A Case Report by: Maureen Sabri , SPT
description
Transcript of A Case Report by: Maureen Sabri , SPT
A CASE REPORT BY:
MAUREEN SABRI, SPT
Does CNS-depressive medication impact the physical therapy prognosis of a 65 year-old patient with chronic stroke
receiving intensive, repetitive-task training intervention?
What is CNS-depressive medication?
Antispastics and antiepileptic drugs (AEDs) MOA: upregulation of GABA agonists down-
regulation of neuronal excitability by binding to ligand-gated ion channels, which control the flow of chloride into the neuron. 1
Antipsychotics Often used in management of IAMs and tremor MOA: block dopamine receptors resulting in a CNS-
depressing effect. 1
Interfere with long term potentiation (LTP). 2
Review of Common CNS-depressing Meds
Common AEDs Barbituates
Phenobarbitol Benzodiazepines
Clonazepam, diazepam GABA analogs
Gabapentin Fatty acids
Valproic acid
Common Antispastics Baclofen Benzodiazepines
Common Antipsychotics: Risperidone Haloperidol or Haldol
Q: Why are CNS-depressive meds important in post-stroke PT?
CVA is very common in the US 800,000 people a year 3
6 million persons with stroke currently living in the US 4
60% have persistent deficits 5
CNS-depressive meds are commonly prescribed post-stroke 5-20% endure seizure(s) 6
AEDs are the gold standard in treatment 19-39% have spasticity 7,8
Antispastic meds are commonly utilized 72% suffer from pain 9
AEDs, antispastics, tricylic antidepressants are prescribed 23% of the time to treat c/o pain post-stroke 9
3.7% experience Involuntary Abnormal Movements (IAMs) 10
Antipsychotics are the gold standard for treatment
Q: Why are CNS-depressive meds important in post-stroke PT?
LTP=“Strengthening of excitatory synapses” 6
Ca in post-synaptic cell exceeds threshold Repetitive stimulation opens NMDA receptors = constitutive activity Protein synthesis
employees.csbsju.edu/.../PSYC340/learning.htm
Q: Why are CNS-depressive meds important in post-stroke PT?
Repetitive practice of a motor task and/or nerve stimulation has been shown to induce LTP-like plasticity in the motor cortex.6
Experimental protocol using e-stim, TMS, and MEPs
Korchounov & Zeiman 2011: LTP-like plasticity is halted by agonists of dopamine, norepinephrine, and acetylcholine 11
Haloperidol (DA antagonist, antipsychotic) Prazosine (NE antatonist, antihypertensive) Biperiden (Ach antagonist, antiparkinsonian agent) Levetiracetam (an AED, mechanism unknown) 12
GABA antagonists have same effect in rat models, unable to test in humans
Q: Why are CNS-depressive meds important in post-stroke PT?A: They may inhibit motor learning.
LTP-like mechanisms are critical to motor recovery post-stroke. Principles of LTP induction include:
Specificity, intensity, duration of stimuli 6
Hmmm…where have we heard these principles before?
LTP=motor learning Researchers speculate that CNS-depressing drugs
will be detrimental to motor learning, memory, and motor re-learning in patients after central legions. 11
No clinical research
Background Info
65 yo male retired veteran s/p seizure lasting >45 min due to discontinuation of clonazepam
Referred to inpatient rehab with a diagnosis of “generalized weakness” 9 days after admission to ICU.
Hospital course included heavy sedation with Ativan due to continuing seizures and agitation in the ICU. Attempted to treated rather unsuccessfully during
acute stay
Past Medical History
L parietal lobe and basal ganglia stroke (STN) R UE and LE hemiparesis R UE spasticity, increased RLE tone RUE hemiballismus Seizure disorder (?) Aphasia Cognitive deficits
HTNDMIICarotid artery stenosisAfibSmoker: 1 pack/day x 30 years +
MedicationsMr. M’s Medications Upon Admission
Medication Name Drug Type Uses Effect on CNS & Mechanism of action
Levetriracetam (Keppra) AED Seizure Inhibitory: Binds to a synaptic vesicle protein, SV2 and
slows nerve conduction across synapses
Divalproex (Depakote) AED Seizure Inhibitory: Enhances neurotransmission of GABA
Clonazepam (Klonopin) Benzodiazepine Seizure,
increased tone
Inhibitory: Enhances neurotransmission of GABA
Venlafaxine (Effexor) Antidepressant (SNRI) Depression,
anxiety
Excitatory: Serotonin and norepinephrine agonist
Lovastatin (Mevacor) Statin lower cholesterol none
Carvedilol (COREG) Beta blocker decrease HR none
Clopidogrel (Plavix) Antiplatelet reduce blood
clots
none
Ranitidine (Zantac) H2 receptor antagonist GERD none
Mr. M’s Medications Upon Evaluation
Medication Name Drug Type Uses Effect on CNS & Mechanism of action
Divalproex (Depakote) AED Seizure Inhibitory: Enhances neurotransmission of GABA
Lorazepam (Ativan) Benzodiazepine Acute seizure, sedative,
muscle relaxant
Inhibitory: Enhances neurotransmission of GABA
Haloperidol (Haldol) Antipsychotic schitzophrenia, IAMS Inhibitory: Dopamine antagonist
Famotidine (Pepcid) H2 receptor antagonist GERD none
Lisinopril (Prinivil) Ace Inhibitor HTN, CHF none
Prior Level of Function
(Gleaned from family due to aphasia/decreased cognition)
Mod I with hemi WC for household distancesMod I with WC<>bed/toilet transfersMod I with basic ADLs
Toileting, prepared spaghettios, upper body dressing
Walked short distances with HHA of daughterCould asc/desc 6 STE with unilateral hand rail &
HHA Only left house for doctor’s appointments
Daughter assisted with complex ADLs
Examination: Relevant Findings
PROM: B knee flexion contractures, R elbow, shoulder, and ankle contractures. R shoulder flexion & abd: ~90◦ R knee ext: -19, L knee ext: -15 R elbow ext: -75 R ankle dorsiflexion: -5
Similar AROM on R, WFL on LStrength: 2/5 for most RUE and LE testing, L:
WFL Sensation: Allodynia to light touch C6-8, L2-S2 *Coordination: RUE impairedProprioception: n/t due to aphasiaDTR: slightly increased on R (2+ vs 1+ on L)
Examination: Outcome Measures
FIM* 29/91 for motor subset Transfer: 1 Gait: 0 Stairs: 0
Modified Ashworth: 3/5 for R bicep and R
hamstring
Mini Mental State Exam 14/30* indicating “severe”
cognitive impairment
FIM Motor Subset PreEating 5Grooming 3Bathing 2Upper Body Dressing 2Lower Body Dressing 1Toileting 1Transfer (toilet) 2Bladder Mgmt 5Bowel Mgmt 5Shower transfer 2Transfer (bed>wheelchair) 1Gait (Walk) 0Stairs 0TOTAL 29
Goals
The patient’s: To go home/to be independent
The family’s: for the pt to return to his pre-admission level of function to decrease burden of care.
The Physical Therapist’s: ?????
Areas of Concern
Lacking social support: Family visited once during month-long hospital course Daughter worked and was not home during the day Continued smoking Pt stated that he did not wear pants at home due to
difficulty with lower body dressing
Prior Falls Family stated that the patient would fall out of his
WC occasionally, but could scoot to the phone to tell his daughter, who would come home to help him up
Clinical Impression
What was the impact of lacking social support? Pt’s care was inadequate at home Perhaps the patient’s immobility is related to lacking
resources/opportunity rather than impairment My goal was to increase the patient’s level of independence
beyond his PLOF to improve QOL by reducing dependence on caregivers.
What is the impact of the patient’s medication on the patient’s prognosis for motor recovery? Seizure, hemiballismus and spasticity are all treated with
CNS-depressive medication.
Clinical Impression
Impairments (practice patterns): Impaired R motor function leading to impaired ROM and
coordination (5D) Deconditioning (6B) Impaired sensation skin breakdown (7A) Impaired cognition
Functional limitations: Unable to independently perform ADLs Unable to walk/climb stairs Unable to perform WC<>bed/toilet transfers Unable to independently navigate his home
Participation: Unable to be an active member in the community Dependent upon assistance of family members
Purpose
Does CNS-depressive medication negatively impact this patient’s prognosis for motor recovery?
Intervention
90 minutes of PT, 60 min OT, 30 min ST/dayLOS: 12 daysFoundations of intervention:
Instructed pt to think about what skills are most meaningful to him at home. Encouraged the patient to make lofty goals and think about what skills will increase independence. The pt identified the following skills to be most
meaningful: Transfers (bed<>WC, toilet<>WC) Sit to stand Gait
Repetitive task training (RTT) of these skills with emphasis on intensity of practice
Intervention
Support for RTT: French et al 2008: systematic review & meta anaylsis
comparing RTT to “usual care”13
Analyzed everything from treadmill training, standing and seated balance training, CIMT
Conclusion: some form of RTT resulted in “modest improvement” across a range of lower limb outcome measures Effective in chronic stroke
Langhorne et al 2009: systematic review of motor recovery after stroke 14
CIMT is best intervention for UE RTT best for transfer training High intensity training best for gait
Intervention
Protocol? Beyond CIMT and BWSTMT, specific protocol for lower
level pts with CVA are difficult to find. Functional, meaningful practice is patient-specific and hard
to quantify
Intervention focused upon meaningful skills with the following concepts of motor learning in mind: Blocked practice (at least 5 min of a task continuously)15
Varied environments/surfaces Tapered verbal feedback Time allowed for processing due to cognitive deficits. Cardiovascular training: 20 min Nustep or bike/day
Results
FIM MCID: 17/91 on motor
subset for acute stroke 16
SEM and MDC not established
Valid and reliable for acute stroke, no data on chronic
Functional Independence Measure Skills Pre Post
Eating 5 5
Grooming 3 2
Bathing 2 3
Upper Body Dressing 2 5
Lower Body Dressing 1 4
Toileting 1 2
Transfer (Toilet) 1 4
Bladder Mgmt 5 6
Bowel Mgmt 5 6
Shower Transfer 2 4
Transfer (bed>wheelchair) 2 4
Gait (walk) 0 2
Stairs (up to 8 stairs) 0 2
TOTAL 29 49
Results
Skills: Transfers: improved from Max A to Min A Sit>stand improved from Max A to Min A
able to tolerate 1 min independent standing balance between trials.
Gait improved to Max A up to 20’ from “activity does not occur”
Pt was discharged below his preadmission level of function.
Cost
CPT Code Procedure Cost Units billed Total Unit Cost
97001 Initial Evaluation $73.13 1 73.13
97112 Neuromuscular Reeducation $31.27 11 343.97
97110 Therapeutic Exercise $29.99 24 719.76
97116 Gait Training $26.70 11 293.7
97530 Therapeutic Activity $32.84 24 788.16
Total Cost: $2,218.72
12 days of therapy x 90 minutes/day = EXPENSIVE!
Medicare A & B covered costs
Would I pay out of pocket?
NO!
Discussion
Multiple poor prognostic indicators: Chronic stroke
Multiple studies show that gains can be made when intensive PT is employed in chronic stroke.
Moore et al, 2010 hypothesized that a “plateau” occurs in PT due to lack of task-specific practice in the clinical setting.17
Older age Most patients with CVA are older, 65 is relatively young
Multiple comorbidities Most patients with CVA have multiple comorbidities
Smoking
Discussion
12 day LOS too short? Other intensive RTT protocols demonstrated
successful results after only 10 days. Fritz et al, 201118
Many CIMT protocols are often 2-3 weeks Lin, 2008: 3 weeks19
Huseyinsinoglu, 2012: 10 days20
Could cognitive deficits have impacted the intensity of practice? Most RTT and CIMT exclude pts with “severe”
cognitive deficitsRole of medication?
Impaired motor learning?
Conclusion
Vision 2020: “doctors of physical therapy, recognized by consumers
and other health care professionals as the practitioners of choice to whom consumers have direct access for the diagnosis of, interventions for, and prevention of impairments, activity limitations, participation restrictions, and environmental barriers related to movement, function, and health.”21
Basic understanding of pharmacology is essential for formulating realistic prognoses. Communication with MDs and family re: expectations,
burden of care, etc.
What would I have done differently?
Intervention limited by facility Treadmill Training
Moore 2010 excluded all pts who couldn’t ambulate 10’ independently
Hornby & Straube showing that intensive locomotor training actually translates into improved transfer and balance skills.
Adhered to a more specific protocol so the intervention could be replicated
Insisted on family trainingCollaborated more with social worker
Home health
Appropriate Resources
SNF informationRespite: http://www.harmonychicago.com/contact
Adult day care: http://emeritus86.reachlocal.net/sem/chicago?track=RESPITE
Smoking cessation resourcesOak Park Vet Center
155 South Oak Park Avenue Oak Park, IL 60302(708) 383-3225
http://saveourvets.com/page4.html
Questions?
Discussion points: Was this patient appropriate for inpatient
rehab?Do you consider the patient’s medication list
when determining prognosis? Do you think our program needs to
incorporate more pharmacology into the curriculum?
References
1. Foster AC, Kemp JA (February 2006). "Glutamate- and GABA-based CNS therapeutics". Curr Opin Pharmacol 6 (1): 7–17. 2. Ziemann U, Meintzshel F, Korchounov, Tihomir V. Pharmacological modulation of plastic in the human motor cortex.
Neurorehabil Neural Repair 2006 20:243.3. Roger VL, et al. Heart disease and stroke statistics- 2011 update: a report from the American Heart Association. Circulation.
2011; 123:e18-e2094. Kelly-Hayes M, et al. The American Heart Association Stroke Outcome Classification: executive summary. Circulation.
1998;97:2427-85. Myint PK, Staufenber EFA, Sabanathan, K. Post-stroke seizure and post-stroke epilepsy. Postgrad Med J 2006;82:568-572.6. Ziemann U, Meintzshel F, Korchounov, Tihomir V. Pharmacological modulation of plastic in the human motor cortex.
Neurorehabil Neural Repair 2006 20:243.7. Sommerfeld DK, Eek E, Svensson A, Holmqvist LW, von Arbin MH. Spasticity after stroke its occurance and association with
motor impairments and activity limitations. Stroke. 2004;35:134-140. 8. Thompson AJ, Jarrett L, Lockley L, Marsden J, Stevenson VL. Clinical management of spasticity. J Neurol Neurosurg Psychiatry
2005;76:459-463. 9. Zorowitz RD, Smout RJ, Gassaway JA, Horn SD. Usage of pain medications during stroke rehabilitation. The post-stroke
rehabilitation outcomes project. Top Stroke Rehabil 2005;12 (4):37-49. 10. Alarcon F,Zijlmans JC, Duenas G, Cevallos N. Post-stroke movement disorders: report of 56 patients. J Neurol Neurosurg
Psychiatry. 2004 75:1568-74. 11. Korchounov A, Ziemann U. Neuromodulatory Neurotransmitters Influence LTP-Like Plasticity in Human Cortex: A Pharmaco-
TMS Study. Neurophychopharmocology. 2011. 36.1894-1902.12. Heidegger T, Krakow K, Ziemann U. Effects of antieleptic drugs on associative LTP-like plasticity in human motor cortex.
European Journal of Neuroscience. 2010. Vol 32. 1215-1222. 13. French B, Thomas L, Leathley M, Sutton C, McAdam J, Forster A, Langhorne P, Price C, Walker A, Watkins C. Does repetitive
task training improve function activity after stroke? A Cochrane systematic review and meta-analysis. J Rehabil Med. 2010; 42:9-15.
14. Langhorne P, Coupar F, Pollock. Motor recovery after stroke: a systematic review. Lancet Neurol 2009; 8:741-54. 15. Dean CM, Richards CL, Malouin F. Task related circuit tranining improves performance of locomotor tasks in chronic stroke: a
randomized, controlled pilot trial. Arch Phys Med Rehabil. 2000: 81: 409-17.16. Beninato M, Gill-Body KM, Salles S, Stark PC, Black-Schaffer RM, Stein J. Determination of the minimal clinically important
difference in the FIM instrument in patients with stroke. Arch Phys Med Rehabil. 2006 Jan;87(1):32-9.17. Moore JL, Roth, EJ, Killian C, Hornby TG. Locomotor training improves daily stepping activity and gait efficiency in individuals
post stroke who have reached a “plateau” in recovery. Stroke. 2010 Jan;41(1):129-35. Epub 2009 Nov 12.18. Fritz S, Merlo-Rains A, Rivers E, Brandenburg B, Sweet J, Donley J, Mathews H, deBode S, McClenaghan BA. Feasibility of
intensive mobility training to improve gait, balance, and mobility in persons with chronic neurological conditions: a case series. J Neurol Phys Ther. 2011 Sep;35(3):141-7.
19. Lin KC, Wu CY, Liu JS, Chen YT, Hsu CJ. Constraint-induced therapy versus dose-matched control intervention to improve motor ability, basic/extended daily functions, and quality of life in stroke.Neurorehabil Neural Repair. 2009 Feb;23(2):160-5. Epub 2008 Nov 3.
20. Huseyinsinoglu BE, Ozdincler AR, Krespi Y. Bobath Concept versus constraint-induced movement therapy to improve arm functional recovery in stroke patients: a randomized controlled trial. Clin Rehabil. 2012 Jan 18. [Epub ahead of print]
21. American Physical Therapy Association http://www.apta.org/Vision2020/. Accessed 1/5/2011.22. Straube and Hornby