stroke rehabilitation in a biopsychosocial context

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. Netter’s 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: 522–527.2 O’Sullivan 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

Review: Brain/CNS Functions

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

Slide # 22

CNS Functions & ICF Levels

Slide # 23


Slide # 24


Slide # 25

FUNCTIONS

LEVELS Sensorimotor Cognitive-perceptual

Limbic-emotional

Pathology Primary motor cortex

Broca’s 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. Umphred’s Neurological Rehabilitation. 6th ed. St. Louis, Missouri: Elsevier Mosby; 2013.

Slide # 28

Overview of Treatments

O’Sullivan 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


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


Slide # 31

• Continued mobilisation

• Aerobic endurance

• Gait training

• Functional training

• ADL training/Work-hardening

• Use of adaptive devices

Bed positioning

http://cdn.quotesgram.com/img/87/16/142879932-113798491.png

Slide # 32

Bed mobility exercises


Slide # 33

Transfers

http://www.allegromedical.com/images/products/pivotdisc-ill2.gif

Slide # 34

ADL training

O’Sullivan SB, Schmitz TJ, Fulk GD (eds). Physical Rehabilitation. 6th ed. Philadelphia, Pennsylvania: FA Davis; 2014.https://s-media-cache-ak0.pinimg.com/736x/8c/de/60/8cde6074710a993e31109a0b62984591.jpg Slide # 35

Gait training

O’Sullivan SB, Schmitz TJ, Fulk GD (eds). Physical Rehabilitation. 6th ed. Philadelphia, Pennsylvania: FA Davis; 2014.http://www.buykorea.org/images/files_new/mp/gd/2013/08/12/20130812095843026_020_RE.jpg Slide # 36

Adaptive devices/Home changes

Slide # 37

Orthoses

Slide # 38

Overview of Neurologic Exercises

Belda Louis J-M et al. Rehabilitation of gait after sroke: a review towards a top-down approach. J of Neuroengineering and Rehabilitation; 2011, 8:66. Slide # 39

• Neurodevelopmental Treatment (NDT) a.k.a. Bobath concept

• Proprioceptive neuromuscular facilitation (PNF)

• Brunnström’s concept

• Rood’s concept

• Johnstone therapy

• Ayres’ method

• Perfetti’s method

• Carr-Shephard’s Motor relearning progrmme (MRP)

• Perfetti’s method

• Affolter’s method

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Economic Impact of Stroke

https://thumbnails-visually.netdna-ssl.com/stroke--how-much-impact-does-it-have-on-the-uk_5029155532671.jpghttp://www.pfizer.com/files/health/VOMPapers_AFIB-Stroke_Infographics0101.jpg Slide # 40

in the U.S.

Stroke Prevention

Slide # 41

Conclusion/Summary

Slide # 42

• Psychological and social factors contribute to a more holistic understanding of the disease than with biomedical factors alone.

• A holistic understanding enables the development of tailor-made rehabilitation programmes.

• Early rehabilitation maximizes potential for functional recovery.

• Task- and context-specific exercises improve functional recovery.

• Stroke remains a challenge given an ageing population.

• Psychological and social factors contribute to a more holistic understanding of the disease than with biomedical factors alone.

• A holistic understanding enables the development of tailor-made rehabilitation programmes.

• Early rehabilitation maximizes potential for functional recovery.

• Task- and context-specific exercises improve functional recovery.

• Stroke remains a challenge given an ageing population.

stroke rehabilitation in a biopsychosocial context

Healthcare