stroke rehabilitation in a biopsychosocial context

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  • Presented by

    Stroke rehabilitation in a

    biopsychosocial context

    13 February 2017

    Gerald F.P. Ramos, PhD, MPhil, BSPT

    Stroke & Physiotherapy

    Neurology

  • Goal(s)

    Slide # 2

    Students will be able to

    identifydescribeanalyzeunderstandexplain

    impairmentslimitationsrestrictions

    of stroke (CVD) patients.

  • Perception (Part vs Whole)

    Slide # 3

    Mercedes de BarcelonaPyke Koch (1930)

  • Framework

    http://www.rehab-scales.org/images/blocks/1176903286/image-1.png?1176975371

    Slide # 4

    The International Classification of Functioning, Disability and Health

  • Framework

    https://media.lanecc.edu/users/howardc/PTA204L/204LNeuromuscReEd/204L%20Hemiplegia.gif

    Slide # 5

    Pathophysiology

    Impairments

    Limitations

    Restrictions

  • Definition of Stroke

    http://worldneurologyonline.com/article/stroke-definition-in-the-icd-11-at-the-who/

    Slide # 6

    Clinical history and examination

    Neuroimaging

    (Neuropathological) autopsy

    Infarction at single or multiple sites of the brain or retina

    Haemorrhage within the brain parenchyma, the ventricular system, or the subarachnoid space

    AcuteONSET

    PRESENTATION

    DURATION

    DIAGNOSIS

    Focal neurological dysfunction

    24 hours (Transient)

    > 24 hours (Major)

    CAUSE

    Clinical history and examination

    Neuroimaging

    (Neuropathological) autopsy

    Infarction at single or multiple sites of the brain or retina

    Haemorrhage within the brain parenchyma, the ventricular system, or the subarachnoid space

    AcuteONSET

    PRESENTATION

    DURATION

    DIAGNOSIS

    Focal neurological dysfunction

    24 hours (Transient)

    > 24 hours (Major)

    CAUSE

  • Review: Circle of Willis

    Visible Anatomy

    Slide # 7

  • Taxonomy of Stroke: Anatomy

    http://www.patienthelp.org/wp-content/uploads/2015/04/Falx-Cerebri.jpg

    Slide # 8

  • Taxonomy of Stroke: Aetiology

    Felten DL & Shetty AN. Netters atlas of neuroscience. 2nd ed. Philadelphia: Saunders Elsevier; 2010.

    Slide # 9

  • Taxonomy of Stroke: Management

    http://www.askdoctork.com/content/uploads/2014/06/iStock_Stroke_000019644735XSmall.jpghttp://3.bp.blogspot.com/-OrccQ6dRj_4/VR1ex1mTtRI/AAAAAAAAGrQ/3QvLKC4NWMw/s1600/stroke%2Bpic.jpg Slide # 10

  • Epidemiology

    http://www.worldstrokecampaign.org/learn/facts-and-figures.htmlhttp://www.world-heart-federation.org/cardiovascular-health/stroke/ Slide # 11

    Worldwide incidence and mortality rates for all strokes

    6deaths

    30incidents

    60seconds

    every

    ~15M incidents/year

    ~6M deaths/year

  • Epidemiology

    Feigin VL et al. Atlas of the global burden of stroke (1990-2013): The GBD 2013 Study. Neuroepidemiology 2015; 45:230-236.

    Slide # 12

    Worldwide prevalence of Ischaemic Stroke in 2013 (per 100,000)

  • Epidemiology

    Feigin VL et al. Atlas of the global burden of stroke (1990-2013): The GBD 2013 Study. Neuroepidemiology 2015; 45:230-236.

    Slide # 13

    Worldwide prevalence of Haemorrhagic Stroke in 2013 (per 100,000)

  • Epidemiology

    Truelsen T et al., Stroke incidence and prevalence in Europe: a review of available data. Eur J Neurol. 2006; 13:581-98.

    Slide # 14

    European stroke events projection (males+females)

  • Epidemiology

    1 Wolma J,et al. Ethnicity a risk factor? The relation between ethnicity and large- and small-vessel disease in White people, Black people, and Asians within a hospital-based population. European Journal of Neurology; 2009; 16: 522527.2 OSullivan SB, Schmitz TJ, Fulk GD (eds). Physical Rehabilitation. 6th ed. Philadelphia, Pennsylvania: FA Davis; 2014.

    Slide # 15

    Non-Modifiable Risk factors for stroke

    Increasing ageEthnicity/Race (varies with type of stroke)1

    Sex: Men > Women except for:2

    Women with menopause before 42 y/o Pregnancy, birth, 6-months postpartum Preeclampsia Contraceptive use

    Genetic predisposition/Family history of stroke

    Increasing ageEthnicity/Race (varies with type of stroke)1

    Sex: Men > Women except for:2

    Women with menopause before 42 y/o Pregnancy, birth, 6-months postpartum Preeclampsia Contraceptive use

    Genetic predisposition/Family history of stroke

  • Epidemiology

    1 Soler EP, Ruiz VC. Epidemiology and Risk Factors of Cerebral Ischemia and Ischemic Heart Diseases: Similarities and Differences. Current Cardiology Reviews. 2010;6(3):138-149.2 https://www.eurekalert.org/pub_releases/2016-07/tl-tls071416.php

    Slide # 16

    Modifiable Risk factors for stroke1

    HYPERTENSION Most important modifiable risk factor2

    HEART DISEASEARRHYTHMIAS Atrial fibrillationDIABETES MELLITUSHYPERCHOLESTEROLEMIA High Bad CholesterolHEMATOCRIT IncreasedSLEEP APNEASMOKINGSEDENTARY LIFESTYLEOBESITYDIETALCOHOL ABUSE

    HYPERTENSION Most important modifiable risk factor2

    HEART DISEASEARRHYTHMIAS Atrial fibrillationDIABETES MELLITUSHYPERCHOLESTEROLEMIA High Bad CholesterolHEMATOCRIT IncreasedSLEEP APNEASMOKINGSEDENTARY LIFESTYLEOBESITYDIETALCOHOL ABUSE

  • Complications + Comorbidities

    Christian A & Batmangelich S (eds). Physical Medicine and Rehabilitation Patient-Centered Care: Mastering the competencies. New York: Demos Medical; 2015 Slide # 17

  • Complications + Comorbidities

    Christian A & Batmangelich S (eds). Physical Medicine and Rehabilitation Patient-Centered Care: Mastering the competencies. New York: Demos Medical; 2015 Slide # 18

  • Complications + Comorbidities

    Christian A & Batmangelich S (eds). Physical Medicine and Rehabilitation Patient-Centered Care: Mastering the competencies. New York: Demos Medical; 2015 Slide # 19

  • Complications + Comorbidities

    Christian A & Batmangelich S (eds). Physical Medicine and Rehabilitation Patient-Centered Care: Mastering the competencies. New York: Demos Medical; 2015 Slide # 20

  • Complications + Comorbidities

    Christian A & Batmangelich S (eds). Physical Medicine and Rehabilitation Patient-Centered Care: Mastering the competencies. New York: Demos Medical; 2015 Slide # 21

  • Review: Brain/CNS Functions

    Adapted from Umphred DA et al. Umphreds Neurological Rehabilitation. 6th ed. St. Louis, Missouri: Elsevier Mosby; 2013; p 101.

    Slide # 22

  • CNS Functions & ICF Levels

    Slide # 23

  • CNS Functions & ICF Levels

    Slide # 24

  • CNS Functions & ICF Levels

    Slide # 25

    FUNCTIONS

    LEVELS Sensorimotor Cognitive-perceptual

    Limbic-emotional

    Pathology Primary motor cortex

    Brocas area Insular cortex

    Impairment Hemiplegia Expressive aphasia Anorexia

    Limitation Drawing Talking/Speaking Malnutrition

    Restriction Not able to draw blueprints

    Meeting at work Less eating out

  • Phases of Stroke Rehabilitation

    Verbeek JM et al. KNGF Stroke Practice Guidelines. 2014.

    Slide # 26

    HyperacuteAcuteSubacuteChronic

    HyperacuteAcuteSubacuteChronic

  • Hypothetical Recovery Pattern

    Dispa D et al. Rehabilitation of motor function after stroke: a multiple systematic review focused on techniques to stimulate upperextremity recovery. Front Hum Neurosci. 2016; 10:442. Slide # 27

  • Possible directions of Adapatation

    Umphred DA et al. Umphreds Neurological Rehabilitation. 6th ed. St. Louis, Missouri: Elsevier Mosby; 2013.

    Slide # 28

  • Overview of Treatments

    OSullivan SB, Schmitz TJ, Fulk GD (eds). Physical Rehabilitation. 6th ed. Philadelphia, Pennsylvania: FA Davis; 2014.

    Slide # 29

    NMES

    Orthoses

    Sitting-Standing balance exercises

    Body-weight supported treadmill training (BWSTT)

    Robot-assisted training

    Circuit class training

    Muscle strengthening

    Hydrotherapy

    Mirroring; Mental imagery

    Simultaneous bilateral therapy

    Constraint-induced movement therapy

    NMES

    Orthoses

    Sitting-Standing balance exercises

    Body-weight supported treadmill training (BWSTT)

    Robot-assisted training

    Circuit class training

    Muscle strengthening

    Hydrotherapy

    Mirroring; Mental imagery

    Simultaneous bilateral therapy

    Constraint-induced movement therapy

  • Acute Rehab Activities/Goals

    Monitoring patient status

    Early mobilisation

    Positioning

    Functional mobility training Bed mobility, sitting/standing endurance, transfers, gait

    ADL training

    ROME

    Splinting

    Patient-Carer education

    Risk factors, pathophysiology, current condition

    Recovery process, POC, care-setting transitions

    OSullivan SB, Schmitz TJ, Fulk GD (eds). Physical Rehabilitation. 6th ed. Philadelphia, Pennsylvania: FA Davis; 2014.

    Slide # 30

    Monitoring patient status

    Early mobilisation

    Positioning

    Functional mobility training Bed mobility, sitting/standing endurance, transfers, gait

    ADL training

    ROME

    Splinting

    Patient-Carer education

    Risk factors, pathophysiology, current condition

    Recovery process, POC, care-setting transitions

  • Post-acute Rehab Activities/Goals

    Continued mobilisation

    Aerobic endurance

    Gait training

    Functional training

    ADL training/Work-hardening

    Use of adaptive devices

    OSullivan SB, Schmitz TJ, Fulk GD (eds). Physical Rehabilitation. 6th ed. Philade

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