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Understanding recovery of movement a2er stroke

Fact or Fiction

Presented by: Anne Burleigh Jacobs, PT, PhD www.sensomotor.com

Photos from website images

A few facts about Stroke Leading cause of long-‐term disability in the United States

Stroke occurs when blood flow to the brain is interrupted. Ø  Ischemic = Clot = Approx 87% of all strokes

Cryptogenic = about 1 in 3 ischemic strokes of unknown cause Ø  Hemorrhagic = Bleed = Approx 13% of all strokes Ø  TIA = Transient Ischemic APack = short lasQng clot

A few facts about Stroke Treatment Emergency Medical Care is CriQcal to Recovery

Fewer than 10% of Americans know the signs of stroke. Ø  Treatment with tPA improves recovery outcome.

Ø More hospitals are invesQng in tPA treatment, telemedicine and stent retrievers, but not enough stroke vicQms are geUng to the hospital in Qme.

Ø  SomeQmes the family must educate the doctors/nurses.

We all have an obliga-on to educate people around us about stroke

Anne Burleigh Jacobs, PT, PhD – March 2017

Fact or Fiction

ì  The majority of stroke survivors fail to thrive following a stroke.

MulQple studies try to develop tools to predict outcome / recovery

Ø  Financially driven Ø O9en self-‐limi-ng

Ø  Set false deadlines Ø O9en do not consider the pre-‐stroke person


“To Survive” versus “To Thrive”

ì  To Survive = to succeed in keeping alive against the odds, to live a2er some event that has threatened one’s existence

25% of those who survive a stroke are left living with minor disability, approx 40% have more severe disabilities.

ì  To Thrive = to succeed in being successful or happy in a parQcular situaQon, especially one that other people would not enjoy


Fact or Fiction

ì  All of the cells in the area of brain injury are dead.

Photo courtesy of WebMD


“Silent Brain does not equal Dead Brain”

ì  Cells that have been denied oxygen/glucose and have died

Different Zones of Injury

ì  Cells that have reduced oxygen/glucose that reduce their cell funcQon in effort to survive

ì  Cells that have lost communicaQon from the injured region of the brain


Fact or Fiction

ì  Only older people suffer from stroke.


“Recovery differs from ReLearning”

ì  Under the age of 55 Ø  High blood pressure, smoking, diabetes Ø  Women rapidly surpassing men Ø  Family History

Approximately one in every four stroke vic-ms is under the age of 65. Of those nearly 200,000 people

ì  Stroke in children Ø  Heart defects , Vascular DissecQon Ø  Sickle Cell Anemia Ø  More recently diabetes and obesity related


Fact or Fiction

ì  Most recovery from stroke has occurred in the first six months. AOer a year, people should not expect much more improvement.


“Recovery differs from ReLearning”

ì  IniQal six weeks to six months, swelling and inflammaQon recede

“… data show that stroke does not just cause focal, circumscribed damage but reorganizes the basic physiology and output proper-es of a distributed set of brain areas.” (Carmichael, 2003)

ì  Cells that have gone silent in effort to survive begin to turn back on – o2en without good corQcal regulaQon

ì  ReLearning / NeuroplasQcity takes a long Qme.


Fact or Fiction

ì  Recovery of is generally complete when the survivor is discharged from Therapy.

Photo courtesy of Duke Health Photo courtesy of John Hopkins


“Recovery is a Continuum”

ì  In-‐paQent

Different Phases of ReLearning

ì  Home-‐based

ì  Community-‐Based Ø  Community College Adap-ve Phys ED

Ø  Personal Trainer / Private Therapist Ø  Stroke survivor groups

Ø  Emerging Technologies and Rehab Tools Ø  ....

ì  Out-‐PaQent


Fact or Fiction

Internet Source.mp3ringtone.info

ì  No Pain, No Gain.


“Different types of pain post stroke”

ì  SomeQmes the stroke damage to the brain can make even normal touch feel painful.

Central Pain

ì  In other cases, pain is felt because of muscle Qghtness or shortening.

Pain Associated with Spasticity or HyperTonicity


“Different types of pain post stroke”

ì  Pulling the flaccid arm or Overstretching the shoulder as tone is developing.

Pain Associated with Over-Stretching

ì  A hand brace or ankle brace that does not fit properly can cause joint changes, skin breakdown, increased tone and pain.

Pain Associated with Poorly Fitting Orthotics


Photo courtesy of Saebo

Poorly fitting orthotics


Poorly fitting orthotics

NOT designed for walking


Fact or Fiction

ì  Walking should be iniTated as soon as possible aOer a stroke.

Human walking is a complex coordinaQon of Ø  Postural Orienta-on

Ø  Balance Ø  Strength

Ø  Sensa-on Ø  Timing


Postural Orientation

ì  Eyes Open – Eyes Open with Head Turn

ì  Eyes Closed -‐ Eyes Closed with Head Turn

Sitting – without any support

Standing – with a straight cane

ì  Eyes Open – Eyes Open with Head Turn

ì  Eyes Closed -‐ Eyes Closed with Head Turn


Learning to Walk ? Are these survivors ready to learn to walk?


Importance of the foot and ankle


Importance of the foot and ankle

Trulife AFO Phat Brace KickStart


Fact or Fiction

ì  Most stroke survivors never recover funcTon of their affected arm or hand.

The en-re upper extremity is designed to help the hand func-on.


“Do not hurt the shoulder”

ì  Post-‐stroke rehab o2en focuses on learning to live with one hand


ì  The subluxed shoulder is painful – protect it! Ø  Taping Ø  Electrical SQmulaQon Ø  Shoulder Slings (change as arm changes)


“Do not allow the hand to get fisted”


ì  The hand no longer has sensory input – touch it!

ì  Gentle range of moQon with rotaQon every day

ì  Exercises for the arm should always start lying on your back with support to the elbow and hand

ì  Change hand splints as the hand changes


Daily stimulation and stretch


Stage 1: No voluntary movement of limb can be initiated. No spasticity noted. The brain is in a state of “shock”

Stage 2: Basic limb synergies begin to appear. Spasticity is mild. Lower brain dominance as nervous system awakens

Stages of Recovery Brunnstrom 1966


Stage 3: Basic limb synergies seen with any effort to move. Spasticity is increased. Lower brain drives flexion of arm, extension of leg *

Stage 4: Some movements begin to deviate from synergies. Spasticity begins to decrease. Cortical areas begin to modulate the lower brain



Stage 5: Relative independence from the limb synergies. Spasticity is mild. Cortical control of movement continues to develop

Stage 6: Individual, isolated joint movements are possible. Spasticity is negligible Movement appears normal



Emerging Tools for Rehab

The landscape of tools for rehabilita-on post stroke is rapidly changing. Unfortunately, the average health care provider is not aware of the tools now available to stroke survivors. Insurance is slow to reimburse for many of these tools.

Presenta-on of products does not cons-tute endorsement of products


Tymo Therapy Plate www.tyromotion.com

v  Visual feedback: Computer monitor v  Standing v  Sit <-‐> to <-‐> Stand v  Weight-‐bearing thru Arms


The changing dynamics of AFOs

Ø  Energy Storage and Release

Ø  Dynamic Dorsiflex Assist

Ø  Flexible Forefoot Plate

Ø  AcQvates the calf muscles


Electronic Orthosis

Walk-Aide Bioness L-300

v  SQmulaQon of Peroneal Nerve for Dorsiflexion

www.bioness.com

www.walkaide.com

Bionic Leg

www.alterg.com

v  Sensors in Foot Plate v  Motor-‐driven Knee v  Auditory Feedback v  Stance Stability v  Extensor Assist v  DecceleraQon Assist

Alter-‐G

www.alterg.com

v  Air-‐filled Bladder v  Reduces Weight Bearing v  Sensory Drive to AmbulaQon v  Therapist Facilitated v  Reduced fear of falling

KickStart by Cadence

www.cadencebiomedical.com v  External Orthosis v  Spring Tensioner v  Assist Hip Flexion v  Facilitates Heel Strike v  Plantar flexion Block v  Stance Stability


TyroMotion

www.tyromoQon.com

Myomo

www.myomo.com

v  External Orthosis v  Biofeedback driven v  Motor Actuator v  Elbow Flexion v  Elbow Extension v  MyoPro has hand posiQoner

Saebo Therapies

SaeboFlex

SaeboGlove

www.saebo.com

v  Exercise Devise /FuncQonal Tone Management v  AcQve Flexion of Digits v  Turn Off v  Assisted Extension of Digits

Saebo MicroStim


Photo from Braintree Rehab

v  External Orthosis v  Five Electrodes: Thumb Extension Wrist Extension Finger Flexion / Extension v  BioFeedback Driven NMES

Bioness H-‐200 www.bioness.com


Leap Motion www.leapmoQon.com


www.flintrehab.com

Music Glove


Is there a fixed time frame for ReLearning ?

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