Recent updates in Stroke Rehabilitation FAROOQ RATHORE FCPS ASSISTANT PROFESSOR DEPARTMENT OF REHABILITATION MEDICINE
CMH LAHORE MEDICAL COLLEGE.
Outline What is Stroke Rehabilitation ? Value of Stroke Rehabilitation
Recent advances Relevance to Pakistan Conclusion and Take home message
What is stroke rehabilitation ? A progressive, dynamic, goal-oriented and coordinated process involving a multidisciplinary approach aimed at enabling a person with an impairment to reach his or her optimal physical, cognitive, emotional, communicative and social functional level. Roth EJ, Heinemann AW, Lovell LL, Harvey RL, McGuire JR, Diaz S. Impairment and disability: their relation during stroke rehabilitation. Arch Phys Med Rehabil 1998; 79:329-35.
The need for stroke rehabilitation?
Rehab has given my husband a life to live. It has improved both his mobility and his communication. Slowly at first, then dramatically, and even today there is still improvement in his communication. This gives me a little more hope for tomorrow.
Ontario stroke system. Consensus Panel on the Stroke Rehabilitation System “Time is Function” http://www.heartandstroke.on.ca
Summary of evidence
Strong scientific evidence that dedicated stroke units/services and a multi-disciplinary team approach results in
• •
Improved functional outcome
Reduced rate of complications
Reduced length of stay (LOS)
Good community re-integration
Indredavik B. What characterises an effective stroke unit? Tidsskr Nor Laegeforen. 2007 3;127(9):1214-8 Ko KF, Sheppard L. The contribution of a comprehensive stroke unit to the outcome of Chinese stroke patients. Singapore Med J. 2006 47(3):208-12.
Recent advances
Recovery mechanism in stroke
Neuroplasticity
Adult central nervous system is adaptive, or plastic, and has some capacity to re-organize itself to recover degraded cognitive and motor functions.
Skilled motor practice
Progressive, skilled motor practice is essential for continued gains at any time after stroke onset.
Training must engage the attention, motivation,
and learning networks
Body Weight-supported Treadmill Training
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Constraint-induced Movement Therapy
Fleet A, Page SJ, MacKay-Lyons M, Boe SG. Modified constraint-
induced movement therapy for upper extremity recovery post stroke: what is the evidence? Top Stroke Rehabil. 2014 ;21(4):31931.
Thrane G, Friborg O, Anke A, Indredavik B. A meta-analysis of
constraint-induced movement therapy after stroke. J Rehabil Med. 2014 ;46(9):833-42.
Corbetta D, Sirtori V, Castellini G, Moja L, Gatti R. Constraint-
induced movement therapy for upper extremities in people with stroke. Cochrane Database Syst Rev. 2015 Oct 8;10:CD004433. [Epub ahead of print] Review
Kwakkel G, Veerbeek JM, van Wegen EE, Wolf SL. Constraint-induced movement therapy after stroke. Lancet Neurol . 2015 Feb;14(2):224-34. doi: 10.1016/S1474-4422(14)70160-7.
Kwakkel G, Veerbeek JM, van Wegen EE, Wolf SL. Constraint-induced movement therapy after stroke. Lancet Neurol . 2015 Feb;14(2):224-34. doi: 10.1016/S1474-4422(14)70160-7.
Functional Electrical Stimulation
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FES: Advantages and Limitations Advantages Production of ‘natural movements’ Replaces impaired or lost feedback Prevention of muscle atrophy, increase in strength Usable at home
Limitations Muscle fatigue Skin irritation Variable stimulus tolerance, pain Electrode placement difficulty
Mechanical Devices to Assist Arm Movements
Kim EH, Chang MC, Seo JP, Jang SH, Song JC, Jo HM. The effect of a hand-stretching device during the management of spasticity in chronic hemiparetic stroke patients. Ann Rehabil Med. 2013 Apr;37(2):235-40.
Mirror Therapy
Thieme H, Mehrholz J, Pohl M, Behrens J, Dohle C. Mirror therapy for improving motor function after stroke. Stroke. 2013 ;44(1):e12.
Mirela Cristina L, Matei D, Ignat B, Popescu CD. Mirror therapy enhances upper extremity motor recovery in stroke patients.
Acta Neurol Belg. 2015 ;115(4):597-603.
Thieme H, Mehrholz J, Pohl M, Behrens J, Dohle C. Mirror therapy for improving motor function after stroke. Cochrane Database Syst Rev. 2012:14;3:CD008449.
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Mirror Therapy
Requires very little training
Easy to set up
Inexpensive equipment
Not taxing to the patient.
Brain Stimulation Noninvasive Transcranial magnetic stimulation (TMS)
Magnetic coil & magnetic field
Transcranial direct current stimulation (tDCS)
Electrodes & current
Brain Stimulation: TMS A noninvasive technique that consists of a magnetic field emanating from a wire coil held outside the head. The magnetic field induces an electrical current in nearby regions of the brain
Brain Stimulation: tDCS A noninvasive technique which uses constant, low current delivered directly to the brain area of interest via small electrodes.
TMS
• • • • •
Lasts up to hours
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Can result in transient headaches
Well established protocols Expensive
Risk of seizures (rare) Limited to superficial brain areas
tDCS
• • • • • •
Lasts up to hours Low -cost Low risk of adverse effects
Concurrent modulation of brain area under reference electrode Protocols less established Can result in transient headaches
Virtual Reality
Laver KE, George S, Thomas S, Deutsch JE, Crotty M. Virtual reality for stroke rehabilitation. Cochrane Database Syst Rev. 2015 Feb 12;2:CD008349. doi: 10.1002/14651858.
Pollock A et al. Interventions for improving upper limb function after stroke. Cochrane Database Syst Rev. 2014 Nov
12;11:CD010820. doi: 10.1002/14651858.CD010820
Fu MJ, Knutson JS, Chae J. Stroke Rehabilitation Using Virtual Environments. Phys Med Rehabil Clin N Am. 2015 Nov;26(4):74757. doi: 10.1016/j.pmr.2015.06.001. Epub 2015 Aug 1.
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Robotic Gloves
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Neofect medical glove
http://www.coolwearable.com/neofect-rapael/
Hand of Hope Rehab glove
Soft Robotic glove
Soft Robotic glove
Upper limb Robotic Devices
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Robotic Exoskeleton
H2 exoskeleton
H2 exoskeleton
Harmony Upper limb Exoskeleton
Commercial Gaming devices
Nintendo Wii
Xbox Kinect
Effective of games in stroke rehab
Cheok G, Tan D, Low A, Hewitt J. Is Nintendo Wii an Effective Intervention for Individuals With Stroke? A Systematic Review and Meta-Analysis. J Am Med Dir Assoc. 2015;16(11):923-32.
Dos Santos LR et al. The Use of Nintendo Wii in the Rehabilitation of Poststroke Patients: A Systematic Review. J
Stroke Cerebrovasc Dis. 2015 ;24(10):2298-305.
Anderson KR, Woodbury ML, Phillips K, Gauthier LV. Virtual reality video games to promote movement recovery in stroke rehabilitation: a guide for clinicians. Arch Phys Med Rehabil. 2015 May;96(5):973-6.
Smart phones
Apps for stroke Rehabilitation
Talking Photo Apps
Augmentative and Alternative Communication (AAC) Apps
Text-to-Speech Apps
Speech Practice Apps
Other Apps
http://stroke.org/sites/default/files/resources/iHOPE%20Aphasia%20Apps%20List%20-updated%209.18.2015_0.pdf
Apps for stroke Rehabilitation
Verbally
MyTalktools
Tactus Therapy
MyVoice Communication Aid
Comprehesnion TherAppy
My Heart&Stroke Health
Speech Trainer 3D
Constant Therapy
http://www.strokewise.info/2011/10/ipad-apps-people-who-have-had-strokes.html
Pharmacologic Interventions
Memantine 1
Ropinirole 2
Fluoxetine and SSRIs 3,4
1. Schuster C, Maunz G, Lutz K, Kischka U, et al. Dexamphetamine improves upper extremity outcome during rehabilitation after stroke: a pilot randomized controlled trial. Neurorehabil Neural Repair. 2011;25(8):749–55. 2. Cramer SC, Dobkin BH, Noser EA, et al. Randomized, placebocontrolled, doubleblind study of ropinirole in chronic stroke. Stroke. 2009;40(9):3034–8. 3. Chollet F, Tardy J, Albucher JF, et al. Fluoxetine for motor recovery after acute ischaemic stroke (FLAME): a randomised placebocontrolled trial. Lancet Neurology. 2011;10(2):123–30. 4. Mead GE, Hsieh CF, Lee R, Kutlubaev M, et al. Selective Serotonin Reuptake Inhibitors for Stroke Recovery: A Systematic Review and Meta-analysis. Stroke. 2013;44:844–50.
Miscellaneous Approaches
Acupuncture 1
Hyperbaric Oxygen 2
Entanercept 3
1. Kong JC et al. Acupuncture for functional recovery after stroke: a systematic review of shamcontrolled randomized clinical trials. CMAJ. 2010;182(16):1723–9. 2. Efrati S, et al. Hyperbaric oxygen induces late neuroplasticity in post stroke patients randomized, prospective trial. PLoS One. 2013;8(1):e53716. 3. Tobinick E et al. Selective TNF inhibition for chronic stroke and traumatic brain injury: an observational study involving 629 consecutive patients treated with perispinal etanercept. CNS Drugs. 2012;26(12):1051– 70.
Relevance to Pakistan
Most updates are not available
Cost
Expertise
No tech support
Patients rely on Dr. Google
Solution !
Low cost Chinese and local versions !
Collaboration and development of local technologies
Summary Points
Stroke rehabilitation is an integral part of comprehensive stroke care plan
It is a continuum of care and NOT an optional activity
Remarkable advances in stroke Rehab
Most of the recent advances -not available to stroke patients in Pakistan
Take home message
Initiate early stroke rehabilitation and refer to Rehabilitation Medicine physician where available
Incorporate where possible and adapt the recent advances as per the local needs
Collaborate with other professionals to deliver better stroke rehabilitation care.
Questions, Comments Additions ?
Interested in knowing more about Stroke rehabilitation interventions? Copy of the presentation ? Send an email
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