PRINCIPLES OF NEUROREHAB Rohini Kumar › sites › default › files...ACUTE INPATIENT REHAB: THE...
73
PRINCIPLES OF NEUROREHAB Rohini Kumar Physical Medicine & Rehab April 26 th 2018
Transcript of PRINCIPLES OF NEUROREHAB Rohini Kumar › sites › default › files...ACUTE INPATIENT REHAB: THE...
PRINCIPLES OF NEUROREHAB Rohini Kumar Physical Medicine & Rehab April 26th 2018
DISCLOSURES
None
AGENDA What is PM&R and who is on the team
Impact of Stroke
Patterns of recovery
Neuroplasticity
Hyperacute Phase
Treatments in rehab
PHYSICAL MEDICINE AND REHABILITATION
Latin ~ habilitas “to make able”
Literal translation “to be able to again”
Our role is to coordinate and facilitate the process to help a person achieve the highest level of function, independence and improve their quality of life.
THE PATIENTS WE WORK WITH NeuroRehab: CVA Trama: Concussions
TBI SCI Amputee Burns GSW/Stabwound
Ortho: Simple joint replacements Multi-fracture Cancer Lymphedema Cardio/Pulm/Deconditioning
INTERVENTIONS PROVIDED Peripheral Joint Injections
Carpal Tunnel Injection
Tendon injections
MSK US
US guided peripheral joint injections
EMG
Botox
Acupuncture
Trigger point injections
Prosthetic/Orthotic Evaluation
Assistive Device or Adaptive Equipment Evaluation
ACUTE INPATIENT REHAB: THE TEAM
-PM&R
-PT
-OT
-SP
-Neuropsych
-Art Therapy
-Music Therapy
-Nurse educator
-SW/CM
-Consultants
-P&O
-Nutrition
-Pastoral Care
CRITERIA FOR ADMISSION TO A COMPREHENSIVE REHABILITATION PROGRAM Stable neurologic status
Significant persisting neurologic deficit
Identified disability affecting at least 2 of 5 functions, including mobility, self-care activities, communication, swallowing and bowel or bladder control
Sufficient cognitive function to learn
Sufficient communicative ability to engage with therapists
Physical ability to tolerate the active program
Achievable therapeutic goals
EXERCISE IS THE BEST MEDICINE
Physical Therapy
ROM, strengthening, balance, coordination, gait-retraining, bracing, endurance, selective sensory stimulation, FES
Occupational Therapy
ADLs, IADLs (executive function), Driving, Home Adaptation, Splinting, FES
Speech Therapy
Swallow, Feeding, Higher level cognitive exercises
Presenter
Presentation Notes
Assist with motor planning, reduction of spasticity, coordination, adaptive stratigies, self care, from dysphasia to aphasia retraining, managing neglect All therapy is not created equal Dependent on volume, repetition, task-specific, enriched environment
FUNCTIONAL E-STIM
FES
FACTS AND FIGURES
Stroke is the #1 cause of disability worldwide Cost burden of $65.5 billion per year
800,000 new strokes per year
650,000 people survive a new stroke annually
7 million Americans live with the complications of stroke
Presenter
Presentation Notes
Focused therapeutic interventions Direct health care services, medications and lost productivity and indirect costs of stroke were estimated to be $65.5 billion per year in the United States 6 billion in rehab A person is having a stroke one every 40 seconds
TWITCHELL
Flaccid Paralysis & Areflexia
Return of reflexes & Spasticity
Voluntary movements & Synergy
Dec in Spasticity
Volitional movements with reduction of synergy
Normalization of volitional movements
Presenter
Presentation Notes
Break the synergistic patterns Restoring isolated movements
WHO ARE THE LUCKY ONES Limited spasticity
Rapid progression through stages Intact proprioception
Proximal muscle return
Preservation of distal motor function Limited neglect
*Predictors of upper limb recovery after stroke: a systematic review and meta-analysis
Fiona Coupar, Alex Pollock, Phil Rowe, Christopher Weir, Peter Langhorne 10/11
Legend: All
Mild
Moderate
* Severe Very Severe
Outcome and Time Course of Recovery in Stroke. Part II: Time Course of Recovery. The Copenhagen Stroke Study Henrik S. Jorgensen, MD, Hirofumi Nakayama, MD, Hans O. Raaschou, MD, JCrgen Vive-Larsen, MD, Mogens St¢ier, MD, Tom S. Olsen, MD, PhD
Presenter
Presentation Notes
Direct correlation between severity of stroke and return or function in self care
RECOVERY PATTERNS IN STROKE PATIENTS Copenhagen Stroke Study Jorgensen et al 1999
Arm function – 9 weeks
Ambulation – 11 weeks
Aphasia – 6 weeks
Neglect – 12 weeks
80% independent mobility
70% independent self care
Presenter
Presentation Notes
Predictable patterns of recovery Twitchell
Presenter
Presentation Notes
Most research supports maximum recovery takes place in the first 3 months but that does not mean that it can not continue.
OUTCOMES 80% will obtain a benefit from rehabilitation
10% will have complete spontaneous recovery
10% will not benefit due to severity of injury
Presenter
Presentation Notes
Impairments remain in 40-65% Effects independent living and economic self-sufficiency
Presenter
Presentation Notes
challenging, repetitive, task-specific, motivating, salient, and intensive for neuroplasticity
Presenter
Presentation Notes
Flex the cortex
HIPPOCAMPUS
Consolidation of new memories
Learning
Spatial orientation
Presenter
Presentation Notes
The hippocampus is a small organ located within the brain's medial temporal lobe and forms an important part of the limbic system, the region that regulates emotions. The hippocampus is associated mainly with memory, in particular long-term memory. The organ also plays an important role in spatial navigation. Ability to learn new cognitive skills Neurogenisis only occurs in the hippocampus
Acute ischemic stroke: Estimated rate of nervous tissue loss without timely intervention
Neurons lost Synapses lost Myelinated fibers lost
Per second 32,000 230 million 200 meters
Per minute 1.9 million 14 billion 12 km
Per hour 120 million 830 billion 714 km
Per stroke 1.2 billion 8.3 trillion 7140 km
Saver JL. Stroke.2006;37:263-266.
Presenter
Presentation Notes
• Compared with the normal rate of neuronal loss in aging, the ischaemic brain ages 3.6 years each hour of stroke evolution without treatment. Source: Saver JL. Stroke.2006;37:263-266.
NEUROPLASTICITY
1) Structural plasticity actual change of the neuron or
the growth of a new neuron
Neurogenesis occurs ONLY in the hippocampus
2) Functional plasticity dormant area of the brain takes over a new function to replace injured brain tissue
Presenter
Presentation Notes
Dopamine a powerful neurotransmitter Increaes the speed of learning Mechanisms of recovery Functional vs Morphological neuroplasticity Acquire new behaviors
EXERCISE INCREASES HIPPOCAMPAL VOLUME
Erikson et al. J Neuroscience. 2011
FUNCTIONAL IMAGING Functional imaging of stroke recovery corroborates this temporal pattern of activation shifts
Presenter
Presentation Notes
Brain activation patterns
The area or somatosensory cortex (black) in a monkey before (A) and after (B) controlled tactile stimulation.
Barbro B. Johansson Stroke. 2000;31:223-230
Copyright © American Heart Association, Inc. All rights reserved.
Presenter
Presentation Notes
The area or somatosensory cortex (black) in a monkey before (A) and after (B) controlled tactile stimulation. Reprinted with permission.21 Post lesion events
IMMOBILITY IS THE ENEMY
During Daytime Hours patients are:
ALONE 60%
IN BED 89%
Only 42% of patients
receive skilled rehab
EARLY MOBILIZATION
Presenter
Presentation Notes
Early mobilization prevents complications, can begin within 24-48 if stable, strong psychological effect
THE ACUTE PHASE Ischemia is a strong inducer of gene expression in the brain.
More than 90 different genes are activated.
Peak within minutes to hours following ischemia and a rapid return to normal or subnormal levels Synaptic changes Inc membrane excitability Unmasking of pre-existing connections
Presenter
Presentation Notes
activity-dependent synaptic changes, changes in membrane excitability, growth of new connections, or unmasking of preexisting connections enriched environment might be caused by increased synthesis of neurotrophic factors
HYPERPLASTICITY Plasticity: inhibited during adulthood but a crucial window opens in post-acute ischemic phase characterized by:
Intense neuronal sprouting Brain capillaries sprout Glial cells activated
Exhibits a re-emergence of childhood organizational patterns
Presenter
Presentation Notes
Primed for recovery Virtual reality for cognitive stimulation Brain rewiring = time Neurogenisis and angiogenesis highly synergistic and strongly orchestrated
Mice Models: learned behavior of picking up a food pellet
Percentage of time the mouse is successful
Days required to train
PERIOD OF HYPERPLASTICITY
HYPERPLASTICITY In the post-acute ischemic phase these 3 processes take place:
Intense neuronal sprouting
Brain capillaries sprout
Glial cells activated
Brain is primed to learn and adapt
Presenter
Presentation Notes
Profound neurorestorative process induced in brain tissue in response to focal cerebral ischemia How can one augment neuroplasticity Change in paradigm- its not just tissue preservation but actual remodeling
USE OF SSRIS IN POST STROKE RECOVERY
Neurogenesis: Increases axonal sprouting Promotes synaptogenesis Stimulates pyramidal cells in the motor cortex
Neuroprotection Inhibits inflammatory cytokines
Autoregulation Upregulates BDNF Drug induced cortex hyper-excitability
Presenter
Presentation Notes
Beyond their ability to improve mood disturbances following stroke, antidepressants can be used to enhance upper extremity motor recovery through their influence on brain neurotransmission. Selective serotonin reuptake inhibitors (SSRI) and noradrenaline reuptake inhibitors (NARI) are the best studied Ischemic strokes- enhances motor recovery in moderate to severe motor deficit MOA- effect on plasticity, anti-inflammatory effect improving global cognitive functioning, specifically in verbal and visual memory functions Functional MRI revealed a single dose of fluoxetine activated motor corticies compared to placebo Drug induced cortx hyperexcitability As a secondary benefit there was much less depression at the 3 month mark After a single dose there was increased activity in motor cortex and improved hand motor function Neuroprotective effect in the post ischemic brain thru anti-inflammatory effects increases hippocampal neurogenesis which improves ischemia induced spatial cognitive deficits
FLAME TRIAL Fluoxetine For Motor Recovery after Acute Ischemic Stroke
Double blind, placebo-controlled trial
9 stroke centers in France
Ischemic strokes with moderate deficits of hemiparesis
Fugl-Meyer Motor Scale (FMMS) < 55 A stroke-specific, performance-based impairment index. Assess motor functioning, balance, sensation and joint functioning in patients with post-stroke hemiplegia. It determines disease severity, describes motor recovery, and plan treatment.
FLAME TRIAL CONT’ Age: 18-85 years old 118 patients Fluoxetine 20 mg daily vs placebo on day 5-10 after the stroke 3 month duration Primary outcome was a change in the FMMS score @ day 0 and @ day 90
RESULTS: FMMS score improved significantly in the fluoxetine group
RESULTS
Fluoxetine =34·0 points [95% CI 29·7-38·4])
Placebo=24·3 points [19·9-28·7];
p=0·003).
Huang et al 2014
Presenter
Presentation Notes
DCX staining and dendritic spine density in the hippocampus. (A and B) The exercise and fluoxetine groups showed more immature neurons in the dentate gyrus compared to controls. (C and D) Golgi staining images reveal higher level of dendritic spine density in the hippocampus (CA1 region) in the exercise and fluoxetine groups. Values are means 6 SEM. * P , 0.05, *** P , 0.001 Several different interventions improve depressed mood, including medication and environmental factors such as regular physical exercise. The molecular pathways underlying these effects are still not fully understood. In this study, we sought to identify shared mechanisms underlying antidepressant interventions. We studied three groups of mice: mice treated with a widely used antidepressant drug--fluoxetine, mice engaged in voluntary exercise, and mice living in an enriched environment. The hippocampi of treated mice were investigated at the molecular and cellular levels. Mice treated with fluoxetine and mice who exercised daily showed, not only similar antidepressant behavior, but also similar changes in gene expression and hippocampal neurons. These changes were not observed in mice with environmental enrichment. An increase in neurogenesis and dendritic spine density was observed following four weeks of fluoxetine treatment and voluntary exercise. A weighted gene co-expression network analysis revealed four different modules of co-expressed genes that were correlated with the antidepressant effect. This network analysis enabled us to identify genes involved in the molecular pathways underlying the effects of fluoxetine and exercise. The existence of both neuronal and gene expression changes common to antidepressant drug and exercise suggests a shared mechanism underlying their effect. Further studies of these findings may be used to uncover the molecular mechanisms of depression, and to identify new avenues of therapy. �Neurogenomic Evidence for a Shared Mechanism of the Antidepressant Effects of Exercise and Chronic Fluoxetine in Mice
POST-STROKE DEPRESSION
Acute phase depression approx. 20%
Chronic long term sequelae 55%
Preventing an inevitable long term effect
INNOVATIVE REHAB TECHNIQUES
Task-oriented functional exercises
Robot assisted technology can achieve a reward system
Immersive vs non-immersive
Provides a three-dimensional and direct sensorial (visual, sensory and auditory) feedback
Virtual Reality for Stroke Rehabilitation Kate Laver, BAppSc (OT), MClinRehab, PhD Candidate; Stacey George, BAppSc (OT), MHSc (OT), PhD; Susie Thomas, BPhysio (Honours), PhD; Judith E. Deutsch, BA, MS (PT), PhD; Maria Crotty, BA, BMed, MPH, PhD, FAFRM Stroke 2012
Rehab vs Wii-hab
BENEFITS OF VIRTUAL REALITY Effectiveness of Virtual Reality Exercises in STroke Rehabilitation (EVEST) trial Int J Stroke 2010 Feb G. Saposnik,1,* M. Mamdani,1 M. Bayley,2 K.E. Thorpe,2 J. Hall,2 L.G. Cohen,3 and R. Teasell4
First randomized parallel controlled trial
Allow for increased intensity of training while providing augmented sensory feedback
Berg Balance Scale
Functional Reach Test Improves UE function
Gait speed
Presenter
Presentation Notes
increased intensity of training
SUMMARY Neuroplasticity
Neurons that fire together wire together
Maximize the acute inpatient stay during hyperplasticity phase
Use of SSRI to improve motor recovery and prevent depression
Use of VR in stroke rehab
REFERENCES Huang, Guo-Jen & Ben-David, Eyal & Tort Piella, Agnes & Edwards, Andrew & Flint, Jonathan & Shifman, Sagiv. (2012). Neurogenomic Evidence for a
Shared Mechanism of the Antidepressant Effects of Exercise and Chronic Fluoxetine in Mice. PloS one. 7. e35901. 10.1371/journal.pone.0035901.
Chollet et al. Fluoxetine for motor recovery after acute ischemic stroke (FLAME): a randomized placebo-controlled trial. Lancet Neurol. 2011 Feb;10(2):123-30. .
Hatem, S. et al Rehabilitation of Motor Function after Stroke: A Multiple Systematic Review Focused on Techniques to Stimulate Upper Extremity Recovery
Robertson AD, Marzolini S, Middleton LE, Basile VS, Oh PI, MacIntosh BJ. Exercise Training Increases Parietal Lobe Cerebral Blood Flow in Chronic Stroke: An Observational Study.Front Aging Neurosci. 2017 Sep 29;9:318.
Nichols-Larsen DS, Clark PC, Zeringue A, Greenspan A, Blanton S. Factors influencing stroke survivors’ quality of life during subacute
recovery. Stroke. 2005;36:1480–4
Teasell R, Meyer MJ, McClure A, et al. Stroke rehabilitation: an international perspective. Top Stroke Rehabil. 2009;16:44–56
Barreca S, Wolf SL, Fasoli S, Bohannon R. Treatment interventions for the paretic upper limb of stroke survivors: a critical review. Neurorehabil Neural Repair. 2003;17:220–6
Wolf SL, Winstein CJ, Miller JP, et al. Effect of constraint-induced movement therapy on upper extremity function 3 to 9 months after stroke: the EXCITE randomized clinical trial. JAMA. 2006;296:2095–104
Crosbie JH, Lennon S, Basford JR, McDonough SM. Virtual reality in stroke rehabilitation: still more virtual than real. Disabil Rehabil. 2007;29:1139–46. discussion 1147–1152
Hayes, M. Time Course of Functional Recovery After Stroke: The Framingham Study Saposnik A. Effectiveness of Virtual Reality Exercises in STroke Rehabilitation(EVREST): Rationale, Design, and Protocol of a Pilot Randomized Clinical Trial Assessing the Wii Gaming System. Int J Neuro 2010 Feb
REFERENCES CONTINUED
Effectiveness of wii-based rehabilitation in stroke? A randomized controlled study. Utkan Karasu A1, Balevi Batur
Virtual Reality for Stroke Rehabilitation Kate Laver, BAppSc (OT), MClinRehab, PhD Candidate; Stacey George, BAppSc (OT), MHSc (OT), PhD; Susie Thomas, BPhysio (Honours), PhD; Judith E. Deutsch, BA, MS (PT), PhD; Maria Crotty, BA, BMed, MPH, PhD, FAFRM
COCHRANE REVIEW
improving upper limb function (standardised mean difference, SMD) 0.53, 95% confidence intervals [CI] 0.25 to 0.81)) based on seven studies, and activities of daily living (ADL) function (SMD 0.81, 95% CI 0.39 to 1.22) based on three studies. No statistically significant effects were found for grip strength (based on two studies) or gait speed (based on three studies).
Animals reared or housed as adults in complex environments with access to various toys and activities develop more dendritic branching and more synapses per neuron and have higher gene expression for trophic factors than animals housed individually or in small groups in standard cages
regularly have to perform a very skilled motor task, the cortical representation for the muscles involved will remain enlarged
VR
manipulating mechanisms of learning and memory, neurogenesis and axonal regeneration, and neurotransmitters and growth factors can facilitate the recovery process in models
Responsivity
Task-orieted functional exercises
Enriched environment
motivation reward interaction enjoyment
Task specific training
RECOVERY TIME LINE
physiology of learning, relearning, training, and neuroenhancement.
Brain reorganization
Presenter
Presentation Notes
Recovery takes a non-linear logarithmic pattern
PROCESS WHILE IN ACUTE REHAB
Evaluation Establish Care Plan with PT/OT/Speech 3 hours of focused exercises Goal Setting Periodic Assessments Discharge Planning Community Reintegration
Predictable rule of recovery first 3 months, one can regain 70 % of their max potential
SMARTS
Compelling evidence to rehab day 1 instead of waiting 1 week
BENEFITS TO VR
Virtual reality: interact with a multisensory simulated environment and receive “real-time” feedback on performance
Robot assisted technology
Immersive vs non-immersive
providing augmented three-dimensional and direct sensorial (visual, sensory and auditory) feedback
MSK
Shoulder pain– subluxation
CRPS/RSD
Muscle contracture
Spasticity: develop as early as 1 week after stroke and occurs in up to 50% of stroke patients
Presenter
Presentation Notes
It is often not medically necessary to treat increased muscle tone, unless spasms or flexor postures of the upper extremity cause pain, skin breakdown or interfere with hygiene. When a muscle is partially paralyzed by the toxin, daily stretching and ranging of the affected joint are necessary to maintain the improvement.
FALLS PREVENTION
Falls are a common outcome for patients recovering from stroke, with an incidence of over 40 percent for more than one fall in the first year
Body weight-supported treadmill training (BWSTT) enables supervised, repetitive, task-related practice of walking
SLEEP WAKE ACTIVITY
Improves memory
