraine, migraine- like features due tofeatures due to large vessel dissection, Difficulty to obtain true large vessel dissection, Difficulty to obtain true history) history) -Migrainous infarction: - Fixed , focal neurologic deficit following an -Migrainous infarction: - Fixed , focal neurologic deficit following an attack attack - 0.5%- 1.5% of all ischemic strokes and 10- - 0.5%- 1.5% of all ischemic strokes and 10-14% of14% of ischemic stroke in young patients ischemic stroke in young patients (Bousser (Bousser

MG et al , 2005)MG et al , 2005) - More often in migraine with aura- More often in migraine with aura

- Mechanism: unusually severe cortical hypoperfusion. - Mechanism: unusually severe cortical hypoperfusion.

- 30% of infarction in occipital lobe - 30% of infarction in occipital lobe

- 2.7 times increased the risk of ischemic stroke in women. - 2.7 times increased the risk of ischemic stroke in women. (Etminan M et (Etminan M et al , 2005)al , 2005)

- Rise in the risk who smokes or uses OCP. - Rise in the risk who smokes or uses OCP. (Lampl c et al , 2006)(Lampl c et al , 2006)

“ “ OCP”OCP”

- - NoNo risk with current low- dose in women without Vascular risk with current low- dose in women without Vascular risk factors. risk factors. - Even low dose OCP with caution in - Even low dose OCP with caution in : - Migraine : - Migraine - smoker - smoker - HTN - HTN ( American college of OB & Gyn, 2006) ( American college of OB & Gyn, 2006)

Hypertension and stroke Hypertension and stroke

- Important for an initial than a recurrent stroke- Important for an initial than a recurrent stroke - stroke occurrence- stroke occurrence: Depends more on the duration of hypertension : Depends more on the duration of hypertension than on the current level of blood pressure than on the current level of blood pressure - - Treatment of only severe hypertension in a patient Treatment of only severe hypertension in a patient with with stroke: stroke: Reduces the rate of Reduces the rate of recurrence significantlyrecurrence significantly

- - optimal drug regimenoptimal drug regimen: * uncertain : * uncertain * with history of MI: Beta- blocker+ ACE * with history of MI: Beta- blocker+ ACE inhibi . inhibi .

Acupuncture and stroke Acupuncture and stroke

- In several systematic reviews the effect is - In several systematic reviews the effect is weakweak or or nonexistent nonexistent . . (zhang SH et al, 2005) ( wu HM et al , 2006) (zhang SH et al, 2005) ( wu HM et al , 2006)

- Other outcomes rather than motor recovery: * postural control - Other outcomes rather than motor recovery: * postural control * Improvement of * Improvement of walking speed walking speed * Improvement of * Improvement of dysphagia dysphagia ( seki T ( seki T et al , 2005)et al , 2005)

- Conclusion:- Conclusion: In the absence of any specific medical contraindications , it is safe In the absence of any specific medical contraindications , it is safe and well- tolerated . So , in some situations try of this is and well- tolerated . So , in some situations try of this is recommended. recommended.

““Task- oriented Training to promote upper extremity Task- oriented Training to promote upper extremity Recovery” Recovery”

- A dominant approach to motor restoration- A dominant approach to motor restoration..

- Definition- Definition: - As a Top- Down approach in “WHO” definition : - As a Top- Down approach in “WHO” definition - Motor learning , Goal- directed training - Motor learning , Goal- directed training - patient as an active problem-solver and focus of - patient as an active problem-solver and focus of rehabilitation on rehabilitation on acquisition of skills. acquisition of skills.

- Task: - Task: * challenging to achieve, involve real objects and activities, * challenging to achieve, involve real objects and activities, goal- directed in nature. goal- directed in nature. * Distinct from exercise- based movements * Distinct from exercise- based movements that can be abstract and without functional goal that can be abstract and without functional goal

- skill: - skill: - Desired outcome of a task- oriented program - Desired outcome of a task- oriented program - Ability to achieve a goal (task) with consistency , flexibility - Ability to achieve a goal (task) with consistency , flexibility and efficiency. and efficiency. (Q uinn L etal , 2003) (Q uinn L etal , 2003)

““Ottawa panel evidence-based clinical guidelines Ottawa panel evidence-based clinical guidelines (EBCPG)” (EBCPG)”

- Dividing ADL into component parts - Dividing ADL into component parts

- practice of individual components then combine them- practice of individual components then combine them - NOT consistent with supporting evidence & misses the essential - NOT consistent with supporting evidence & misses the essential outcome of Task-oriented approach outcome of Task-oriented approach (skill). (skill).

Task-oriented Training Task-oriented Training VS. VS. Neuromuscular Re- Neuromuscular Re- education education

- For example: Brunnstrom, Bobath, Rood, knott and Doman- - For example: Brunnstrom, Bobath, Rood, knott and Doman- Delgado. Delgado.

- Their bases never externally validated. - Their bases never externally validated.

- Very few outcome measures existed. - Very few outcome measures existed.

- Focus just on the impairment without attention to voluntary - Focus just on the impairment without attention to voluntary participatory behaviors or quality of life. participatory behaviors or quality of life.

What are the active ingredients? What are the active ingredients?

1- 1- Challenging : Challenging : * should be enough to require new learning with * should be enough to require new learning with attention to solve the motor problem attention to solve the motor problem (plautz EJ et al , 2000) (plautz EJ et al , 2000)

2-2-Progressive and optimally adaptedProgressive and optimally adapted: : optimally adapted to the patient’s capability and the optimally adapted to the patient’s capability and the environmental context , not too simple or repetitive to environmental context , not too simple or repetitive to challenge and not too difficult to cause a failure of motor challenge and not too difficult to cause a failure of motor learning learning (Lee TD et al , 2005) (Lee TD et al , 2005)

3-I3-Interesting enough to invoke active participationnteresting enough to invoke active participation: : * to engage a “ particular type of repetition “ referred to as * to engage a “ particular type of repetition “ referred to as “problem- solving” “problem- solving” * Voluntary movement elicits motor learning more than passively * Voluntary movement elicits motor learning more than passively induced movement. induced movement. (Lotze M et al , 2003) (Lotze M et al , 2003)