Stroke B Past Paper PDF

Clinical Sciences: Medical and Neurological conditions Cerebral Vascular Accident (CVA) / Stroke B Tony Wong Assistant Professor of Practice, PolyU Stroke Team (last slide in previous lecture) Stroke Physician Neurologist Nurses Physiotherapist Oc...

Clinical Sciences: Medical and Neurological conditions Cerebral Vascular Accident (CVA) / Stroke B Tony Wong Assistant Professor of Practice, PolyU Stroke Team (last slide in previous lecture) Stroke Physician Neurologist Nurses Physiotherapist Occupational therapist Speech therapist Pharmacist Dietitian Social worker Clinical psychologist Learning Outcome After this lecture, you will be able to Understand some medical treatments for different types of CVA Familiar with the Stroke rehabilitation phases and process Identifying the Stroke rehabilitation approaches (both conventional and update) Outline Medical Treatments Stroke Complications Overview of Stroke rehabilitation Stroke rehabilitation process Acute care Rehab phase Community phase & integration Various treatment approaches Resources for practice knowledge and service information Medical Treatment to acute stroke Keep close neuro-observation Keep close monitoring of changes of GC Close monitoring of vital sign (body temp, BP, HR, SpO2) Stroke Care Pathway The first 24 hours Barthel Index good functional outcome, If vd/c in the first few days Discharge Plan Sit out of bed Medical Treatment (cont’) Ischemic Stroke intravenous (IV) recombinant tissue-type Plasminogen Activator (rtPA) improve the proportion of patients with complete neurological recovery when given within 4.5 hours(but generally suggest 180 mins) of symptom onset #some case may receive the rtPA even >4.5 hours which depends on imed) tissue Doctor’s decision type plasminogen activator - IV-type (X oral medication Special Care in ASU Enhance personal hygiene Prevention of pressure sore after long-term immobilisation blood flow I : blood a lot from large vein g thigh) form transfer to other sites g heart (e - s > attack. e. Prevention of Deep Vein Thrombosis (DVT) -.. brain -> Stroke Caring of patients (frequent visit by Medical Officer) 8 Service Model Acute Stroke Unit 24 hours IV rTPA (Tissue Plasminogen Activator) service Early supported discharge program TIA fast track clinic & neglect > develop 2nd stroke which is - more serve , within the first few weeks rTPA service provide in HA Features of Stroke Unit I Care coordinated by a multidisciplinary team Team consists of professionals interested and specializing in stroke Team meeting at least weekly Involvement of caregivers in patient care rtPA therapy Candidates NOT fit for r-tPA therapy A brain CT scan to make sure there has NOT been any bleeding More than 3 – 4.5 hours from the onset of first symptoms DM or kidney diseases A recent head injury Bleeding problems Bleeding ulcers Pregnancy Recent surgery ↓ prevent blood clot esp for thick-blood patient , Taken blood thinning medications such as Warfarin & 2x risk to r Trauma bleeding Uncontrolled (severe) high blood pressure IV t-PA treatment and circulation : frontal MCA : parietal temporal , circulation : post occipital , cerebellum Medical Treatment (cont’) Stroke Care Unit reduce death and dependence significantly Multidisciplinary team involvement Swallowing assessment er stop oral feeding Early mobilization prevent complication g DVT affect cardiac condition ~ e.. , Management protocols to correct physiological derangement ganticoagulatant prevent blood clot , , oral medication Aspirin started within 48 hours reduce death or dependence and acting as acute secondary prevention (for those who not suitable for rtPA cases)  Medical Treatment Primary : by any disease , general health Secondary Prevention vDx/ constant: signs & symptoms who formal Ax Antiplatelet treatment Prevent E Aspirin (75mg) + dipyridamole modified release (200mg bd) > Aspirin alone Plavix (Clopidogrel) = aspirin-dipyridamole (Sacco et al 2008) Blood pressure lowering treatment Controlling of high BP by IV anti-hypertensive agents (ONLY for hemodynamically stable patients) Xany patient.. If BP is too low , immediately lack of blood supply Sufficient blood supply to save brain tissot Cholesterol control by Statins : ensure a class of drugs used to lower cholesterol levels by inhibiting the enzyme HMG-CoA reductase, which plays a central role in the production of cholesterol in the liver, which produces about 70 percent of total cholesterol in the body Medical Treatment Anticoagulation Warfarin prevent stroke in Atrial Fibrillation (AF) Carotid endarterectomy Surgical remove of atherosclerotic material from the carotid arteries in recent symptoms carotid stenosis Medical Treatment In summary for secondary prevention Aspirin in 1978 Aspirin+Dipyridamole (prevents blood clots) in 1987 Carotid endarterectomy for symptomatic cartoid artery stenosis > 70% in 1991 Warfarin for patients with AF in 1993 Plavix (Clopidogrel) in 1996 Aspirin + Plavix for minor stroke & TIA in 2013 BP reduction with perindopril and indapamide or Ramipril in 2001 Cholesterol reduction with Statin in 2006 Surgical intervention Craniotomy s helpful for EVD blood released from SDH - the brain Drainage via burr hole , External ventricular drainage (EVD) of intra ventricular blood Burr hole and Craniotomy Craniotomy and Craniectomy https://youtu.be/N7-wNsANn8g Stroke Complications Cardiac complications Pulmonary complications Gastrointestinal complications Genitourinary complications Venous thromboembolism Musculoskeletal complications Other complications Cardiac complications High occurrence of serious cardiac events and non-stroke vascular death in patients with stroke slimited blood supply to induce damage /e infarction mo Myocardial High risk: established coronary artery disease, diabetes, peripheral vascular disease, and severe strokes Cardiac arrhythmias Congestive heart failure and cardiomyopathy Associated with sudden death, congestive heart failure, and I recurrent thromboembolism  Pulmonary complications common Pneumonia : most pt sip water food + One of the most frequent medical complications and the most common cause t risk of of fever within the first 48hr; 3X increased risk of death silent > high fever - Aspiration pneumonia; aspiration pneumonitis aspiration > - observex-ray Risk factors : Old age (>65 years), speech impairment, severity of post-stroke the lurg disability, cognitive impairment, and dysphagia over : restrict from feeding & eating Rx: evaluation of swallowing function, appropriate dietary modifications, frequent suction, prophylactic antibiotics = preventive Oxygen desaturation and apnoea Risk factors : severe strokes, increased age, swallowing impairments, and pre- existing cardiac and pulmonary disease Obstructive sleep apnoea and central periodic breathing Gastrointestinal (GI) complications Dysphagia ~37% - 78%, a major risk factor for stroke-associated pneumonia Nasal Gastric (NG) tube at early stage or Percutaneous Endoscopic Gastrostomy (PEG)at chronic stage; protection against aspiration pneumonia Gastrointestinal bleeding ~1.5% - 3%; associated with recurrent strokes, venous thromboembolism, and myocardial infarction Risk factors : severe stroke, history of peptic ulcer disease, cancer, sepsis, renal failure, and abnormal liver function Faecal incontinence ~30% - 56% Genitourinary (GU) complications Urinary tract infections (UTI) Risk factors : Increased age, use of urinary catheters, stroke severity, and female sex Rx : avoid unnecessary catheterization and meticulous catheter care Urinary incontinence Risk factors : advanced age, lesion size, diabetes, hypertension, premorbid disabilities, and initial stroke severity Venous thromboembolism Deep vein thrombosis (DVT) DVT can develop if don't move for a long time (bed bound after stroke or hemiparalysis) can be serious the clots can travel through the bloodstream and get stuck in the lungs, blocking blood flow (pulmonary embolism) Pulmonary embolism Most fatal pulmonary embolisms occur between the second and fourth weeks after a stroke. Prophylaxis with low-dose unfractionated Heparin can prevent DVT and pulmonary embolism and lower the risk of death but increase the risk of major bleeding. Musculoskeletal complications Hip fractures Risk of fractures 7X higher during the first year after stroke Risk factors : woman, advanced age, and having moderate disabilities Pain Central post-stroke pain syndrome; shoulder pain & mostly : in appropriate handling Other complications Fatigue Depression ~33 % Risk factors : Women, younger patients, and those with greater disabilities Fever ~5% among patients hospitalized within a few hours; ~60% of patients with ischemic stroke developed fever within the first 72 h Infection, systemic stress, impairment of central thermoregulation Pressure injury – prolong bed rest or immobilize by patient Overview of Stroke rehabilitation Acute treatment to rehabilitation (after management in AED) Acute Stroke Unit (ASU) Early supported discharge teams Therapy-based rehabilitation at home Stroke Rehabilitation General Principles Multidisciplinary team care Goal setting, specific measurable and time dependent recovery goal to guide management Good rehab. outcome associated with high patient motivation and engagement Training should target the goals that are relevant for the needs of the patients (Task specific training) Training should be preferable in the patient’s own environment High-intensity practice, increase therapy or intervention for d/ prepare High complex treatments Intervention provided by more than one individuals/professional Comprise of a COMPLEX package of treatment E.g. cognitive rehabilitation, early support discharge service, integrated care pathway, OT, PT, ST and therapy based rehabilitation services, etc Specific rehabilitation treatments Target at specific stroke related impairments E.g. Ankle Foot Orthosis (AFO), Bilateral arm training, EMG Biofeedback, Constraint-induced movement therapy (CIMT), robotic training, etc Acute Stroke Unit (ASU) Stroke unit vs general medical unit A reduction of mortality rates, Shorten length of inpatient stay (LOS) and improved independence in activities of daily living (ADL) Cochrane Library (2000) reviewed : stroke unit care + early D/C + support care in community can reduce cost by 15% with influencing clinical outcome and shorten pt’s stay in Rehab Hospital Acute Stroke Unit (ASU) cont’ Integrated approach early mobilization and rehabilitation, prevention of post-stroke medical complications: pneumonia, deep vein thrombosis, …… rehabilitation plans involving carers early assessment and planning for discharge needs. Stroke acute care besides medical care (Trombly p. 1022) = flow of training 1. Assessment & Triaging 2. Positioning In bed Out of bed (in W/C, with cushion) 3. Early mobilization & functional training Assumption on early mobilization : prolong lack of active movement following stroke can lead to subsequent loss of function in adjacent, undamaged regions of the brain 4. Fall prevention 5. Patient & family & Staff education to extent the effect of therapy 6. Swallowing assessment Early supported discharge teams Should be provided by skilled multidisciplinary teams whose work is coordinated by regular meeting. Patient return home earlier with a reduced need for long-term institutional care. Increase likelihood of regaining independence of daily activities (ADL). Most effective for patient with mild to moderate disability. Therapy-based rehabilitation at home Therapy from multidisciplinary team (OT, PT, community nurse) in patient home could prevent deterioration in activities of daily living. Meta-analysis showing that OT services at home delivered within 1 year improved both ADL and IADL (Elaine et.al 2010) Rehabilitation Phase Rehabilitation is the cornerstone of stroke management Stroke rehabilitation is the process of assisting a person who has become disabled as a result of a stroke to returnlife to an optimal level of acc to their role engage + , health, activity and participation, within the limits of the persisting stroke impairment (ICF concept) Rehabilitation aimed at facilitating reorganization of residual brain function (remediation approach) Based on neuronal reorganization underlies functional recovery from stroke Processes underlying neuronal recovery remain not fully understood At present, rehabilitation based on both on clinical assumptions & the science of recovery (evidence base) Priorities in stroke rehabilitation 1. Prevention of complications (reduce LOS, improve outcome) 2. Interventions to minimize disability (remedial therapy) 3. Adaptations to minimize handicap and enhance function (home modification and use of aids) 4. Counselling & education (mood monitoring and empowerment) 5. Empowering patients/carers (to improve QOL) 6. Organized multidisciplinary care (efficiency) Community Phase & Reintegration Discharge planning Home modification and prescription of assistive device Carer’s & pt education Carer’s education Educational class (sharing & mutual support) Involve in patients’ treatment sessions (enhance communication between patient & family members) Information pamphlet (info to keep) Information provision content and strategies Related to recovery, (esp hidden difficulty patient is facing) Practical caring tasks (transfer, use of assistive devise…) Planning of social activities and support Introduction of resources available in the community & make referral Community Reintegration RCT of 300 patients and caregivers in UK, Formal (educational) training of caregivers during patient’s rehab associated with: 1. Less caregiving burden 2. Better psychological outcomes in patients and caregivers 3. Higher QOL in patients and caregivers 4. Reduced overall costs of health and social care Kalra et al., 2004 Kalra L, Evans A, Perez I, et al. Training carers of stroke patients: randomised controlled trial. BMJ. 2004;328:1099-1103. Conclusions on community supports Scope of social support Access to Day Care center, community support-services (e.g. home care service by professionals, Meals on wheels, home help, volunteer visit) Family’s support is a key factor discharge destination, esp for more severe stroke Higher levels of social support associated with greater functional gain, less depression, improved mood social activity/interaction Evidence of a positive benefit of education one-on-one training/ counseling with provision of tailor made info is more effective than written information Pt with severe stroke who receive rehab (on prevention of complications, e.g. contractures, bed sores & D/C planning, e.g. home mod, equipment needs, arrangement of social support) can shorten hospital LOS & reduce mortality rates. Challenges in community integration Integrating caregivers into rehabilitation Community facilities (lacking of appropriate facilities, manpower……) Caregivers ill and burnout issue (respite service) Caregivers training during rehabilitation phase has positive outcomes but ongoing support is needed (ongoing new challenges) Treatment approaches in Stroke Rehabilitation Traditional Contemporary * Bobath/Neuro Motor Re-learning Developmental Therapy – Motor Re-learning Program by Carr & (NDT) Sheppard Rood Approach – Constraint Induced therapy (CIMT) by E. Taub – Task specific training PNF (Proprioceptive – Functional Electrical stimulation (FES) Neuromuscular Facilitation) – Robotic assisted training – (Contemporary) NDT Brunnstrom Movement – NEURAL-IFRAH Therapy Approach Mental Imagery Bobath / Neurodevelopmental Therapy (NDT) Developed by Dr. Karel & Berta Bobath in 1940s in UK, NDTA established in 1960s in N. America Major treatment aims (at the time): focus on a progression of movement through the developmental sequence inhibition of primitive reflexes/spasticity, and facilitation of higher-level control Focus on: – physical problems in stroke – Abnormal coordination of movement patterns, – poor balance, – sensory deficits, – abnormal tone Bobath concept theory and clinical practice in neurological rehabilitation. Chichester : Wiley-Blackwell 2009  Brunnstrom Movement Therapy Trombly, C.A. 2008; p.668-684 Treatment 6 stages progresses Example of recovery developmentally on UL with flexor follow synergy the trend in recovery Treatment aim 1 Flaccidity Unable to move Push to spasticity, help the limb to move in synergy (mass flexor /extensor pattern) hypotonicappearing & move spasticity - 2 Spasticity Some voluntary movement appearing & move in Help the limb to move away from in full synergy synergy pattern + associated reaction synergy & in isolated voluntary movement 3 Decrease in spasticity (out of Spastic UL move in full synergy pattern: Help the limb to further move away synergy, i.e. reducing synergy) Scapular retraction and/or elevation, Shoulder from synergy abduction and external rotation, elbow flexion, forearm supination, wrist flexion, thumb abduction 4 Spasticity further reducing Synergy pattern continues + shoulder & elbow is able to (i.e. synergy disappearing) more “pure” flexion, move elbow extension (i.e. some components can be performed voluntarily) 5 Movement near normal Good/ isolated shoulder flexion, elbow & wrist More precise isolated movement (Synergy no longer dominant, movement seen. Each component can move on its most of isolated movement) own. 6 Normal movement Able to perform rapid, coordinated movement Normal Isolated joint movements without spasticity Rood Approach Principles Use of sensory stimuli to facilitate or inhibit movement through progressive stages of movement control Characteristic: use of sensory stimuli, still using in many preparatory stage Facilitation (Heavy works) Inhibition (Light works) Tactile stimuli Tactile stimuli – Light touch, brushing – Rhythmical moving touch Thermal stimuli Thermal stimuli – Icing – Neutral warmth Proprioceptive stimuli – Prolonged cooling – Quick stretch of muscle Proprioceptive stimuli – Vibration – Prolonged stretch – Stretch to finger intrinsic – Joint approximation – Heavy joint compression – Tendon pressure – Resistance Vestibular stimuli – Slow rolling/ rocking Proprioceptive Neuromuscular Facilitation (PNF) Principles: Stimulation of the proprioceptors to facilitate or inhibit movement Characteristic: – PNF diagonal patterns All parts of the body, head and neck, trunk, limbs, and even facial muscles have two diagonal patterns based on normal motor activity – Techniques Diagonal movement patterns Relaxation techniques of the agonist to increase range of motion Emphasis on breathing Contemporary Basis Of Stroke Rehabilitation take over the I job of original one Neuro re-organization & neuroplasticity Contemporary NDT Motor re-learning theory Use it or lose it principle & CIMT Task specific therapy Robotic Assisted Therapy Neuroplasticity roots for gexplore new function Assumption: Brain has an intrinsic ability to modify its structural and functional organization. 4 possible mechanism: 1. collateral sprouting of new synaptic connections 2. unmasking of previously latent functional pathways 3. assuming function by undamaged, redundant neural pathways 4. regenerative proximal sprouting Experimental evidence indicates that plasticity can be altered by several external factors, including pharmacologic agents, electrical stimulation, and environmental stimulation Neuroplasticity (cont’) Neuroplasticity is a primary rationale for treatment intervention. Plasticity underlies all skill learning and is a part of CNS function. The CNS and neuromuscular system can adapt & change their structural organization in response to intrinsic and extrinsic information (i.e., they are plastic). Changes within the structure of the CNS can be organized (thro’ therapy) or disorganized (as effect of stroke) producing adaptive or maladaptive sensorimotor behavior. The manipulation of information can directly affect a change in the structural organization of the CNS through spatial and temporal summation and the facilitation of pre- and postsynaptic inhibition  FMRI studies of Neuroplasticity A segment of one hemisphere is damaged (shown in red)because of stroke and resulting in a loss of a particular function Over time of rehabilitation training, the opposite hemisphere can take over the lost function in the damaged segment (shown in green) FMRI studies of Neuroplasticity (cont’) New & functionally related areas take over the function of damaged brain Other distant areas of the brain are involved in relearning and recovery Different strokes have different recovery patterns The shift from strict localization to multiple circuits However, great variability between studies and lack of longitudinal data FMRI studies of Neuroplasticity (cont’) may be related to reorganization activity in contralateral side of Brain in activation of adjacent, undamaged area on ipsilateral side Eg: Patient with severe stroke with R UL dysfunction, may be the R hemisphere also take up the control as some tracks do not cross from L hemisphere (original motor site) Current concepts in Bobath/NDT Therapy aims at: us abnormal hyper hypo :... , 1. focused on relearning these normal relearn e movement through experience movement with active participation of the patient expected better limb control - 2. to regain of more effective & efficient postural & (selective) uni movement strategies to attain the individual’s maximum potential rather than (perfection of) normal movement. to reeducate the patient’s own internal referencing system to provide accurate afferent input giving the patient the best opportunity to be efficient, specific, and have movement choices. Current concepts in Bobath/NDT Assumption: 1. balance and selective movement are basis for functional activity. 2. Selective movement of the trunk and limbs, are interdependent & interactive with a postural control mechanism. 3. Functional activity must then be practiced to improve efficiency and promote generalization. 4. Abnormal tone and mass movement patterns were interpreted as plastic responses of the CNS brought about by the patient's compensatory attempts to move. Current concepts in Bobath/NDT Contemporary NDT handling techniques is greatly influenced by new findings in motor learning theories (Ryerson & Levit, 1997; Runyan, 2006) Use of manual cues for recovering functional use of components of movement (i.e. accessing missing components of movement) Manage muscle tone is not only related to spasticity, but to changes in motor recruitment patterns & joint alignment Therapist not just to change tone as the end result, but reeducate new movement patterns Principles in Normalizing tone in NDT Abnormal Muscle tone: 1. Hypertonic/spasticity 2. Hypotonic/flaccidity 3. Rigid Aim of tone normalization: 1. (Hypertonic) to create the appropriate motor control (lengthen in muscle length and alignment, muscle recruitment) so to prepare for subsequent training. 2. (Hypotonic) to access optimal muscle activation to achieve the functional task. Technique: 1. Therapists emphasize the reduction of increased tone and facilitation of movement by cutaneous, proprioceptive, and other handling techniques. 2. Weight bearing can help normalize tone (only if the patient is able to adapt and change muscular alignment actively). Motor Re-learning Theory Principles of motor learning Patient’s active participation on either an automatic & volitional basis Opportunities for practice Identify the movement components repetition is important in consolidation of motor control (may not be the same way though) Supervised practice Provide feedback meaningful goals goal oriented and task specific Human motor behavior is based on continuous interaction between the individual, the environment, and the task  Animal study of motor relearning Rehabilitation training (enriched environments with animals) increases brain reorganization with subsequent In animal studies key factors functional recovery promoting recovery include increased activity and a complex, stimulating environment Lack of a stimulating active environment causes decline in cortical representation and delays recovery Dobrosssy M.D. and Dunnett S.B. (2001) The influence of environment and experience on neural grafts. NeuroSci. 2(12). 871-9. Animal study (cont’) The earlier the better Day 5 admission marked improvement, Day 14 moderate improvement, Day 30 no improvement vs. controls Early admission to specialized rehab program and better functional outcomes (FIM, BI) Constraint-Induced Movement Therapy (CIMT) Mechanism of CIMT discourage the use of the unaffected extremity (mainly UL) & encourage active use of the hemiplegic arm Affected UL has “learned non-use”: Treatment thus aims at ceasing the reliance on the less affected parts & "learn" to improve the motor ability of the affected parts. Taub et al (2000) restraint of use of the stronger arm in a sling or mitt for 90% of waking hours over a period of 2 to 3 weeks, while at the same time intensively training the weaker arm in therapy (6 hrs) & at home. Basic criteria: At least 20 degree active wrist extension without excessive spasticity on hand  CIMT training (home program) Good side (Right) is restrained Affected side (Left) is encouraged to participate in rehabilitation training. Task-specific therapy Stroke rehab must be task-specific; functional reorganization of cortex greater for tasks meaningful to animal; repetitive activity not enough (Hubbard, 2009) Rehab must be task-specific, focusing on tasks important and meaningful to patient, patients were given challenging tasks which simulated real-life tasks early on Task-specific therapy reduce LOS Technology-based rehabilitation Robotic assisted rehabilitation - Provide controlled guidance to paralyzed muscles with specific tasks to enhance motor learning The robot initiate the movement & produce an assistive force to push the patient for a certain movement Robotic + Functional Electrical Stimulation (FES) – enhance high repetitive practice and motor relearning Armeo robotic training Armeo Power Armeo Boom Resources for practice knowledge and service information Information for patients, carer & therapist Local service information Smart Patient, Hospital Authority, Hong Kong Department of Health Community programs for stroke survivors and family by NGO Global Resources World Health Organization (WHO) Heart and Stroke Foundation, Canada National Stroke Association, US