Presented by Stroke rehabilitation in a biopsychosocial context 13 February 2017 Gerald F.P. Ramos, PhD, MPhil, BSPT Stroke & Physiotherapy Neurology
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
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. Umphred’s 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
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
O’Sullivan 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
O’Sullivan SB, Schmitz TJ, Fulk GD (eds). Physical Rehabilitation. 6th ed. Philadelphia, Pennsylvania: FA Davis; 2014.
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
O’Sullivan SB, Schmitz TJ, Fulk GD (eds). Physical Rehabilitation. 6th ed. Philadelphia, Pennsylvania: FA Davis; 2014.
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.