recent advances in stroke...
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Important of stroke rehabilitation
• 30000+ stroke per year in HK• 3443 died (2009), 4th leading cause of mortality, first
leading cause of disabilities• ~ 40% reduction in mortalities: increase stroke survivors• Ageing population: 7% over 65 (1983), 14% in 2013 & 21%
in 2024• Physicians like to focus on acute stroke management: t-PA,
surgical or endoscopic treatments - no. of clients beneficial is actually small
• Others focus on primary & secondary prevention, community reintegration or long term care.
• Demand for stroke rehabilitation will dramatically increase in future 10-20 years
Recovery process
• Restitution: Restoring the functionality of damaged neural tissue
• Substitution: Reorganization of partly spared neural pathways to relearn lost functions
• Compensation: Improvement of the disparity between the impaired skills of a patient and the demands of their environment
Pharmacology
• Restitution: stem cell therapy, Growth factors (Vascular Endothelial, fibroblast, BD, glial cells etc)
• Antidepressants: fluoxetine,
• Dopamine agonists
• Cholinesterase Inhibitors, memantin
Neural PlasticityKleim & Jones 2008
• Use it or Lose it
• Use it and Improve it
• Specificity matters
• Repetition Matters
• Intensity Matters
• Time Matters
• Salience Matters
• Age Matters
• Transference
• Interference
Message 2:Acute stroke vs. Subacute stroke vs.
Chronic stroke
Chronic stoke can be improved through training and special methods
Neurological impairments or disabilities in stroke
• Motor manifestations• Sensory manifestations• Language: aphasia, alexia & dysarthria• Dysphagia• Cognitive dysfunction• Right hemispheric neurobehavioral syndromes• Bladder & bowel dysfunction• Depressions or other psychological Complications• Loss of visual acuity, visual field• Lack of energy, motivation, fatigue
Motor Dysfunctions
• LMN lesion: flaccid weakness
• UMN lesion: Muscle spasticity, co-contractions, hyper-reflexia
• Hemiplegia shoulder pain
Interventions for flaccid weakness in chronic stroke
• CIMT / mod. CIMT• Bilateral arm therapy• Mirror therapy• Mental practice• Electric Stimulation (TENS, FES)• Robotic assisted training• +- virtual reality system• Transcranial magnetic stimulation (rTMS)• Transcranial Direct current stimulation (tDCS)• Brain Computer Interface (BCI)
Constraint Induced Movement Therapy
– Restraint of good limb
– Forced use of the affected limb
– Increased practice time: 6 hr/day• Adaptive task practice
• Repetitive task specific practice (15-20 min continuous)
• Shaping strategies
EXCITE trial JAMA 2006
Trial• Multicenter RCT• 222 first stroke• Post-stroke 3-9 m• Intact cognition, language• Extend wrist 20 degree• Extend finger 10 degree• 6 hr per day, 2 week program
of CIMT• Repetitive task practice• Statistically significant
improvement persist at least 1 year
Mod. CIMT
• 3 hr/day
• 3 times per week
• 2 weeks prolong to 10 weeks
• Acute phase
• + mental practice
• + donepezil
• + automated device
Bilateral arm training
• Useful in severe functional deficit
• CIMT better in hand function vs. BAT better in proximal arm function
• ? who will benefit or training protocol
Mirror Therapy
• Convey visual stimuli to the brain through observation of one's unaffected body part as it carries out a set of movements.
• Upper limb as well as lower limb
Mirror therapy
• Cochrane 2012: 14 RCTs: modest benefit, improve in ADL, pain & neglect
• Esp in neglect cases, subacute phase
• + NMES
• 30 mins per session, total 20 sessions in 5 weeks
• Safe, cheap, home based treatment, less labor dependent
Mental practice
• Mental practice is a training method during which a person cognitively rehearses a physical skill using motor imagery in the absence of overt, physical movements for the purpose of enhancing motor skill performance
Using mental practice in stroke rehabilitation: a framework Clinical Rehabilitation 2008; 22: 579–591
Effects of functional task training with mental practice in stroke: A meta analysis. NeuroRehabilitation 2012
Electric stimulation (ES)
• Trancutaneous electric nerve stimulator (TENS)
• ES + prosthetic application = FES
• EMG triggered neuromuscular electric stimulator
• Parameters: current Intensity, frequency, pulse form, pulse width, pulse repetition rate etc
• Useful in all phases
Electric stimulation (FES)
• Cyclic NMES, EMG triggered NMES, neuroprosthetic
• Kroon review 2002, Cochrane review 2006 (ES better than no Tx or placebo)
• Meilink 2008: EMG Triggered NMES to extensor muscles – non statistically significant treatment
• Improves UL function < 6 months, less effect in chronic cases
Functional Electric Stimulation
• Common peroneal nerve• Weak ankle dorsiflexion• Single channel vs. multiple
channel• 10-60 mins, 3-5 times per
week, 1 weeks to 4 weeks• + PT vs. PT alone• + treadmill test with PWS• + robotic assisted training• + Biofeedback• Effect disappear after removed• Meta analysis on 8 studies
(Kottink 2004): 38% increase in walking speed
Virtual reality
• an approach to user-computer interface that involves real time stimulation of an environment, scenario or activity that allows for user interaction via multiple sensory channels.
• Immersion (HMD) vs. non immersion• With robots, movement tracking,
sensory glove system• 13.7% to 20% improvement in
impairment level (Levin 2011)• Cochrane review 2011• Popular gaming system: Playstation
EyeToy and Ninetendo Wii gaming system
• Tele-rehabilitation
Meta-analysis of RCTs using VR systems in upper extremity
impairment (A) and motor function (B, C).
Saposnik G et al. Stroke 2011;42:1380-1386
Copyright © American Heart Association
25mm
15mm20mm
70x60
55x4540x30
0
5mm
Practical Considerations - stimulation depth
Cannot stimulate medial or sub-cortical areas
The Concept• Inter-hemispheric inhibition
• High frequency >5Hz –excitatory – lesion brain
• Low frequency <= 1Hz -inhibitory – normal brain
• Apply on normal, lesion or both
• Post-stroke: motor recovery, aphasia, dysphagia, depression, dementia
• No adverse effects
• Safe, seizures only occur at high intensity and prolong duration
• Subacute or chronic
• 20 minutes per session
• 10 days treatment
• Caution: epilepsy, on SSRI
Transcranial Direct Current Stimulation
• Safe, non invasive brain stimulation
• Weak constant direct current 1-2 mA provided by 9-V alkaline battery
• Active & reference electrode: Saline soaked electrodes 15-25 cm2 applied to targeted cortex
• 10-20 mins, 10-14 days
tDCS
• Anodal stimulation (excitatory) to lesion side as the active electrode
• Cathodal (inhibitory)stimulation to normal side as active electrode
• Anode stimulation to lesion M1 area together with Cathodal stimulation to normal M1 area
• Modulate NMDA receptors, augment synaptic plasticity, affect regional blood flow
t DCS in stroke
Applications
• Stroke motor recovery
• Aphasia
• Dysphagia
• Neglect
• Depression
• Dementia
Side effects
• Safe
• Cheap
• Side effects are mild
• Local itching, tingling or burning sensation
• Skin irritation, transient headache or insomnia
Study Year No Design Stimulation IntensityDuration
Results
Fregni 2005 6 CO C & A 1 mA / 20 m Hand+
Hummel 2005 6 CO A 1 mA / 20 m Hand+
Hummel 2006 11 CO A 1 mA / 20 m decrease RT
Boggio 2007 9 RCT C & A 1 mA / 20 m 4 weeks
Hand+
Hesse 2007 10 OL A & robots 1.5 mA / 7 m20 m RT for 30 s
3+7-
Jeffery 2009 8 RCT C & A & Sham
2 mA / 10 m Increase MEP
Kim 2010 10 CO A 1 mA / 20 m Finger+
Lindenberg 2011 20 RCT Bispheric 1.5 mA / 20 m 5 days Improve
Bolognini 2011 14 RCT Bispheric 2 mA / 40 m 10 days Improve
Madhaven 2011 9 OL A 0.5 mA / 15 m Increase effects
Tanka 2011 8 CO A 2 mA / 10 m Increase force
Hesse 2011 96 MC RCT C+R, A+R, S+R
2 mA / 20 m All improve but not stat. difference
Motor Dysfunctions
• LMN lesion: flaccid weakness
• UMN lesion: Muscle spasticity, co-contractions, hyper-reflexia
• Hemiplegia shoulder pain
What is spasticity?
• A common upper motor syndrome.
• Has a range of definitions.
“ a motor disorder characterized by a velocity
dependent increase in the tonic stretch reflex
(muscle tone) with exaggerated tendon jerks,
resulting from hyper excitability of the stretch
reflex, as one component of the upper motor
neuron syndrome”
(Lance 1980)
Management StrategyManagement Strategy
Prevention of Provocative Factors
Team Decision Making
Treatment OptionsPhysical Medical
Generalised
Spasticity
Regional
Spasticity
Botulinum Toxin
Phenol Blockade
Focal
Spasticity
Intra-Thecal
BaclofenOral Agents
Treatment options
• Prevention and removal of noxious stimulus
• Physical (stretching exercise) and occupational therapies (splinting or casting)
• Oral medications: Baclofen, diazepam, mydocalm, tizanidine, dantrolene etc
• Chemodenervation: Botn & phenol injection
• Intrathecal Baclofen
• Neurosurgery
• Orthopedic surgery
Oral Agents: Baclofen
40% Side-effects
Narrow margin for
tolerance, therapeutic effect and
side-effects
Motor Point Block:
• Intra-muscular injection (BoT: dysport or botox) in the target muscle
• Ultrasound guided
• Nerve stimulator guided / EMG guided
• Follow anatomical site injection
• Use accompany with PT / OT
• Last ~ 3 months
• Improves the spasticity but may increase weakness, not increase in function
Upper limb spasticity
Joints Movements Muscles
Shoulder AdductedInternal rotated
Pectoralis major Lattisimus dorsiSubscapularisTeres major
Elbow Flexed BicepsBrachialisBrachioradialis
Forearm Pronated Pronator teresPronator quadratus
Wrist Flexed FCR, FCU
Fingers Flexed FDS, FDP
Thumb FlexedAdducted
FPL, FPB, OP, AP, First DI
Lower limb spasticity
Joint Movements Gait Muscles
Hip Flexed Iliacas, Psoas
Adducted Scissor leg Adductor L, B, M
Knee Extended Stiff knee gait QuadricepsRectis F, VM, VI, VL
Flexed Crouch gait Medial & lat harmstringsGastrocnemius
Ankle Planter-flexed
Inverted
Equinovarus Gastrocnemius & Soleus, FDL, FHLTA & Tibialis Post.
Toe Flexed Clawed toe FDL, FDB, FHL
Extended great toe Striatal toe EHL
Motor Dysfunctions
• LMN lesion: flaccid weakness
• UMN lesion: Muscle spasticity, co-contractions, hyper-reflexia
• Hemiplegia shoulder pain
Causes of hemiplegic shoulder pain
• Muscles: Subscapularis spasticity, Pectoralisspasticity, Rotator cuff disease,
• Joint capsule: Frozen shoulder (Adhesive Capsulitis)
• Joint: Subluxation, OA GH, OA AC
• Bursa: Bursitis
• Tendon: Bicep Tendonitis
• Nerve: CRPS type I (RSD),
• Brain: Central post-stroke syndrome (CPSP)
• Brachial plexus traction injury
Managements
• Diagnosis: clinical, special tests, Ultrasound, MRI• Prevention• Physical modalities: Transcutaneous electric
stimulation (TENS), Functional electric stimulation (FES)• OT: splinting• Pharmacological: Pain killers, Anti-spastic medications,
Anti-neuropathic medications, Subscapular nerve block, botulinum toxin injection & intra-articular steroid injection to shoulder joint,
• Others: trigger point injection, aromatherapy, Bowen’s therapy, acupuncture
Treatment modalities
All causes Good position, handling, exercise
Hemiplegicshoulder pain
TENS
Spasticity Anti-spastic medicationsBoTn injecion to subscapularis / pectoralis major
Rotator cuff disease
Intra articular injection of steroid
Tendonitis Bursitis
Intra articular steroid injection
OA joints Analgesic medicationsIntra articular injection of steroid
Adhesive capsulitis Intra articular steroid injection
Subluxation Strapping, Splinting, Functional Electric Stimulation
CPSP TCA, lamotrigine, pregabalin
CRPS Oral steroid, calcitonin, ganglion block, CIMT
Post stroke dysphagia
• Positioning, diet modifications
• Swallowing maneuver
• Vitalstim stimulation (sensory)
• Neuromuscular electrical stimulation (NMES)
• Transcranial direct current stimulation (tDCS)
• Repetitive transcranial magnetic stimulation (rTMS)
• +- Kinesio-taping in swallowing
Post-stroke aphasia
• Intense language therapy
• Computer assisted program
• Melodic intonation therapy
• Transcranial direct current stimulation (tDCS)
• Repetitive transcranial magnetic stimulation (rTMS)
• Piracetam, donepazil, galantamine, memantin
Future directions
• Stem cell therapy
• Growth factor therapy
• Mixed or combination therapies
• Best protocols
• Non invasive neurostimulative devices
• Brain computer interface: Neuro-prosthesis
• Telerehabilitation
• Home exercise training etc
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