Recovery and Rehabilitation
after Stroke
NICK WARD
UCL INSTITUTE OF NEUROLOGY
QUEEN SQUARE
n.ward@ucl.ac.uk
Follow us on Twitter @WardLab
For more information go to
http://www.ucl.ac.uk/ion/departments/sobell/Research/NWard
Plan
1.
2.
3.
4.
5.
6.
7.
Why?
When?
How?
Compensation vs Recovery
Upper Limb
Language
Prediction
Rehabilitation – why?
http://wellcometrust.wordpress.com/category/series/focus-on-stroke-series/
Rehabilitation – why?
http://wellcometrust.wordpress.com/category/series/focus-on-stroke-series/
Where is rehabilitation on the treatment path?
1° Prevention
Acute
Therapy
2° Prevention
Rehabilitation
Rehabilitation – what is it?
Rehabilitation is a process of active change by which a
person who has become disabled acquires the
knowledge and skills needed for optimum physical,
psychological and social function.
Rehabilitation is the application of all measures aimed at
reducing the impact of disability and handicap and
improving quality of life.
Rehabilitation - structure
A rehabilitation service comprises a multidisciplinary
team of people who:
1. Work together towards common goals for each patient
2. Involve and educate the patient and family
3. Have relevant knowledge and skills
4. Can resolve most of the common problems faced by their
patients
Rehabilitation - process
Rehabilitation is a reiterative, active, educational, problem
solving process focused on a patient's behaviour (disability),
with the following components:
1. Assessment the identification of the nature and extent of the
patient's problems and the factors relevant to their resolution
2. Goal setting
3. Intervention, which may include either or both of
(a) treatments, which affect the process of change;
(b) support, which maintains the patient's quality of life and his
or her safety
4. Evaluation to check on the effects of any intervention
Rehabilitation - outcome
The rehabilitation process aims to:
1. Maximise the participation of the patient in his or
her social setting
2. Minimise the pain and distress experienced by the
patient
3. Minimise the distress of and stress on the patient's
family and carers
Neuro-rehabilitation: iterative process
1.
2.
3.
4.
5.
6.
7.
Avoid complications
Assessment - MDT
Measurement
Planning
Treatment
Evaluation
Reassessment
Avoid complications after stroke
• painful shoulders
• pressure sores
• contractures
• incontinence
• malnutrition
• aspiration pneumonia
Avoid complications after stroke
Avoid complications after stroke
Don’t
•
•
•
•
…pull on the hemiparetic arm
…get the patient to squeeze your fingers
…leave the patient in one position
…catheterise if possible
Avoid complications after stroke
Do
•
•
•
•
•
•
•
•
•
•
…sit the patient out
…use pressure relieving mattresses
…ask/check for pressure sores
…check the swallow
…check the mouth care
…ensure adequate nutrition
…toilet regularly
…assess orientation
….Make a difference
…assess mood
…talk
Planning – Goal setting
• A process of discussion and negotiation in which the
patient and staff determine the key priorities for
rehabilitation for that individual, and agree the
performance level to be attained by the patient for
defined activities within a specified time frame.
• A key element in the rehabilitation process.
• Commonly employed as a technique to actively
engage patients in their rehabilitation programme.
• Occupational/organisational literature 1970s
Planning – short term goals
• To wash my face and clean my teeth standing at the
sink with an upright posture
• To wash myself in sitting, reaching down to my feet
• To dress my top half, following written prompts
• To move independently from sitting to lying in the
gym
Planning – long term goals
To return home able to
• …Walk indoors with my frame feeling more confident
• …Participate in personal care and light domestic tasks
incorporating standing
• …Able to turn myself in bed
• …Able to complete car transfers independently
With advice on:
• …Exercise programme
• …Bladder and bowel management
• …Standing programme/tone management
Who should be referred?
• In-patient or out-patient
• Patients
–
–
–
–
who are medically stable (-ish)
with multiple interacting problems
who need input from two or more disciplines
with potential to make functional gains
• Before you refer identify any previous input
and its outcome
Compensation versus Recovery
“…it is useful to divide
neurorehabilitation into
(1) measures primarily aimed at
assisting adaptation to (or
compensating for) impairment, and
(2) those primarily aimed at reducing
impairments
The latter address underlying
neurological deficits more directly
but are relatively poorly understood”
….. and are based on advances in our
neuroscientific understanding of how
the brain is organised
What is brain plasticity?
Axon arborisation in vivo
Hua et al., Nature 2005; 434: 1022-1026
Niell et al., Nat Neurosci 2004; 7: 254-260
Dendritic growth in vivo
dendrites
axon
What is brain plasticity?
affected
side
A
10 days
post stroke
infarct
B
17 days
post stroke
24 days
post stroke
31 days
post stroke
3 months
post stroke
affected
side
OUTCOMES
Barthel
ARAT
GRIP
NHPT
Patient A
20/20
57/57
98.7%
78.9%
Patient B
20/20
57/57
64.2%
14.9%
When is best to treat?
1. EARLY – helps avoid complications
2. Natural history of recovery may be misleading
3. Can late treatment change impairment?
This patient made 90%
improvement 20 years after stroke
Treating upper limb impairment
Task specific training is better than general exercise –
motor learning?
Works better in patients with reasonable residual
motor control
Optimal dose is important but not clear
Motor practice/ Motor learning
Constraint induced therapy
Robotic assisted devices
Virtual environments
Treating upper limb impairment
Treating upper limb impairment
Doeslanguage
it work impairment
- Dose
Treating
Problem: average amount of out-patient speech therapy ~ 12 hours
Predicting recovery after stroke
Predicting recovery after stroke
Stinear, C. M. et al. Brain 2007 130:170-180
Predicting recovery after stroke
Recovery and rehabilitation after stroke
• Rehabilitation required by everyone (motor, language,
cognitive)
• Rehabilitation starts on day 1 through MDT
• Avoid complications
• Goal setting is done for patients benefit
• Intensity and dose of intervention mahes a difference
• Never too late ….. As long as complications are
avoided