4th Annual Current Concepts in Brain Injury Rehabilitation November 2-3, 2013 Advances in Stroke Rehabilitation Jennifer Shen MD Jennifer Shen •UPMC: Director of Stroke Rehabilitation at Mercy Concussion, outpatient follow up, EMG, consults •Mayo Clinic, Rochester, MN: Physical Medicine & Rehabilitation residency •University of Illinois, Peoria, IL: MD •University of Illinois, Chicago, IL: BA in chemistry Advances in Stroke Rehabilitation 1 4th Annual Current Concepts in Brain Injury Rehabilitation November 2-3, 2013 Disclosures • None Objectives • Identify advances in rehabilitation for the stroke patient • Identify physiologic mechanisms of recovery in the stroke patient • Understand the concept of neuroplasticity Rehabilitation Acute care Inpatient Rehab Home care Advances in Stroke Rehabilitation Outpatient Rehab 2 4th Annual Current Concepts in Brain Injury Rehabilitation November 2-3, 2013 The Goals of Stroke Rehabilitation Manage Comorbid Medical Conditions Maximize Functional Independence Enhance Quality of Life Facilitate Community Reintegration Optimize Psychosocial Adaptation Physiatrist OT PT Rehab RN SLP Maximize Functional Independence Manage Comorbid Medical Conditions Enhance Quality of Life Case management Facilitate Community Reintegration Optimize Psychosocial Adaptation Neuropsychology PT OT Neuropsychology SLP PT OT SLP Physiatrist OT PT Rehab RN SLP Maximize Functional Independence Manage Comorbid Medical Conditions PT Enhance Quality of Life OT Case management SLP Facilitate Community Reintegration Optimize Psychosocial Adaptation SLP Physiatrist Case Neuropsychology management Neuropsychology Advances in Stroke Rehabilitation OT PT 3 4th Annual Current Concepts in Brain Injury Rehabilitation November 2-3, 2013 PT OT SLP Physiatrist OT PT Rehab RN SLP Manage Comorbid Medical Conditions PT Maximize Functional Independence A MULTIDISCIPLINARY APPROACH Enhance Quality of Life OT SLP Case management Facilitate Community Reintegration Optimize Psychosocial Adaptation SLP Physiatrist Case Neuropsychology management Neuropsychology OT PT • Why? – Staff intensive – Significant resources – Length of stay – Additional cost – Time intensive • Meta-analysis of 36 Studies • 3717 patients • Rehab Program patients performed better than 65% of patients in comparison groups. • Rehab Program had greatest effects on: ADLs, Visuospatial function and Mobility Early Initiation rather than Duration of Intervention Advances in Stroke Rehabilitation 4 4th Annual Current Concepts in Brain Injury Rehabilitation November 2-3, 2013 • Randomized Controlled Trial, Norway • 220 patients: 110 to Stroke Unit, 110 to Gen Med Ward Stroke Unit patients: • More likely to live at home (56% vs. 33% at 6 weeks; 63% vs. 45% at one year) • More ADL independence at 6 weeks and one year • Less mortality (7% vs. 17% at 6 weeks; 25% vs. 33% at one year) • • • • Prospective controlled study 245 patients; stratified by prognosis as best/intermediate/poor Same acute care workup/management Stroke Inpatient Rehab Unit vs. General Medical Ward Good prognosis: IRU = GMW Poor prognosis: IRU: Less mortality, shorter LOS Fair prognosis: IRU: better ADL, more home discharges, shorter LOS, less mortality Therapy time v. therapy type • All randomized trials comparing inpatient stroke units to less organized conventional care • 31 clinical trials • Stroke units: coordinated multidisciplinary teams, special interest in stroke, caregivers involved, continued education and training • Reduced death, institutional care, length of stay (4 days) Advances in Stroke Rehabilitation 5 4th Annual Current Concepts in Brain Injury Rehabilitation November 2-3, 2013 Occupational Therapy • Goal is to increase independence and safety with daily tasks • Self care (ADLs) – – – – Hygiene & grooming Bathing Dressing tasks Feeding • Restorative and compensatory strategies used OT: Instrumental ADLs Cooking, paying bills, medication management, use of technology Wii Advances in Stroke Rehabilitation 6 4th Annual Current Concepts in Brain Injury Rehabilitation November 2-3, 2013 • Neglect Neglect – Decreased awareness of one side of the body/environment • Treatment: – Visual scanning exercises, head turn techniques – Visual, auditory, tactile cues – Family education Armeo Armeo: Robotic arm with video game component • Increase AROM • Isolate muscle groups • Increase motivation • Increase visual scanning Armeo Video Advances in Stroke Rehabilitation 7 4th Annual Current Concepts in Brain Injury Rehabilitation November 2-3, 2013 Myomo/Myopro Physical Therapy Challenges to therapy • • • • • • • Weakness Sensory deficit Cognitive impairment Fatigue Neglect Spasticity Pusher syndrome Advances in Stroke Rehabilitation 8 4th Annual Current Concepts in Brain Injury Rehabilitation November 2-3, 2013 Pusher Syndrome (Karnath 2003) Gait Training • Locomotor Training • Body Weight Support Treadmill Training • Nonsupported gait training Gait training: Orthosis Advances in Stroke Rehabilitation 9 4th Annual Current Concepts in Brain Injury Rehabilitation November 2-3, 2013 Tibion/AlterG Bionic Leg • • • • Pressure-sensing shoe insert Angle sensor in the knee Two motors Therapist programs the amount of support to be provided • Two motors Alter G Antigravity Treadmill MECHANISMS OF RECOVERY Advances in Stroke Rehabilitation 10 4th Annual Current Concepts in Brain Injury Rehabilitation November 2-3, 2013 Mechanisms of Recovery • Early improvement – Resolution of edema, ischemic penumbra, diaschisis Mechanisms of Recovery • Late: CNS reorganization/Plasticity – Unmasking of ipsilateral/alternate pathways – Synaptogenesis – Increased synaptic strength NEUROPLASTICITY Advances in Stroke Rehabilitation 11 4th Annual Current Concepts in Brain Injury Rehabilitation November 2-3, 2013 • 1985 • Rehab Special Interest social • 2007 • >400 researchers Society for Neuroscience Levin, MF, Kleim, JA, Wolf, SL. Neurorehabilitation and Neural Repair, Vol 23, No 4 May 209 Use It or Lose It • Visual, auditory, somatosensory, cerebellar development • Loss of cortical function versus re-designation – fMRI activation in visual cortex in blind patients – Activation in auditory cortex in deaf patients • 13 stroke patients; 12 days of constraint induced therapy • Transcranial magnetic stimulation to map motor output of hand • Post treatment, muscle output size was significantly enlarged • Shifts of the center of output map imply additional recruitment of adjacent regions • 6 months: motor performance remained high; cortical regions similar between hemispheres Advances in Stroke Rehabilitation 12 4th Annual Current Concepts in Brain Injury Rehabilitation November 2-3, 2013 • Normal intact primates • Trained on small object retrieval task: Digit representations expanded, wrist/forearm zones contracted • Intracortical microstimulation mapping of Primary motor cortex (M1) • Progressive • Reversible • Trained on key turn task: forearm zone expanded, digits contracted “Use it and improve it” • Synaptogenesis • Increased synaptic responses • Dendritic growth • • • • Also noted in contralesional hemisphere Somatosensory cortex Auditory cortex Enhance effectiveness of other restorative treatments • Food pellets from small well v. large well • Role of learning versus. repetition • Conclusion: “motor skill acquisition, or motor learning, is a prerequisite factor in driving representational plasticity in M1” Advances in Stroke Rehabilitation 13 4th Annual Current Concepts in Brain Injury Rehabilitation November 2-3, 2013 Specificity • • • • • • Gene expression Dendritic growth Synaptogenesis Neuronal activity in motor cortex, cerebellum fMRI Transcranial magnetic stimulation Specificity • • • • • • Gene expression Dendritic growth Synaptogenesis Neuronal activity in motor cortex, cerebellum fMRI Transcranial magnetic stimulation Repetition Matters • Repetition • Repetition • Repetition For lasting neural changes Advances in Stroke Rehabilitation 14 4th Annual Current Concepts in Brain Injury Rehabilitation November 2-3, 2013 Intensity Matters • Skilled reaching task – 60 times versus 400 times per day – Increased synapses in motor cortex • Low intensity stimulation can induce weaker synaptic responses • Higher intensity stimulation can cause long term potentiation Intensity Matters: Potential for overuse • Particularly during early period, very intense • Rats with limb-restricting vests for 7 days after ischemia – Increased excitotoxicity in vulnerable tissues • Rats with TBI with voluntary wheel running – first 6 days  reduced expression of plasticity related molecules in the hippocampus – 2 weeks  enhanced expression, better spatial memory Time Matters Advances in Stroke Rehabilitation 15 4th Annual Current Concepts in Brain Injury Rehabilitation November 2-3, 2013 Time Matters • Rats with ischemic stroke • 5 weeks of rehabilitation starting on day 5, 14, 30 • Improvements in skilled forelimb reaching, ladderrung- and narrow-beam-walking, less use of unaffected forepaw for postural support • Increased cortical dendritic growth Salience Matters • It’s gotta be important! • Basal forebrain cholinergic system Age Matters • With age, there is decreased: – Experience-dependent synaptic potentiation – Synaptogenesis – Cortical map reorganization – Onset of neural sprouting (young adult rats v. aged) • With age, there is increased infarct size Advances in Stroke Rehabilitation 16 4th Annual Current Concepts in Brain Injury Rehabilitation November 2-3, 2013 Age Matters • Not all animal studies show an age difference • Aged animals with brain injuries “benefit from complex motor skills training, exercise and exposure to complex and social environments.” Transference • “the ability of plasticity within one set of neural circuits to promote concurrent or subsequent plasticity” • Increased excitability with repetitive transcranial magnetic stimulation • Improved motor recovery, synaptic responses, motor map reorganization • Complex housing environments, exercise Interference • Plasticity may reduce induction of new plasticity, expression or existing plasticity within the same neural circuit • Noninvasive cortical stimulation • Peripheral stimulation (swallow) • “Bad habits” Advances in Stroke Rehabilitation 17 4th Annual Current Concepts in Brain Injury Rehabilitation November 2-3, 2013 • Primates • Induced ischemic stroke in hand representation of M1 • At 12 weeks, mapping demonstrated increases to ventral pre-motor hand area • Proportional to the area of infarct Principles of Neuroplasticity Use it or Lose it Time Matters Use it and Improve it Salience Matters Specificity Age Matters Repetition Matters Transference Intensity Matters Interference Principles of Experience-Dependent Neural Plasticity: Implications for Rehabilitation after Brain Damage. Klein JA, Jones, TA. Journal of Speech, Language, and Hearing Research. Vol 51 S225-S239. February 2008 SLP AND THE IPAD Advances in Stroke Rehabilitation 18 4th Annual Current Concepts in Brain Injury Rehabilitation November 2-3, 2013 SLP and the iPad • • • • Magazines, newspapers Executive Function/Memory Aides Cognitive games Language therapy SLP and the iPad AAC (alternative augmentative communication) • ideal for dysarthria, apraxia, trachs • can be personalized Aac.mp4 Naming.mp4 Naming2.mp4 Advances in Stroke Rehabilitation 19 4th Annual Current Concepts in Brain Injury Rehabilitation November 2-3, 2013 Recording the Gait of Stroke Patients During Rehab to Improve Motivation, Satisfaction and Outcomes Prakash Jayabalan MD, PhD (PGY-2 Resident), Patrick Kortebein MD, Julie Lanphere MD, Jennifer Shen MD, Michael Boninger MD Department of Physical Medicine & Rehabilitation Accredited Stroke Units (UPMC Mercy and Montefiore) UPMC Rehabilitation Institute THE INTERVENTION 1. Identified patients consent to video Video record patient walking during gait rounds 2x/week at UPMC MERCY AND MONTEFIORE accredited stroke units. Better ? Assess motivation, satisfaction and patient outcome Timed up and go test 1x/week 2. + Video and graphical progress shown to patient. Outcomes compared to patients who do NOT undergo this intervention Advances in Stroke Rehabilitation Bone Layer 10m walk test 1x/week 20 4th Annual Current Concepts in Brain Injury Rehabilitation November 2-3, 2013 Closing the Gap Optimizing Rehabilitation Outcomes for Individuals with Cognitive Impairments after Acute Stroke Elizabeth R. Skidmore, PhD, OTR/L Scientist, UPMC Rehabilitation Institute Associate Professor, Department of Occupational Therapy School of Health & Rehabilitation Sciences FUNDING SOURCES: R03 HD 07377, UPMC Rehabilitation Institute, and University of Pittsburgh Office of Research Health Sciences University of Pittsburgh/University of Pittsburgh Medical Center Cognitive Performance Laboratory Scott M. Bleakley, MS, PT Emily S. Grattan, MS, OTR/L Shannon B. Juengst, MS, CRC Juleen L. Rodakowski, OTD, OTR/L Rachel MacMillan, BS, OTS Ruth Plasterer, BS, OTS Ashley Shearer, BS, OTS Courtney Zon, BS, OTS Aby Sedwick, MOT, OTR/L Carla Tcruz, MOT, OTR/L Amalie Andrew Ward, MOT, OTR/L Laura Waterstram, MOT, OTR/L Occupational Therapy Margo B. Holm, PhD, OTR/L Joan C. Rogers, PhD, OTR/L Rotman Research Institute/Baycrest University of Toronto Cognition in Everyday Life Laboratory Deirdre R. Dawson, PhD, OT Reg (ON) Anne Hunt, MSc, OT Reg (ON) Occupational Therapy Deirdre R. Dawson, PhD, OT Reg (ON) Helene Polatajko, PhD, OT Reg (ON) Physiotherapy Sara McEwen, PhD, PT Reg (ON) 8 June, 2012 Psychiatry James T. Becker, PhD Meryl A. Butters, PhD Mary Amanda Dew, PhD Ellen M. Whyte, MD Physical Medicine & Rehabilitation Michael L. Boninger, MD Michael C. Munin, MD Jennifer Shen, MD Douglas J. Weber, PhD Elizabeth R. Skidmore, PhD, OTR/L Study Design UPMC Mercy Inpatient Rehabilitation Unit UPMC Montefiore Inpatient Rehabilitation Unit Rehabilitation Admission Screening Assessment Individuals with Cognitive Impairments Study Admission Baseline Assessment Descriptive Measures, ADL Disability Intervention (Daily Sessions) Rehabilitation Discharge, Wks 12, 24 Usual Rehab + Strategy Training Usual Rehab + Control Follow-up Assessments ADL Disability Funding Sources: R03 HD 073770, UPMC Rehabilitation Institute, University of Pittsburgh Office of Research Health Sciences Principal Investigator: Elizabeth R. Skidmore, PhD, OTR/L September 2012 Advances in Stroke Rehabilitation 21 4th Annual Current Concepts in Brain Injury Rehabilitation November 2-3, 2013 Pilot Study Intervention Strategy Training – Strategy sessions (5 days/week for inpatient rehabilitation length of stay) • • • • identification of self-selected goals instruction in dynamic performance analysis global strategy training (goal, plan, do, check) therapeutic use of guided discovery – Workbook (daily entries) • applying global strategy to self-selected goals Dawson et al., 2009; Skidmore et al., 2011 Funding Sources: R03 HD 073770, UPMC Rehabilitation Institute, University of Pittsburgh Office of Research Health Sciences Principal Investigator: Elizabeth R. Skidmore, PhD, OTR/L September 2012 Pilot Study Intervention Attention Control – Discussion sessions (5 days/week for inpatient rehabilitation length of stay) • rehabilitation activities • stroke education – Workbook (daily entries) • descriptions of rehabilitation experiences • questions or comments to discuss with the team Funding Sources: R03 HD 073770, UPMC Rehabilitation Institute, University of Pittsburgh Office of Research Health Sciences Principal Investigator: Elizabeth R. Skidmore, PhD, OTR/L September 2012 Functional Independence Scores F3,38=7.65, p<.001; Cohen’s f=.78 Funding Sources: R03 HD 073770, UPMC Rehabilitation Institute, University of Pittsburgh Office of Research Health Sciences Principal Investigator: Elizabeth R. Skidmore, PhD, OTR/L September 2012 Advances in Stroke Rehabilitation 22 4th Annual Current Concepts in Brain Injury Rehabilitation November 2-3, 2013 Medications • • • • • • • • Citicholine Amantadine Donepezil Bromocriptine Methylphenidate Modafinil Levodopa Fluoxetine Stem cells Motor Advances in Stroke Rehabilitation 23 4th Annual Current Concepts in Brain Injury Rehabilitation November 2-3, 2013 PATHWAYS OF CARE Advances in Stroke Rehabilitation 24 4th Annual Current Concepts in Brain Injury Rehabilitation November 2-3, 2013 Pathways of care Neuro diagnosis: CVA Mild Moderate Severe Other medical issues Social support Prior level of function Age Other medical issues Social support Prior level of function Age Other medical issues Social support Prior level of function Age Inpatient Rehab Inpatient Rehab SNF Home SNF Inpatient Rehab Home Pathways of care Neuro Neuro diagnosis: diagnosis: CVA CVA Mild Moderate Moderate Mild Severe Severe Other medical issuesissues Other medical issues issuesOther medical issues issues Other medical Other medical Other medical Social Social supportsupport Social Social supportsupport Social support Social support Prior level function function function Prioroflevel of function Prior level Prioroflevel of functionPrior level Prioroflevel of function Age Age Age Age Age Age Inpatient Rehab Inpatient Rehab Home Home Inpatient Rehab Inpatient Rehab SNF Home SNF SNF SNF Inpatient Rehab Inpatient Rehab Home Advances in Stroke Rehabilitation 25 4th Annual Current Concepts in Brain Injury Rehabilitation November 2-3, 2013 • Thanks to: Michael Boninger MD, Elizabeth Skidmore PhD, OTR/L, Kerry Deluca, MD, Mary Beth Ventura, SLP, Terry Breisinger PT, Ashley Cole OT, Mary Synnott, Hallie Zeleznik PT • MyoPro • Other papers/points about neurorehab • Brain computer interface • Other ipad apps, Just writing notes Advances in Stroke Rehabilitation 26