Transcript STROKE REHABILITATION LOOKING BACK

AN OVERVIEW OF STROKE
Recent perspectives
DR. A.V. SRINIVASAN
“Knowledge can be communicated but not Wisdom”
- Hermann Hesse
Introduction
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Improved technology and treatment for stroke
has decreased mortality and prolonged survival
but disability from stroke remain Major health
care concern.
Although Rehabilitation is one of the oldest
forms of treatment, it is least understood. Some
physicians uneasiness with rehabilitation has its
origin in Medical Training. Traditional Medical
training emphasis on diagnosis and curative
treatment. When cure is not possible patient
needs Rehabilitation Therapy, Counseling and
Support in the face of physical disability, feeling
of failure and futility.
“The True Art of Memory is
The Art of Attention” - S.Johnson
Injured Brain
1.
45
25% men
85 yrs - Stroke occurs
20% women
2.
Guidelines for 24hrs: Mandatory
Level of Evidence
Level A: Based on RCT or Meta analy. of RCT
Level B: Based on Robust Experiment or
Observation Studies
Level C: Based on Expert opinion.
According to WHO
Doctor assessment of Handicap may not coincide with Patients
Assessment. Neurologist depends on physiotherapy, occupation
therapy and speech therapy in rehabilitating the stroke patients.
NEUROLOGIC PREDICTORS.
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Flaccid Paralysis for more than 96 hrs
When tendon reflexes recover without return of voluntary
movement – prognosis poor
Recovery of sensory less in usual to a degree. Postion
sense recovers but not pain and temperature
Recovery from Dysphasia is never complete
Dysarthria usual improves and Dysphagia never improves
Diplopia due to brain stem is usually permanent
Conjugate gaze – recovers
Vertigo improves but hearing loss is permanent
Pseudobulbar palsy permanent
REHABILITATION OF
STROKE
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Assessment of function
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cognitive,
Independence and self-care
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Motor,
postural,
perceptual,
communication and autonomic
Walking dressing washing, toileting and feeding
Available services
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Nursing
Physiotherapy
Occupational therapy
Clinical psychology
Medical social worker plus self-help groups (‘Stroke
Club’)
EARLY MANAGEMENT AND
REHABILITATION
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1.
2.
3.
4.
5.
6.
Consist of
Skin care
IV therapy in disabled patients
Caution due to confusion
Auditory and visual deficit
Splint and braces
Complications include the following
Complications include the
following:
A.
Contractures
Complications include the
following:
b. Treatment of Spasticity
TREATMENT MODALITIES FOR SPASTICITY
Surgery
Nerve Blocks
Motor Point Blocks
Drugs: Dantrolene, Baclofen, Diazepam
Muscle Stretching Program
Prevention of Nociception
Complications include the
following:
c. Reflex sympathetic Dystrophy
d. Physiological Deconditioning.
PHYSIOLOGICAL DECONDITIONING
Loss of Normal Postural
Reflexes
Increased Resting Pulse Rate
Catabolic Nutritional StatePsychological Depression
Lower Vital Capacity
Slowing of GI Tract
Venous Stasis
Urinary Stasis
Complications include the
following:
e. Swallowing disorders
f. CVD and Heterotrophic ossification
7. Psychological factors
FACTORS GOVERNING THE
OUTCOME OF STROKE
REHAB.
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Good outcome –
Mild to moderate neurologic damage
with mild moderate paresis not
associated with sensory or visual
problems
 Patients not demented or depressed
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FACTORS GOVERNING THE
OUTCOME OF STROKE
REHAB.
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Walking 150 feet without assistances
(Goal )
 Motor alone – 0.9
 Motor Sensory Visual – 0.5
 Barthal index score – 95 normal
• Motor alone
- 0.6
• Motor Sensory Visual – 0.5
FACTORS GOVERNING THE
OUTCOME OF STROKE
REHAB.
Motor deficits alone reach their goals
within 12 weeks
 Framinham study – recovery from
stroke 3 months
 Adams – recovery from stroke 2
years
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FUTURE TRENDS IN REHABILITATION
(Sensory Modulation)
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Anatomical Principles
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Somatosensory System
Limbic System
Visual System
Phantom Experiences
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The man who missed his foot for penis
Gaze Tinnitus
Ear Lobe stimulation produces as an eroatic
sensation in nipple
Phantom Pain
FUTURE TRENDS IN REHABILITATION
(Sensory Modulation)
Role of Parietal Lobe
 Clinical Implications
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Synesthesia
 Allesthesia sensation
 Caloric test
Anosognosia
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Virtual reality box
Extinction of referred
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Disappearance of
SUMMARY
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The goal of rehabilitation is to permit a
return to function. In pursuit of this goal,
proper
management
of
secondary
disabilities is essential. Clinical objectives
include: prevention of contractures,
retardation
of
deconditioning,
maximization
of
nutritional
status,
optimal treatment of associated medical
problems, and providing appropriate
psychological support to family and
patients.
1.
History And Examination
a. Stroke clerking Performa (1994) R.C.P.
1.
2.
3.
Improved patient Assessment
Improved Management - not clear
Improved outcome - not clear
b. Examination
1.
2.
3.
Secure Diag of Stroke
Specify Impairment
Identify sub type of Ischemic stroke
“ We Sometimes think we have forgotten something when
in fact we never really learned it in the first place”
Imp.Your Memory Skills
Through Action You Create your Own Education
- D.B. ELLIS
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Guide: 3
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(B) - CPR
Impaired Consciousness - From Stroke
Resuscitation is rarely successful Schneider
1993
Guide: 4(B) Investigations:(Sagar
1995)- 435 PTS)
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Chest x-ray 16% ABN
Only 4% change clinical management
Order x-ray chest if WT Loss or chest
symptoms present
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Guide 5: (B) ECG:
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Cardiac cause of Death (30 days) Ebrahim 1990.
All conscious patients to have ECG
Guide 6: (C) CT:
Routine CT Head is a Intell lazy approach
 King’s fund forum(1988) gives useful framework
 Weir 1994 Clinical scoring cannot distinguish
Do CT if a)
Uncertainty of Stroke
b)
If Anticoagulation or Anti Platelet
treatment contemplated
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Guide 7:(B) M.R.I.
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Moha 1995, - Unclear for Implications
for clinical practice
No Routine MRI indication in Acute
Stroke
Whatever the Mind can conceive and Believe,
the mind can Achieve
Napoleon Hill
Imagination is more
Important than Knowledge
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Guide 8: (B) ECHO no Routine
Echo in Acute Stroke
 TOE Vs. TTE
 Amer Heart Asson (1997) - same
conclusion
 Yield is very low. (Leung 1993;
Chambors 1997)
 Only when ABN ECGS - change clinical
management
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Guide 9: (A) - Dopp scan for
selected PTS:
80% > more benefits from
Endarterectomy
 Minor stroke -No disability
 Subst Storke -Good recovery
doppler
 Medically fit
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do
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Guide 10: (B) Management:
Fever (Worst Prog.) Reith 1996
 Hypoxia ( Moroney 1996) - Exac. by seizures
Pneumonia and Arrythmias - Worst outcome
 Hyperbaric O2 ineffective (Nighoghossaln
1995)
 Haemodilut. Plasm Expanders; venesection
 No evidence for efficacy (As plund - 1997)
Check ABG only if Hypoxia suspected.
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Guide 11: (A) Steroids and
Hyperosmolar agents Unproven
treatment - should not be used
Tumor oedma responds but not
cytotoxic stroke oedma qialbash 1997
- No effect on survival or improv. In
funct. Outcome
 Manntol - (Boysen 1997) - short term
effective statistically in conclusive
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You are what you think and not
what you think you are
Annoymous
We learn by thinking and the quality of the learning
outcome is determined by the quality of our
thoughts
R.B. Schmeck
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Guide 12: (B) - Blood Pressure
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Defer - acute reduction of BP - 10 days unless
HT Encephalopathy or adrtic dissection
present
Moris 1997 - Increase BP - falls in 10 days
UK - 5mm in D.B.P. 1/3 storke - Low BP
prompt correct of hypovoll. and withdrawal of
hypotonic drugs
Collins 1994 - HT - Prim. stroke prevent
Neal 1996 (Current RCT) - HTs in stroke
survivors -study needed
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Guide 13: (A/B) - AF
AF / ISCH Stroke/ Mild disability warfarin after 48 Hrs (Longer for
larger)
 Aspirin for others
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EAFT 1995 Less than 2 PT - No
effect
 SPAF 1996 > 5 - Bleeding
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Guide 14:(B/C) - Blood sugar
Weir (1997) > 8 mm d/Lit - Poor
outcome
 Acute MI + 11 mm d/Lit - Intensive
Insulin - improved (Malmberg 1997)
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A great many people think they are
thinking when they are merely re
arranging their prejudices
W. James
Many Ideas grow better when transplanted into
another mind than in the one where they sprang
UP
O.W. Holmos
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Guide 15: (A) Cholesterol
Prosp. Study collob.: 1993 - Epidem
study do not support
 Blaun 1997: Metranauetic - Chollest &
statin 30% decrease - stroke in CAHD
patients.
 Sacks 1996 - Tot chol: decrease to 4.8
mmol/Lit benefits
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Guide 16: (A/C) Deep vein thrombosis
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Kalra 1995 - 10 days - stroke Pts - 50%
Sandercock 1993 - Pul embol 6-16% only
Ist 1997 - 5000 IV or 12500 twice daily Hemorrage greater
Gradual stocking value - useful in Surg - pts
but its value not evaluated - (Wells 1994)
Use with caution - if periph artery insuf. is
present hence do not use heparin on
stockings.
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Guide 17: (A/B) Pressure sure
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Event health care (1995) specialised
low pressure mattress systems to be
used than stand Hospital - mattress
Every discovery contains an
irrational element or 4 creative
intuition
Khrl Popper
I have never let my Medical schooling interfere
with my education
Mark Twain
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Manag of infarction
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Guide 18: (A)
• Aspirin 75 - 150 /Day
• 3 yrs 40% reduces of vascular events in
1000 pts (APTC - 1994)
• Stroke sub type value ? (TACI, PACI, LACI,
POCI)
• Dienners - 1996, synergy possibel with
clopidogrel ticlopidine etc.
Anti Coagulation
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Warfarin - AF
In sinus rhythm - uncertain
 Spirit 1997 low dose ABP + Warfarin in
TIA & Minorstorke - Stopped of HE
 Heparin (IST 1997) - Signif. reduction
in early death (12 fewor in 1000) not
better than aspirin
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So avoid Heparin (A)
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Thrombolysis (A)
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Warlow 1997 - Uncertain clinical
benefit at the expense of greater
hazard avoid - thrombolysis
When they tell you to grow up,
they mean stop growing
P. Diccaso
A (Neurologist’s) life is like a piece of paper on
which everyone who passes by leaves an
impression
- Chines proverb
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Guide 20: (I) Hemorrhage
Hankey and hon 1997: Supra tentorial
evacuation for ICH is controversial Avoid
 Infra tentorial - Yes
 Main Indication - Deteriorating or
depressed consciousness
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224 Pts
131
Intubation
64 Dischar
93
Not Intub
67 Died
34 Redtag
21 disch to
nver home
8 Disc for
pallima
3 Died
7 Died
3 Died
1 Disc
Home
Guide 21 : Ventilation
-Decreased level of
consciousness - increased
mortality and poor final
outcome
- Absent pupillary light
responses - poor prognosis
A medical school should not
be a preparation for life. A
school should be life
“By the deficits we may know the talents
By the exception we may discern rules
By studying the pathology,
We construct the model of health
And tools we need to affect our own life mould our
destiny,
Change ourselves and our society
In ways that as yet we can only imagine”
- Lawrence Miller
STROKE-TO-DEMENTIA
(Dr. A.V. Srinivasan, Dr. S. Balasubramanian,
Dr. R. Sowntharya, Dr. S. Rajesh)
Dr. A. V. Srinivasan
Addl. Prof. Of Neurology
Institute of Neurology,
Chennai.
Pathogenesis of dementia
due to SIVD
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2.
3.
Lacunar hypothesis
Binswanger’s subtype of SIVD
VaD with coexisting Alzheimer’s
disease
Expert is one who think to his
chosen mode of ignorance
Two diverging/converging
pathways associated with SIVD
Risk factor CVD Ischemic Brain injury
MRI lesion Clinical syndrome
HTN
Arteriosclerosis 1. occlusion complete
infarct lacune  lacunnar state
Arteriosclerosis 2. Hypoperfusion
incomplete infarct WHSM 
Bingswanger syndrome
Experience can be defined as
yesterday’s answer to today’s problems
Clinical syndromes
1.
2.
3.
Lacunar state --- 85%
Strategic infarct dementia(e.g.
thalamic dementia) --- unknown %
Binswanger’s syndrome --10 – 15%
Take time to think; it is the source of power
Take time to read; it is the foundation of wisdom
Take time to work; it the price of success
Features suggestive of
vascular dementia
From the history
Onset associated with a stroke
Improvement following acute event
Abrupt onset
From the exam
Findings typical of stroke e.g.,
hemiparesis, hemianopia
From imaging
Infarct(s) above the tentorium
Every thing should be made as simple as
possible; but not simpler
Categories of vascular
Dementia
Category
Clinical presentation
Lacunar infarctions
Progressive dementia, focal deficits, or
apathetic, frontal-lobe-like syndrome,
may have no stroke history
Single strategic
infarctions
Sudden onset aphasia, agnosia,
anterograde amnesia, frontal lobe
syndrome
Multiple infarctions
Step-wise appearance of cognitive &
motor deficits
Mixed AD – VaD
Progressive dementia with remote or
concurrent history of stroke
White matter
infarctions
(Binswanger’s
disease)
Dementia, apathy, agitation, bilateral
cortico-spinal/bulbar signs
NINDS-AIREN criteria for VaD
Probable vascular dementia : cognitive decline
from a previously higher level in three areas of
function including memory; evidence of
cerebrovascular disease by neurologic exam
and neuroimaging; onset of dementia either
abruptly or within 3 months of a recognized
stroke.
Possible vascular dementia : Dementia in the
absence of either neuroimaging evidence of
infarction or in the absence of a clear temporal
relationships between dementia and stroke.
NATURE, TIME AND PATIENCE
are the 3 great physicians
NINDS-AIREN criteria for VaD
contd…
AD with cerebrovascular disease : Patients
with possible AD who have imaging evidence
for infarction, or clinical history of stroke, both
of which appear incidental by clinical
judgement
Definite vascular dementia : Probable vascular
dementia plus histopathological evidence of
infarction in the absence of other histological
markers of dementia (e.g., plaques, tangles,
pick bodies, etc.,)
Truth comes out of error sooner than that of confusion
Diagnostic criteria
1.
2.
3.
4.
5.
Hachinski’s ischemic score
DSM IV criteria
ADDTC criteria
NINDS – AIREN criteria
Binswanger’s criteria
Opinion is ultimately determined by the feelings
and not by the intellect
Short comings
1.
2.
3.
4.
5.
Not interchangeable hence four fold rise in
frequency
DSM IV R most liberal
NINDS- AIREN criteria conservative
Gold standard for VaD (pathological definition
difficult)
Most of the criteria failed to distinguish
between small and large vessel subtypes
“Healthy Mind and Healthy expression of
Emotion go hand in Hand”
Diagnosis and prognosis
Risk factors
Modifiable
Non-modifiable
Hypertension
Age
Hyperglycemia
Gender
Race
Heredity
Discipline Weighs ounces
Regret weighs Tons
Diagnosis and prognosis
contd….
Vascular phenotype : “CVD”
 Arteriosclerosis
 Amyloid angiopathy
 Other small vessel disease
“You have got to be before you can do
and do before you can have”
Diagnosis and prognosis
contd….
Vascular
distribution
Single artery
Small arteriole
Single artery
Border zone
Small arteriole
Mechanism of
Brain injury
Pathological
phenotype
“Infarct”
Acute ischemia Multiple lacunar
infarcts
Acute ischemia Single
strategically
placed lacunar
infarct
Chronic
White matter
hypo perfusion demyelination
and axonal loss
Diagnosis and prognosis
contd….
Neuro imaging phenotype
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CT lucency (lacunes and leukoariosis)
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MRI hyper intensity (lacunes and WMSH)
A true commitment is a heart felt promise to
yourself from which you will not back down D. Mcnally
Diagnosis and prognosis
contd….
Localisation /
neural network
Clinical phenotype or syndrome
Cortico-basal ganglia – Lacunar state
thalamocortical loops
Apathy, depression, abulia
Dysexecutive syndrome
Normal visual fields
parkinsonism
Cortico-basal ganglia
thalamocortical loops
Strategic infarct dementia
Dysexecutive syndrome
Frontal lobe syndrome
Deep white matter
connections
Binswanger’s syndrome
Slowly progressive depression,
bradykinesia, dysexecutive syndrome, gait
apraxia, urinary incontinence
Prognosis
1.
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Risk factors
Advanced age
Education
Lacunar subtype
Lt. Hemisphere CVA
Non white
Develops dementia
following ischemic
stroke
“Fools Admire but of men of sense approve”
- A. Pope
Prognosis
contd….
2. In Lacunar stroke - Leukoariosis is
a poor prognosis
3. Recurrence of stroke
Hence
 Atrophy
 cognitive impairment
 WMSH are inter related in SIVD
“Social Isolation is in itself a pathogenic
Factor for disease production”
Prevention & Treatment
Primary prevention
Control of risk factors in mid life
a. Framingham Heart Study
b. HASS
c. ARIC
d. Systolic hypertension in Europe double
blind trial
At twenty the will rules
At thirty the intellect
At forty Judgment
Prevention & Treatment
contd…
Secondary prevention
Below 135 mm of Hg cognitive impairment
 Presence of lacunes and white matter
changes may be used as a marker for
high risk group
 Little is known – for effectiveness in
other risk factors
A woman’s desire for revenge outlasts all her other emotions
Prevention & Treatment
contd…
Anti dementia drug trials (not based on
subtype of VaD)
Alkaloid derivatives
(hydergine or nicergoline)
Pentoxyfylline
Modest benefit
Piracetam
Memantine
Donepezil
Gingko biloba
Thought is the labour of the intellect
Reverie is its pleasure
Role of RIVASTIGMINE
in SIVD
No.of patients
: 10
Age group
: 50 – 80 years
Female
: 4
Male
: 6
Most of them had diabetes and hypertension
Not based on subtype of VaD
30% showed remarkable cognitive, curative and
affective deficit
Future study needed
“ He who cannot forgive others destroys the bridge
over which he himself must pass”
- Annoy
Strategies to prevent –
STROKE-TO-DEMENTIA
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Treat hypertension optimally
Treat diabetes
Control hyperlipidaemia
Persuade patients to cease smoking and
decrease alcohol intake
Prescribe anticoagulants for atrial fibrillation
Provide antiplatelet therapy for high risk
patients
A open foe may prove a curse ; but
a pretended friend is worse
Strategies to prevent –
STROKE-TO-DEMENTIA
contd…
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Perform carotid endarterectomy for severe (>70%)
carotid stenosis
Use dietary control for diabetes, obesity and
hyperlipidaemia
Recommend lifestyle changes (e.g., weight loss,
exercise, reduce stress, decrease salt intake)
Intervene early for stroke and transient ischemic
attacks with neuroprotective agents (e.g.,
propentofylline, calcium channel antagosists,
N-methyl-D-aspartate receptor antagonists,
antioxidants)
Provide intensive rehabilitation after stroke
READ not to contradict or confute
Nor to Believe and Take for Granted
but TO WEIGH AND CONSIDER
THANK YOU