Stroke Rehabilitation at a Crossroads: Will We Be Just Good or Will We Be Great? Robert Teasell MD FRCPC Professor, Physical Medicine and Rehabilitation Western University Parkwood Institute Research, Lawson Research Institute 1
Faculty/Presenter Disclosure Faculty : Robert Teasell Relationships with commercial interests : Grants/Research Support : Allergan Speakers Bureau/Honoraria : Allergan (2015) Consulting Fees: None Other : None
Conflicts of Interest Allergan – research grant
Objectives 1. Appreciate key principles in stroke rehabilitation needed to maximize stroke rehabilitation outcomes 2. Understand the challenges in how those principles are operationalized in the real world. 4
Stroke Impact • Stroke is a common life-altering event • In Canada 62,000 people per year suffer a stroke and >405,000 are living with stroke complications of stroke; will increase over next 2 decades. • 36-42% stroke survivors with discernable disability or still dependent for ADLs 5 years post stroke (Hankey et al 2002; Hackett et al 2000). • Caregivers experience increase in physical demands (Sit et al 2004) along with decrease in health-related quality of life (Godwin et al 2013); 2.5X greater risk of psychological distress (Simon et al 2009). • Up to 50% of chronic stroke patients report depression (Visser-Meily et al 2008). Hankey et al. Stroke 2002; 33(4):1034-40 Godwin et al . J Neurosci Nurs 2013; 45(3):147-54 Hackett et al. Stroke 2000; 31(2):440-7 Simon et al. Soc Sci Med 2009; 69(3):404-10 Sit et al. J Clin Nurs 2004; 13(7):816-24 Visser-Meily et al. Patient Educ Couns 2008; 73(1):153-8
21 st Century Stroke Rehab in Canada • Exponential increase research evidence-base ( >300 RCTs/yr) (www.ebrsr.com ) • Initiated Ontario Stroke Strategy in 1999, followed by Canadian Stroke Network and Strategy, followed by Ontario QBP; Canadian Stroke Guidelines (6 th edition) (Hebert and Teasell et al. 2016) • Over past decade dramatic changes in stroke rehab; in Ontario, FIM efficiency has almost doubled; 1.0 is new normal; proportion of severe strokes admitted up to 41%; Ontario leads the country • Early, intensive, task-specific, organized care (EITSOC) is becoming recognized standard across Canada; in Ontario wait times are down • Innovative new approaches to achieve EITSOC commonplace across Canada • Stroke rehab is integrating into stroke continuum and last 5 years a big push to better organize and improve rehab services across Canada Hebert D, Lindsay P, … Teasell R. International J Stroke July 2016
Stroke Rehabilitation at a Crossroads As we are achieving many of our provincial goals, the question is how do we get better? Directions for Stroke Rehabilitation 1. Better Understanding Stroke Rehab and Recovery 2. Standardizing Care: Guidelines, Benchmarking and Increased Accountability 3. Role of Technology/Medications 4. Shifting Rehabilitation to the Community 8
Stroke Rehab and Recovery 9
Brain Reorganization • The brain has significant capacity to reorganize itself to recover from loss of function following a stroke; depends on training or rehab Rehabilitation training (enriched environments with animals) increases brain reorganization with subsequent functional recovery In animal studies key factors promoting recovery include increased activity and a complex, stimulating environment Lack of rehab causes decline in cortical representation and delays recovery
Brain Reorganization • Key elements of stroke rehab should be increased activity and a complex and stimulating environment
Recovery Post-Stroke Recovery after a stroke is associated with cortical reorganization Motor recovery is a complex process combining: 1. Neurological or Spontaneous Recovery. Recovery of impairment or normal way of moving as measured by Fugl- Meyer score or 3D Kinematics (restoration of normal motor patterns) 2. Functional Recovery. Recovery of tasks or activities often through learned compensatory movements (new motor patterns) as measured by ARAT, Barthel Index or arguably the FIM Both involve changes to the remaining motor cortex and relationship is not fully understood
Motor Learning Theory Rehab has been transformed over the last two decades by the concept that: 1. repetitive practice, 2. of increasingly challenging task-related activities, 3. assisted by a therapist in an adequate dose, 4. will lead to gains in motor skills, 5. through brain reorganization. (Dobkin 2016) Dobkin et al. Neurorehabilitation and Repair 2016
Recovery by Fixed Proportion (Spontaneous Recovery) • Within 6 mos upper limb impairment resolves by fixed proportion • For those with weakness secondary to cortical damage but relatively intact corticospinal (motor) tract function, 70% of maximum possible improvement occurs regardless of initial impairment (i.e. Fugl-Meyer score) (Prabhakaran et al 2008) • Holds true for patients across all ages and countries with different rehab services (Byblow et al. 2015) • Exception is irreversible structural damage to the corticospinal tract severely limits recovery of the upper limb movement (Stinear et al 2007; 2012) Prabhakaran et al. Neurorehabil Neural Repair 2008; 22:64-71 Byblow et al. Ann Neurol 2015; 78:848-859 Stinear et al. Brain 2007; 130:170-80. Stinear et al. Brain 2012; 135:2427-35
Proportional Resolution of Upper Limb Impairment • Proportional resolution of U/E impairment is minimally affected by rehab therapy • 3D kinematics in subacute and chronic stroke victims have shown motor recovery associated with rehabilitation is driven more by adaptive (or compensatory) learning strategies (Jolkkonen and Kwakkel 2016) • Most clinical tests (i.e. Action Reaction Arm Test (ARAT) or walking speed 6MWT) only assess a patient’s ability to accomplish a certain task or function; do not measure impairment (Jolkkonen and Kwakkel 2016) • Rehab promotes largely, likely entirely, adaptive or compensatory motor recovery and brain reorganization reflects that relearning by remaining functioning brain. Jolkkonen and Kwakkel. Translational Stroke Research 2016
Predict Recovery Potential (PREP) Algorithm • Combines clinical measures and biomarkers to predict upper extremity recovery. • Step 1 (<72 hrs post stroke). Assessment paretic shoulder abduction and finger extension (SAFE score) (sum of Medical Research Council scores max =10); SAFE > 8 Excellent potential; <8 move to Step 2. • Step 2 (10 days post stroke): Transcranial Magnetic Stimulation : MEP present = Good potential; MEP absent = Limited or No Potential; then move to Step 3 which involves diffuse-weighted MRI to determine assymetry of mean fractional anisotropy of posterior limbs of internal capsule . • In New Zealand in a comparative study of 192 stroke patients , pts with PREP algorithm result revealed had reduced length of hospital stay of 1 week ; algorithm successfully predicted patient outcome 80% of time. Stinear et al. Stroke 2017; 48:1011-1019.
Early Rehab • Animal studies suggest there is a time window when brain is “primed” for maximal response to rehab therapies, such that delays are detrimental to recovery (Bernaskie et al. 2004) • Brain is “primed” to “recover” early in post -stroke period • Clinical association between early admission to rehab and better functional outcomes (Paolucci et al. 2000, Salter et al. 2006 and Bai et al. 2012) • The effects of training after stroke are generally greater when started early after stroke , perhaps because of a “sensitive period” of enhanced Bernaskie et al. J Neuro sci 2004; 24(5):1245-54 neuroplasticity. Paolucci et al. Arch Phys Med Rehab 2000; 81(6):695-700 Bai et al. J Clin Neurosc i 2012; 19(10):1376-9 Salter et al. J Rehabil Med 2006; 38(2):113-7
AVERT Trial: Can Rehab Be Too Early? • Patients < 24 hrs post stroke randomly assigned to standard care (SC) (N=1050) or SC + Very Early Mobilization (VEM) (N=1054) until discharge or 14 days • 56 site international RCT over 8 years • VEM group started earlier (18.5 vs. 22.4 hrs post stroke), got more out of bed sessions (6.5 vs. 3.0) and received more therapy (31 min/day: total 201 min vs. 10 min/day: total 70 min) • More pts in Usual Care (n=525) than VEM (n=480) (p=.001) had favourable outcome (modified Rankin Scale [0-2] at 3 mos post stroke) • Later analysis (Bernhardt et al. 2016) found improved odds of favourable outcome with increased daily frequency of out-of-bed sessions • Overall, shorter more frequent early mobilization improves chance of regaining independence; higher doses of long-term mobilization worsens outcomes. The AVERT Trial Collaboration Group. Lancet 2015; 386:46-55 Bernhardt et al. Neurology 2016; 86:2138-2145
Role of Intensity of Therapy • Greater intensity of practice results in better outcomes most of the time • However, research with animals involves thousands of repetitions • Pollock et al. (2014) in a review of upper extremity stroke rehab found that “adequately powered high - quality RCTs confirmed the benefit of … a high dose of repetitive task practice”. • Van Peppen et al. (2004) noted additional therapy time of 17 hours over 10 weeks is necessary to see significant positive effects ; affirmed by Verbeek et al. (2014) • Canadian Stroke Guidelines note stroke rehab patients should receive a minimum of three hours of direct task-specific therapy, five days a week , delivered by the inter- professional team. Van Peppen et al. Clinical Rehab 2004; 18:833-862. Verbeek et al. PLOS ONE 2014; 9(2):e87987
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