Dr. Sindhu Pandit, MD, MBA

800,000 new strokes

10% of stroke survivors recover almost completely

25% recover with minor impairments

40% experience moderate to severe impairments requiring special care

10% require care in a nursing home or other long-term care facility

15% die shortly after the stroke

The Impact

- National Stroke Association

“There is increasing evidence that rehabilitation can have

a big impact on survivors’ quality of life, so the time is right to review the evidence in this complex field and highlight effective and important aspects of rehabilitation,”

- Carolee J. Winstein, Ph.D., lead author of the scientific statement published in the May 2016 issue of the American Heart Association journal Stroke

Prevent Complications

Minimize Impairments

Maximize Function

Goals of Rehabilitation

Depending on the severity of the stroke, rehabilitation

options can include:

A rehabilitation unit in the hospital with inpatient therapy

A subacute care unit

A rehabilitation hospital with individualized inpatient therapy

Home therapy

Returning home with outpatient therapy

A long-term care facility that provides therapy and skilled nursing care

Post Acute care

- National Stroke Association

Recovery

Resolution of edema surrounding the area of the infarct

Reperfusion of the ischemic penumbra

Diaschisis - state of low reactivity or depressed function as a result of a sudden interruption of major input to a part of the brain remote from the site of brain damage

With injury to one area of the brain, other areas of brain tissue are suddenly deprived of a major source of stimulation

Stroke Rehabilitation Clinician's Handbook – Canadian Partnership for Stroke Recovery

Later Recovery

Neuroplasticity - the ability of the central nervous system (CNS) to undergo structural and functional change in response to new experiences

Stroke Rehabilitation Clinician's Handbook – Canadian Partnership for Stroke Recovery

Timeline

Majority of neurological recovery occurs within the first 1- 3 months

Formal rehab continues for approximately 3-4 months after the event

Ongoing recovery for 6 months to a year

The two most important factors which predict motor

recovery are:

Stroke Severity: The most important predictive factor which reduces the capacity for brain reorganization

Age: Younger patients demonstrate greater neurological and functional recovery and hence have a better prognosis compared to older stroke patients

Predictors

Adunsky et al. 1992; Hindfelt & Nilsson 1977; Marini et al. 2001; Nedeltchev et al. 2005

Medical Management in the Rehab Setting

Prevention of Skin breakdown and Contractures

Prevention of DVT

Bowel and Bladder Management

Hemiplegic shoulder pain

Central Pain

Fall Prevention

Seizure Prevention

Poststroke Depression

Poststroke Osteoporosis

Functional Assessment

Motor Impairment

Mobility

Balance

Cognition and Memory

Communication

Hearing/Visual Impairments

Dysphagia

Traditional rehabilitation practice has often focused

on strengthening exercises and compensatory training

Emerging studies/approaches emphasize restorative treatments to reestablish lost functions through intensive task-based practice or direct brain stimulation

Approaches to Rehab

Stroke Rehabilitation: Strengthening Synapses to Achieve Optimal Outcomes By Mosunmola Oyawusi, MD; Uri Adler, MD; and A.M. Barrett, MD Today’s Geriatric Medicine, Vol. 7 No. 5 P. 12

Constraint-induced movement therapy (CIMT)

Immobilizing the unaffected limb restored competent, symmetric movements in the affected limb

CIMT example

Approaches used in Rehab

Functional Electrical Stimulation (FES)

Paretic muscles can be made to contract by applying electrical currents to the intact peripheral motor nerves innervating them.

electrically elicited muscle contractions are coordinated in a manner that provides function

FES example

Approaches to Rehab

BiManual Arm trainer

Undergoing clinical trials

“… simulated canoeing device at NYU Langone engages both arms simultaneously in an effort to retrain the paralyzed hand and the affected portion of the brain”

Approaches to Rehab

“High-Tech Tools Show Promise for Stroke Recovery” Author: Emma Court, WSJ June 2016

Approaches to Rehab

Body-Weight-Supported Gait Training

Allows the patient to practice complex gait cycles unweighted

Allows the patient to practice nearly normal gait patterns and to avoid developing compensatory walking habits, such as hip hiking and circumduction

Involves the patient being suspended in a harness system hanging from an overhead frame

Traditionally, the frame is situated over a treadmill or flat ground, with 1 to 2 physical therapists providing assistance for balance and advancement of the paretic limb

Approaches to Rehab

Rehabilitation—Emerging Technologies, Innovative Therapies, and Future Objectives Nneka L. Ifejika-Jones & Anna M. Barrett

Robotic-assisted body weight supported treadmill training using over-ground gait training (OGT) in adults with chronic stroke

Approaches to Rehab

Approaches to Rehab

Powered exoskeleton-assisted walking

Exo-Skeleton Example

Approaches to Rehab

Stimulation-Based Approaches

Transcranial magnetic stimulation (TMS)

- electromagnetic technology to create an electrical current that can depolarize neurons

Approaches to Rehab

Stroke Rehabilitation: Strengthening Synapses to Achieve Optimal Outcomes By Mosunmola Oyawusi, MD; Uri Adler, MD; and A.M. Barrett, MD Today’s Geriatric Medicine, Vol. 7 No. 5 P. 12

Stimulation-Based Approaches

Transcranial direct current stimulation (tDCS)

- electrical stimulation to enhance cortical excitability

- Saline-soaked pads placed on the scalp apply a very weak current in 10 - 30 minute sessions to modify rather than generate neuronal activity in cortical neurons by generating an electrical field that fosters neural network interaction

Approaches to Rehab

Stroke Rehabilitation: Strengthening Synapses to Achieve Optimal Outcomes By Mosunmola Oyawusi, MD; Uri Adler, MD; and A.M. Barrett, MD Today’s Geriatric Medicine, Vol. 7 No. 5 P. 12

The better we understand the choices we have been

making, either consciously or unconsciously, the more say we will have in the world we create. Neurocircuitry may be neurocircuitry, but we don't have to run on automatic.

- Jill Bolte Taylor

My Stroke Of Insight

Thank you!