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neurorehabilitation

Indications: Rehabilitation for patients with disabling stroke. Proposed standard of care (also see rehabilitation) Timing: - neurorehabilitation should begin when a stroke patient is medically stable Factors affecting outcomes of neurorehabilitation 1) cognitive status is the most important factor 2) delirium is a risk factor for poor outcomes 3) level of independence prior to stroke Complications: 1) bladder dysfunction a) urinary incontinence (60% in 1st week) b) urinary tract infection (40%) 2) dysphagia: risk of aspiration 3) pain a) musculoskeletal (very common) b) central (neurogenic pain) (< 5%) 1] most common after thalamic-parietal stroke 2] agents: a] antidepressants (SSRI, TCA) b] carbamazepine c] clonidine d] gabapentin e] benzodiazepines f] baclofen 4) depression a) very common b) agents: 1] antidepressants (SSRI, TCA) 2] methylphenidate c) counseling 5) skin ulcers 6) seizures a) 5% within 2 weeks, most within 72 hours b) focal & generalized seizures c) prophylactic anticonvulsants 1] in general, not necessary 2] often used following subarachnoid hemorrhage 7) sleep disorders (1/3) a) reversal of sleep-wake cycle common with cognitive dysfunction b) polysomnography if obstructive sleep apnea suspected 8) spasticity a) dantrolene 25 BID -50 mg QID b) baclofen 5 mg BID - 40 mg QID c) clonazepam 0.5-2.0 mg BID/TID d) tizanidine 2 mg BID - 8 mg QID e) locally injected botulinum toxin 9) sexual dysfunction 10) cognitive dysfunction & dementia a) neuropsychologic testing b) memory loss & hemi-inattention or neglect most common c) 9-fold increased risk of dementia in 1st year after stroke d) stroke severity & cognifive impairment affect choice of appropriate therapy [4] 11) deconditioning is common - fatigue associated with lower extremity weakness [9] Management: 1) goals: - optimize physical, cognitive, behavioral, psychosocial & vocational potential 2) Health care team: - neurologist - psychiatrist - primary care physician - nurses - physical therapist - occupational therapist - recreational therapist - speech therapist - social worker - neuropsychologist - orthotists - dietician - bioengineers 3) Assessment: a) measures of independence in activities of daily living - Barthel index - functional independence measure b) disability c) handicap d) within 1st 2-3 days after stroke - physical therapy & occupational therapy evaluation - assessment of swallowing e) Postural Assessment Scale for Stroke can be used for prediction of independent ambulation for stroke patients after a course of inpatient rehabilitation 4) Settings: a) in the home - able to sit for 1 or more hours [2] - adequate support facilities - improvements similar to high-tech equipment [6] - generally reserved for patients requiring a slower pace of neurorehabilitation [2] - frequent therapist visits reduces hospital readmission & mortality [21] - early supported discharge allows patients with mild to moderate stroke to be discharged home - functional outcomes similar to those with inpatient rehabilitation, with shorter hospital stays & lower costs of care. - appropriate for patients who do not require skilled-nursing services & have access to good community services & caregiver support [2] - setting of choice if patient has returned home, not eligible for Medicare reimbursement of rehabilitation in skilled nursing facility [2] - home-bound by Medicare standards b) skilled nursing facilities (SNF) - generally reserved for patients requiring a slower pace of neurorehabilitation & lack of in home support facilities [2] - repetitive task training delivered in a SNF improves upper limb & lower limb function, walking distance, & walking ability after acute stroke [2] - requires 3 day hospitalization for Medicare reimbursement c) in-hospital rehabilitation unit - average length of stay 18-30 days - better outcomes for moderately impaired patients in rehabilitation setting than general medicine ward - longer survival - better 5 year functional independence - rehabilitation in an inpatient stroke unit associated with greater likelihood of discharge to home [20] 5) Physical therapy for mobility: - deconditioning is common - recovery of ambulation correlates with leg strength - cardiovascular training, especially walking, can improve walking speed [20] - walking may be achieved if patient can flex hip & extend hemiparetic knee against gravity - task-oriented therapy tailored to disability - repetitive movement practice for cognitively impaired patients [4] 6) Occupational therapy for self-care: [5] - manages efforts to improve upper extremity function, self care skills, use of assistive devices for ADLs, dysphagia, cognitive problems - early forced use of affected arm or hand leads to better outcomes 7) Language therapies: - aphasia in 18% - recovery generally within 10 weeks, less for milder strokes 8) pharmacologic therapy a) selective serotonin reuptake inhibitor (SSRI) - may improve rehabilitation outcomes after stroke [2,12] - may help treat new-onset depression after stroke [20] - not recommended for preventing depression [2,20] - SSRI benefit even if patient does not meet criteria for depression (GRS9) [2]; GRS11 walks this recommendation back - no motor benefit from 6 months of fluoxetine use after stroke [18] b) no benefit of dextroamphetamine prior to physiotherapy [15] c) exercise more effective than antiplatelet agents &/or anticoagulants [7] d) direct oral anticoagulants are not approved for post-stroke DVT prophylaxis [2] - use LMW heparin 9) electromagnetic stimulation - cerebellar intermittent theta-burst stimulation promotes gait & balance recovery in patients with stroke by acting on cerebellar-cortical plasticity [17] - Vivistim vagus nerve stimulation paired with rehabilitation FDA-approved to treat upper extremity motor deficits after ischemic stroke [22] 10) Mechanisms of nervous system recovery: - multiple representational maps for movements in a parallel distributed system provides important substrate for rehabilitative gains - behaviorally relevant tasks with optimal scheduling & feedback seem capable of enhancing recovery - more intensive practice seems to enhance subsequent performance - motor recovery occurs early, most in 1st few days, complete within 6 months - sensory neglect more difficult to rehabilitate than sensory impairment 11) transcranial direct current stimulation may be of benefit in patients with aphasia after stroke [14] 12) cardiac rehabilitation may benefit stroke survivors - mixed aerobics & walking most beneficial [19] 13) vigorous walking exercise can improve walking capacity within 4 weeks, but >= 12 weeks are needed to maximize gains [24] 14) repeated 1-minute bursts of high-intensity interval training [25] - more effective than moderate, continuous exercise for aerobic fitness after stroke 15) prognosis - predictors of poor neurorehabilitation outcomes - severe paralysis - neglect* (unilateral neglect in hemispheric stroke) - inability to follow more than one-step command - receptive aphasia - poor cognition - sensory deficits - impulsivity - prior stroke - older age * may be strongest predictor Notes: - occupational therapy & speech therapy can be combined with neurorehabilitation to meet guidelines for Medicare reimbursement [2] - formal fall prevention program prior to hospital discharge [11] - home safety - medication reconciliation - training with assistive devices - balance training for at risk patient - mobility-task training to relearn skills such as stair climbing - eye exercises for patients with accomodation difficulty - personalized exercise program to improve cardiovascular fitness after formal rehab has ended [11]

Related

stroke; cerebrovascular accident (CVA)

Specific

cognitive rehabilitation

General

rehabilitation

References

  1. Dobkin, BH. In: Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 12-15, 2001
  2. Geriatrics Review Syllabus, American Geriatrics Society, 5th edition, 2002-2004; 7th edition 2010 - Geriatric Review Syllabus, 9th edition (GRS9) Medinal-Walpole A, Pacala JT, Porter JF (eds) American Geriatrics Society, 2016 - Geriatric Review Syllabus, 11th edition (GRS11) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2022
  3. Brummel-Smith K. In: Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 29-Oct 2, 2004
  4. Taub E et al, A placebo-controlled trial of constraint-induced movement therapy for upper extremity after stroke. Stroke 2006, 37:1045 PMID: 16514097 - Cirstea CM et al, Feedback and cognition in arm motor skill reacquisition after stroke. Stroke 2006, 37:1237 PMID: 16601218
  5. Legg L et al, Occupational therapy for patients with problems in personal activities of daily livinv after stroke. Systematic review of randomised trials. BMJ 2007, 335:922 PMID: 17901469 - McPerson KM & Ellis HC, Occupational therapy after stroke. BMJ 2007, 335:894 PMID: 17974650
  6. Associated Press American Stroke Association conference Feb 2011 http://www.usatoday.com/yourlife/health/medical/2011-02-11-stroke-therapy_N.htm
  7. Naci H and Ioannidis JPA Comparative effectiveness of exercise and drug interventions on mortality outcomes: metaepidemiological study. BMJ 2013;347:f5577 PMID: 24473061 http://www.bmj.com/content/347/bmj.f5577
  8. Langhorne P, Bernhardt J, Kwakkel G. Stroke rehabilitation. Lancet. 2011 May 14;377(9778):1693-702 PMID: 21571152
  9. Lewis SJ, Barugh AJ, Greig CA et al Is fatigue after stroke associated with physical deconditioning? A cross-sectional study in ambulatory stroke survivors. Arch Phys Med Rehabil. 2011 Feb;92(2):295-8 PMID: 21272727
  10. Bates B, Choi JY, Duncan PW et al Veterans Affairs/Department of Defense Clinical Practice Guideline for the Management of Adult Stroke Rehabilitation Care: executive summary. Stroke. 2005 Sep;36(9):2049-56. PMID: 16120847
  11. Young K, Sadoughi S, MD, Saitz R AHA and ASA Issue First Stroke Rehab Guidelines Physician's First Watch, May 5, 2016 David G. Fairchild, MD, MPH, Editor-in-Chief Massachusetts Medical Society http://www.jwatch.org - Winstein CJ, Stein J, Arena R et al Guidelines for Adult Stroke Rehabilitation and Recovery. A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. May 4, 2016 PMID: 27145936 http://stroke.ahajournals.org/content/early/2016/05/04/STR.0000000000000098.full.pdf+html
  12. Mead GE, Hsieh CF, Lee R et al Selective serotonin reuptake inhibitors (SSRIs) for stroke recovery. Cochrane Database Syst Rev. 2012 Nov 14;11:CD009286. Review. PMID: 23152272
  13. Gittler M, Davis AM Guidelines for Adult Stroke Rehabilitation and Recovery. JAMA. 2018;319(8):820-821. February 27, 2018 PMID: 29486016 https://jamanetwork.com/journals/jama/article-abstract/2673525
  14. Fridriksson J, Rorden C, Elm J et al Transcranial Direct Current Stimulation vs Sham Stimulation to Treat Aphasia After Stroke. A Randomized Clinical Trial JAMA Neurol. Published online August 20, 2018. PMID: 30128538 https://jamanetwork.com/journals/jamaneurology/fullarticle/2696529
  15. Goldstein LB, Lennihan L, Rabadi MJ et al. Effect of dextroamphetamine on poststroke motor recovery: A randomized clinical trial. JAMA Neurol 2018 Aug 27; PMID: 30167675 https://jamanetwork.com/journals/jamaneurology/fullarticle/2696968
  16. Medical Knowledge Self Assessment Program (MKSAP) 18, American College of Physicians, Philadelphia 2018
  17. Koch G, Bonni S. Casula EP et al Effect of Cerebellar Stimulation on Gait and Balance Recovery in Patients With Hemiparetic StrokeA Randomized Clinical Trial JAMA Neurol. Published online November 26, 2018. PMID: 30476999 https://jamanetwork.com/journals/jamaneurology/fullarticle/2715116
  18. FOCUS Trial Collaboration. Effects of fluoxetine on functional outcomes after acute stroke (FOCUS): A pragmatic, double-blind, randomised, controlled trial. Lancet 2018 Dec 5 PMID: 30528472 Free Article https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)32823-X/fulltext
  19. Lyles A Cardiac Rehab Might Benefit Stroke Survivors, Too - Mixed aerobics and walking was most beneficial. https://www.medpagetoday.com/cardiology/strokes/81598 - Regan EW, Handlery H, Beets MW, Fritz SL Are Aerobic Programs Similar in Design to Cardiac Rehabilitation Beneficial for Survivors of Stroke? A Systematic Review and Meta- Analysis. J Am Heart Assoc. 2019;8(16). Aug 14. PMID: 31409176 Free full text https://www.ahajournals.org/doi/full/10.1161/JAHA.119.012761
  20. Sall J,Eapen BC, MD; Tran JE et al The Management of Stroke Rehabilitation: A Synopsis of the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline. Ann Intern Med. 2019. Nov 19 PMID: 31739317 https://annals.org/aim/fullarticle/2755728/management-stroke-rehabilitation-synopsis-2019-u-s-department-veterans-affairs - D'Anci KE, Uhl S, Oristaglio J et al Treatments for Poststroke Motor Deficits and Mood Disorders: A Systematic Review for the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense Guidelines for Stroke Rehabilitation . Ann Intern Med. 2019. Nov 19 PMID: 31739315 https://annals.org/aim/article-abstract/2755729/treatments-poststroke-motor-deficits-mood-disorders-systematic-review-2019-u
  21. Gould J, Asimopoulos M Number of Therapist Visits Inversely Associated With Readmissions, Death in Patients With Stroke. Annals of Long-Term Care. August 17, 2021 https://www.hmpgloballearningnetwork.com/site/altc/podcasts/number-therapist-visits-inversely-associated-readmissions-death-patients-stroke
  22. George J Novel Stroke Rehab Treatment Wins FDA Approval. Neurostim system approved for upper limb deficits. MedPage Today August 27, 2021 https://www.medpagetoday.com/neurology/strokes/94253
  23. Meyer MJ, Pereira S, McClure A et al A systematic review of studies reporting multivariate models to predict functional outcomes after post stroke inpatient rehabilitation. Disabil Rehabil. 2015 37(15):1316-1323 PMID: 25250807
  24. Boyne P, Billinger SA, Reisman DS et al Optimal Intensity and Duration of Walking Rehabilitation in Patients With Chronic Stroke. A Randomized Clinical Trial. JAMA Neurol. Published online February 23, 2023. PMID: 36822187 PMCID: PMC9951105 (available on 2024-02-23) https://jamanetwork.com/journals/jamaneurology/fullarticle/2801947
  25. Moncion K, Rodrigues L, De Las Heras B et al Cardiorespiratory Fitness Benefits of High-Intensity Interval Training After Stroke: A Randomized Controlled Trial. Stroke. 2024 Sep;55(9):2202-2211. PMID: 39113181 Free article. Clinical Trial.