Serious games for upper limb rehabilitation following stroke
Rehabilitation Following CVA
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Transcript of Rehabilitation Following CVA
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Rehabilitation Following CVA
Nachum Soroker, M.D.Loewenstein Rehabilitation Hospital Raanana, and Sackler Faculty of
Medicine, Tel-Aviv University, Israel
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Lecture overview
• Epidemiological considerations in stroke rehabilitation.
• Brief survey of the brain vascular supply and of stroke syndromes.
• Principles of medical care and rehabilitation in stroke.
• Rehabilitation oriented assessment of structural impairment in different cortical regions following stroke.
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Stroke statistics
• Incidence: ~ 2000/106 per year First event / Recurrent events = 5/1
– ~ 30 % die within the first 3 weeks• Stroke – 3rd leading cause of death behind heart diseases
and cancer• 7.6 % of ischemic strokes and 37 % of hemorrhagic
strokes result in death within 30 days• Stroke death rate fell ~ 15% from 1988 to 1998
– ~ 30 % recover completely– ~ 40 % left with disability :
• ~ 90 % initially unable to walk• ~ 75 % initially have upper limb plegia / paresis• ~ 50 % have some language / speech problems
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Stroke statistics (cont.)
• Prevalence: ~ 6000/106 (60% - 3600 - disabled)• Recurrence rate following 1st stroke or TIA: 14 % within 1y• % survival in 1 and 4 years following ischemic stroke, in
different age groups:– <65y : 81, 70 | 65-74y : 81, 59 | 75-84y : 67, 42
• Stroke survivors - 24 % of all severely disabled people living in the community
• ~ 28 % of strokes occur in people under the age of 65• ~ 50-70 % of stroke survivors regain functional independence,
but 15-30 % are permanently disabled ; ~ 20 % require institutional care at 3 months after onset.
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Admission of the stroke patient to rehabilitation
• Pre admission (things to do in the general hospital):
– Establish diagnosis – Neuroimaging
– Reduce secondary brain damage (Neuroprotection?, TPA, Normoglycemia, Hypothermia?)
– Identify and treat risk factors
• HTN, DM, IHD post MI, AF, Dyslipidemia, Hypercoagulability & Thrombophilia, Smoking, Morbid obesity, Alcoholism, Vasculitis, Carcinomatosis
• Specific importance: Carotid stenosis, LV mural thrombus• In hemorrhagic conditions (SAH, ICH): Consider angiography / MRA / CTA
– Prevent complications (Aspiration pneumonia, UTI, Pressure sores, DVT - PE, Upper GIT bleeding, Convulsions)
– Select preventive strategy to reduce risk of recurrence
– Decide: Rehabilitation needed or not; if yes - where?
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Neuroimaging in the study of structural impairment
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CT lesion imaging in ACA, MCA and PCA infarctions
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CT lesion imaging in capsular-putaminal (A) and thalamic (B) hemorrhages
A B
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Application of the Lesion Effect Paradigm (LEP) in the study of structural impairment
Use of normalized lesion data in the study of aphasia
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Application of the LEP in the study of structural impairment (cont.)
Use of normalized lesion data in the study of neglect
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Cerebral blood supply
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Cerebral vascular territories
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Cerebral vascular supplycoronal section
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• Verify diagnosis
– Special care: ICH - r/o underlying malignancy or focal vascular pathology
• Complete identification and treatment of risk factors
• Adjust secondary prevention
– antithrombotics/anticoagulants, statines, ace-inhibitors, folate & Vit B
• Treat coexisting disease conditions
– Special care: IHD, peptic disease
Medical care and physician role in stroke rehabilitation
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Medical care and physician role in stroke rehabilitation (cont.)
• Prevent and treat complications– Aspiration pneumonia, UTI, Pressure sores, DVT & PE, Upper GIT
bleeding– Post-stroke depression, anxiety, hypoarousal, motivational problems– Post-stroke epilepsy– Post hemorrhage hydrocephalus
• Organize a coherent list of tasks and objectives to guide follow-up of the patient throughout the rehabilitation period – Disease processes, control of risk factors, secondary prevention– Impairment - Disability - Handicap
• Lead interdisciplinary team work
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Rehabilitation oriented assessment of structural impairment in sensory-motor cortex following stroke
MCA and ACA supply of the cortical sensory-motor cortex
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Rehabilitation oriented assessment of structural impairment in damage to the frontal lobes
• General: Impaired working memory; increased environmental dependency & reflexive behavior (stimulus boundness); impaired goal setting, behavioral planning and control.
• Dorsolateral prefrontal: Executive behavior deficits: Impaired data retrieval, set shifting, response inhibition, abstraction, creativity.
• Orbitofrontal: Social behavior deficits: Disinhibited, tactless, impulsive behavior; imitation & utilization behavior.
• Medial frontal: Motivational behavior deficits: Apathy, reduced interest & initiative.
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Rehabilitation oriented assessment of structural impairment in damage to the left peri-Sylvian regions
•General: Aphasic syndromes; acquired dyslexia; ideomotor & ideational apraxia.
•Posterior-inferior frontal areas: Speech production; phonology; syntax.
•Posterior-superior temporal areas: Speech comprehension; semantics.
•Inferior parietal regions: Reading; calculation; praxis; repetition; auditory-verbal short-term memory.
•Superior temporal regions: Auditory perception & gnosis.
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Rehabilitation oriented assessment of structural impairment in damage to the right peri-Sylvian regions
•General: Neglect phenomena; construction and dressing apraxia; impaired pragmatic control of language.
•Posterior-inferior frontal areas: Expressive prosody; contribution to pragmatics.
•Posterior-superior temporal areas: Receptive prosody; contribution to pragmatics.
•Inferior parietal regions: Spatial cognition; spatial motor behavior; spatial attention.
•Superior temporal regions: Auditory perception; music ?
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Rehabilitation oriented assessment of structural impairment in damage to occipito-temporal & occipito-parietal regions
•General: Impaired visual perception, and visually-guided behavior.
•Occipito-temporal regions: Impaired functioning of the “system of What” (ventral stream); visual agnosia; prosopagnosia.
•Occipito-parietal regions: Impaired functioning of the “system of Where” (dorsal stream); optic ataxia; neglect phenomena
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Rehabilitation oriented assessment of structural impairment in damage to structures of the limbic system
•General: Emotion; memory; motivation.
•Amygdala: Impaired emotional behavior.
•Hippocampus: Amnesia.
•Cingulum: Impaired motivational behavior; impaired attentional selection.