Stroke effects on cognition, mood and movement: Implications for practice

1. Stroke effects on cognition, mood and movement: Implications for practice Pamela W Duncan Ph.D., P.T, FAPTA, FAHA Duke University Thinking, Moving and Feeling September 6, 2007

2. Funding Sources • NIA Claude D Pepper Center: University of Kansas • NINDS/NCMRR LEAPS Trials • American Heart Association

3. Walking recovery post stroke • Of stroke survivors living in the community, 40% require assistance with walking, of those who are independent, 60% are limited in community ambulation-60 to 80% walk less than .8ms • Limitation in walking ambulation is among the most debilitating aspects of stroke sequelae

4. Range of Steps Taken 2 months Post Stroke (Individuals independently walking but <.8m/sec from the Leaps Trial)

5. Walking Recovery Post-Stroke • Macko- Topics in Stroke Rehabilitation Mar-April 2007 • 79 Chronic Stroke • Daily steps ( 1389 +/- 797) • Very few steps at high intensity > 30/steps per minute • Peak Oxygen Consumption was consistent with profound aerobic activity

6. Consequences are huge: • 73% incidence of falls • 4-fold increase in falls risk • Of those who fall, stroke survivors experience a 10-fold increase in hip fracture compared to non-stroke • Limited mobility leads to social isolation and depression

7. Whitson, et al: JAGS 2006 • Increase fractures rates in FRG 4-7 ..first year

8. Kaplan-Meier Results: Time to first fracture 2.7% 4.7% Estimated 1-Year Fracture Rate: 2.7% (95% CI 2.3-3.1%) Estimated 2-Year Fracture Rate: 4.7% (95% CI 4.1-5.3%)

9. Results: Total FIM Score and Fracture Risk after Stroke Discharge FIM Score <54 Discharge FIM Score >90 Discharge FIM Score 54-90 Time to first fracture (years)

10. Results: Total FIM Score at Discharge and Subsequent Fracture Risk Relative Hazard of Fracture FIM Score At Discharge

11. Conclusions • Fracture rates in this stroke cohort are 2-7 times higher than expected population rates • Characteristics associated with lower fracture risk after stroke - high cognitive FIM scores - black race - male gender • Stroke patients with intermediate functional impairment are more likely to fracture than those with severe or minimal impairment

12. Predictors of Recovery of Walking

13. Kaplan-Meier Estimates of Cumulative Probability of Achieving FIM Walking Independence Over 6 Months 100 90 80 70 60 50 40 30 20 10 0 0 1 2 3 4 5 6 7 8 9 % M (n=122) MS (n=111) MH (n= 35) MSH (n= 92) p < 0.0001 Months From the Initial Assessment

14. Percent of stroke patients with stationary gait function and leg motor strength recovery during conventional rehabilitation. N=804 95% get no better after 11 weeks with routine care. Jorgenson et al. Arch Phys Med Rehabil 1995

15. PT PT PT PT PT Current Model Healthy Mobility Activity & Participation Mobility Limitation (Gradual Onset) Mobility Limitation (Sudden Onset) Age in Years

16. Determinants of Gains in Walking Are Multifaceted and Depends on Severity • Poor Performers : 16% of variance in gains attributable to improvements in balance • High Performers: 28% of variance in gains attributable to improvements in peak VO2 and LE Fugal-Meyer • Pohl, Perra, Duncan et al: Neurorehabilitation and Neural Repair March 2004

17. Determinants of Limitations in Walking Are Multifaceted and Depends on Severity • Determinants of walking function after stroke: differences by deficit severity. Patterson et al Archives of PM&R 2006 • Long-distance walking is mostly explained by balance in those who walk slowly (< .48m/sec) but in those who walk faster ( >=.48m/sec) it is cardiovascular endurance.

18. Walking Recovery Following Stroke Intervention Mechanisms Mobility • Training Methods • Parameters (dosage) • - timing • - duration • - intensity • Adjunctive therapies • Contributions to walking • Neural- • Neuromuscular • Biomechanical • Cardiovascular • MOOD • COGNITIVE • Functional role • Community/social • Quality of life Abnormal Gait: - Gait Deviations - Increased energy expenditure - Increased risk of falls Can we map gait deficits onto the most efficacious treatment for gait deficit to get the most meaningful outcomes for mobility and ultimately quality of life.. from Rose DK and Duncan PW

19. Stroke and Cognitive Deficits • Focus of most assessements and practically all clinical trials have been measurement of physical deficits • 65% of stroke survivors show cognitive impairments • Cognitive deficits interfere with rehabilitation efforts and have been associated with additional strokes

20. Summary of Cognitive Deficits Seen in Stroke Syndromes According to Vascular Distribution and General Neuroanatomic Localization Donovan NJ, Kendall, DL, Heaton, SC, Kwon S, Velozo, CA, Duncan, PW. (Accepted) Conceptualizing Functional Cognition In Stroke. Neurorehabilitation and Neural Repair

21. Orpington Predicts Stroke Recovery ?

22. ORPINGTON PROGNOSTIC SCALE (CIRCLE THE APPROPRIATE RESPONSE) A. Motor deficit in arm Lying supine, patient flexes shoulder to 90 and is given resistance. 0.0 = MRC grade 5 (normal power) 0.4 = MRC grade 4 (diminished power) 0.8 = MRC grade 3 (movement against gravity) 1.2 = MRC grade 1-2 (movement with gravity eliminated or trace) 1.6 = MRC grade 0 (no movement)

23. B. Proprioception (eyes closed) - Locates affected thumb: 0.0 = Accurately 0.4 = Slight difficulty 0.8 = Finds thumb via arm 1.2 = Unable to find thumb C. Balance 0.0 = Walks 10 feet without help 0.4 = Maintains standing position (unsupported for 1 minute) 0.8 = Maintains sitting position 1.2 = No sitting balance

24. D. Cognition - Hodkinson's Mental Test: Score one point for each correct answer: 1. Age of patient 2. Time (to the nearest hour) I am going to give you an address, please remember it and I will ask you later: 42 West Street 3. Name of hospital 4. Year 5. Date of birth of patient 6. Month

25. 7. Years of the Second World War 8. Name of the President 9. Count backwards (20-1) 10. What is the address I asked you to remember? 42 West Street 0.0 = Mental test score of 1 0 0.4 = Mental test score of 8-9 0.8 = Mental test score of 5-7 1.2 = Mental test score of 0-4

26. Barthel Recovery > 90 at 3 Mos

27. Get to Places Out of Walking Distance at 3 Months (%)

28. Performance in Complex Environments • Yang et al : Gait and Posture, Feb 2007 • Even among highly recovered community ambulators post stroke, introducing divided attention tasks significantly changes gait variables and stability compared to healthy age matched controls.

29. McDowd J et al J of Gerontology 2003 • 55 individuals with stroke ( mean MMSE of 27) and 39 health older adults with no history of stroke • Stroke subjects have higher incidence of divided attention deficits and these deficits strongly correlated with limitations in physical functioning ( SIS) and social participation

30. Kemper et al: Aging, Neurpsychology and Cognition 2005 • Baseline language compared to language collected while performing concurrent motor tasks in stroke and age matched controls. • Healthy adults few costs to language in concurrent tasks, stroke survivors language was disrupted during concurrent tasks.

31. Stroke decreases cognitive reserve .. • Post-stroke – motor, visual, impairments require increasing dependence on cognitive reserve in order to compensate • Post-stroke individuals may be unable to draw upon sufficient cognitive reserve to successfully maintain balance and mobility

32. Post Stroke Depression • Occurs in approximately one third of stroke survivors • Associated with diminished recovery, lower recovery trajectories, even when adjusting for other important covariates, including stroke type and severity.

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36. Jorgensen et al , Stroke 2002 • Concluded that falls are more frequent among noninstitutionalized long-term stroke survivors than among community control subjects and that the risk of falling and depressive symptoms are related in stroke patients.

37. A Randomized Trial of Therapeutic Exercise in Sub-Acute Stroke Funded by NIA- Claude D Pepper Center Duncan, Studenski et al Stroke, September 2003

38. Purpose of the Post-Stroke Intervention Study • To determine the effect of a reproducible, physiologically based, progressive exercise program on strength, balance, endurance, and upper extremity function after stroke.

39. Methods • Prospective, randomized, single-blind clinical intervention trial

40. Sample: Inclusion Criteria • Age > 50 years old • Stroke onset within 30-120 days of randomization • Expected to live 6 months • Able to care for themselves prior to stroke • Lived within 50 miles of participating facility • Controlled blood pressure • Folstein Mini-Mental Status Exam score > 16

41. Sample: Inclusion Criteria • Ambulate independently for 25 feet • Mild to moderate stroke deficits: • Fugl-Meyer Score within 27-90 for total upper and lower extremity score • Palpable or more wrist extension • Orpington Prognostic Scale score within 2.0-5.2

42. Control Group • Received usual care as prescribed by their physicians • Visited by research assistant every 2 weeks • those in therapy got educational materials about stroke and community resources • those without or d/c’d from therapy had blood pressure, heart rate, and O2 saturation checked • Those receiving therapy • treating therapist completed log of content of program (intensity, duration, and activity type)

43. Intervention: Characteristics • Protocol based structure with defined progression for each component • Therapist supervised, in-home exercise program • Frequency: 3 times/week for minimum of 32 visits or 12 weeks • Session duration: 90 minutes

44. Components of Intervention • Flexibility • Strengthening • PNF • Theraband • Functional Activities • Balance • Sitting • Standing – Static & Dynamic • Gait Challenge Endurance –Stationary Bike

45. Therapy Received

46. Therapy Received

47. Therapy Received

48. Change in Balance & Mobility Primary Outcomes

49. Change in Endurance Primary Outcomes

50. Studenski, Duncan et al: Stroke 2005Program to improve strength, balance and endurance improve depression • The intervention group improved more than usual care in • Emotion [5.6 points; P=0.0240] CONCLUSIONS: This rehabilitation exercise program led to more rapid improvement in aspects of physical, emotional, social, and role function than usual care in persons with subacute stroke..