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

• cognitive status is the most important factor
• delirium is a risk factor for poor outcomes
• level of independence prior to stroke

Complications

• bladder dysfunction
  • urinary incontinence (60% in 1st week)
  • urinary tract infection (40%)
• dysphagia: risk of aspiration
• pain
  • musculoskeletal (very common)
  • central (neurogenic pain) (< 5%)
    • most common after thalamic-parietal stroke
    • agents:
      • antidepressants (SSRI, TCA)
      • carbamazepine
      • clonidine
      • gabapentin
      • benzodiazepines
      • baclofen
• depression
  • very common
  • agents:
    • antidepressants (SSRI, TCA)
    • methylphenidate
  • counseling
• skin ulcers
• seizures
  • 5% within 2 weeks, most within 72 hours
  • focal & generalized seizures
  • prophylactic anticonvulsants
    • in general, not necessary
    • often used following subarachnoid hemorrhage
• sleep disorders (1/3)
  • reversal of sleep-wake cycle common with cognitive dysfunction
  • polysomnography if obstructive sleep apnea suspected
• spasticity
  • dantrolene 25 BID -50 mg QID
  • baclofen 5 mg BID - 40 mg QID
  • clonazepam 0.5-2.0 mg BID/TID
  • tizanidine 2 mg BID - 8 mg QID
  • locally injected botulinum toxin
• sexual dysfunction
• cognitive dysfunction & dementia
  • neuropsychologic testing
  • memory loss & hemi-inattention or neglect most common
  • 9-fold increased risk of dementia in 1st year after stroke
  • stroke severity & cognifive impairment affect choice of appropriate therapy
• deconditioning is common
  • fatigue associated with lower extremity weakness

Management

• goals:
  • optimize physical, cognitive, behavioral, psychosocial & vocational potential
• Health care team:
  • neurologist
  • psychiatrist
  • primary care physician
  • nurses
  • physical therapist
  • occupational therapist
  • recreational therapist
  • speech therapist
  • social worker
  • neuropsychologist
  • orthotists
  • dietician
  • bioengineers
• Assessment:
  • measures of independence in activities of daily living
    • Barthel index
    • functional independence measure
  • disability
  • handicap
  • within 1st 2-3 days after stroke
    • physical therapy & occupational therapy evaluation
    • assessment of swallowing
  • Postural Assessment Scale for Stroke can be used for prediction of independent ambulation for stroke patients after a course of inpatient rehabilitation
• Settings:
  • in the home
    • able to sit for 1 or more hours
    • adequate support facilities
    • improvements similar to high-tech equipment
    • generally reserved for patients requiring a slower pace of neurorehabilitation
    • frequent therapist visits reduces hospital readmission & mortality
    • 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
    • setting of choice if patient has returned home, not eligible for Medicare reimbursement of rehabilitation in skilled nursing facility
    • home-bound by Medicare standards
  • skilled nursing facilities (SNF)
    • generally reserved for patients requiring a slower pace of neurorehabilitation & lack of in home support facilities
    • repetitive task training delivered in a SNF improves upper limb & lower limb function, walking distance, & walking ability after acute stroke
    • requires 3 day hospitalization for Medicare reimbursement
  • 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
• Physical therapy for mobility:
  • deconditioning is common
    • recovery of ambulation correlates with leg strength
  • cardiovascular training, especially walking, can improve walking speed
  • 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
• Occupational therapy for self-care:
  • 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
• Language therapies:
  • aphasia in 18%
  • recovery generally within 10 weeks, less for milder strokes
• pharmacologic therapy
  • selective serotonin reuptake inhibitor (SSRI)
    • may improve rehabilitation outcomes after stroke
      • may help treat new-onset depression after stroke
      • not recommended for preventing depression
    • SSRI benefit even if patient does not meet criteria for depression (GRS9); GRS11 walks this recommendation back
    • no motor benefit from 6 months of fluoxetine use after stroke
  • no benefit of dextroamphetamine prior to physiotherapy
  • exercise more effective than antiplatelet agents &/or anticoagulants
  • direct oral anticoagulants are not approved for post-stroke DVT prophylaxis
    • use LMW heparin
• electromagnetic stimulation
  • cerebellar intermittent theta-burst stimulation promotes gait & balance recovery in patients with stroke by acting on cerebellar-cortical plasticity
  • Vivistim vagus nerve stimulation paired with rehabilitation FDA-approved to treat upper extremity motor deficits after ischemic stroke
• 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
• transcranial direct current stimulation may be of benefit in patients with aphasia after stroke
• cardiac rehabilitation may benefit stroke survivors
  • mixed aerobics & walking most beneficial
• vigorous walking exercise can improve walking capacity within 4 weeks, but >= 12 weeks are needed to maximize gains
• repeated 1-minute bursts of high-intensity interval training
  • more effective than moderate, continuous exercise for aerobic fitness after stroke
• 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
• formal fall prevention program prior to hospital discharge
  • 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

More general terms

• rehabilitation

More specific terms

• cognitive rehabilitation

Additional terms

• stroke; cerebrovascular accident (CVA)