1. Challenging issues in Stroke RehabilitationAlirezaAshraf, M.D.Associate Professor of Physical Medicine & Rehabilitation Shiraz Medical school

2. The effect of timing on rehabilitation- Fewer days between the onset of stroke and admission to inpatient rehabilitation : * Better functional outcome regardless of initial severity * shorter stay in hospital - Transfer of patients to rehabilitation before they are medically stable. (Horn SD etal,2005)- Earlier gait activities: significant association with outcome, regardless of how much additional therapy or admission functional level (Horn SD et al, 2005)

3. Intensity of rehabilitation- Weakly correlated with improved functional outcome.(cifuDx et al , 1999 ), ( Duncan pw et al , 2005)- Less intense (30-45 min/day ) task-specific training regimens with the more affected limb:produce cortical reorganization and meaningful functional improvements ( page SJ, 2003)- Too much or the wrong type of activity early in the rehabilitation of the upper limb: worse outcome & increasing spasticity . (Turton A et al, 2002)

4. -Massed versus Distributed practice schedules: Less rest between performance epochs has a detrimental effect on learning so , “ massed practice” may be impractical. (Dobkin BH , 2004)- Intensity of Training: Total time of practicing is less important than the nature of practice (Bell KR et al, 2005)- Contents of Training : * Enriched environments better than standard one * Low evidence in humans.

5. Stroke unit VS General ward * lesser cost * more favorable outcome * shorter stay in hospital ( kalra L, 1994) Age * Although age has a significant impact , it is a poor predictor of individual functional recovery and can not be as a limiting factor in rehabilitation ( kugler c et al , 2003) , (Bagg S et al , 2002)

6. Ashworth scale VS Tardieu scale * Ashworth and Modified scales: * low intra-rater and inter-rater reliability * “clustering” effect of the patients in the middle grades * Tardieu scale: * Not only quantifies the muscles reaction to stretch, but it controls the velocity of the stretch and measures the angle at which catch or clonus occurs. * spasticity angle: Difference between the angle at the end of passive range of motion at slow speed and the angle of catch at fast speed This angle estimates contributation of spasticity and mechanical restraint of soft tissues.

8. -Evidence for the use oral antispastic medications in stroke is weak(Montane A, et al , 2004)- Due to complications : “ start low and go slow” * Rather than higher doses of one drug, a combination of lower doses of 2 drugs may be better tolerated (Nance p , 2001) * Taper slowly- Higher doses of BTX-A : Greater hypertonia reduction without any advantage in the duration of effect. (smith SJ et al ,2000)

9. The incidence of antibody to BTX in the spastic hypertonia: Less than 1% (yablon SA et al, 2005) & (Turkel C et al , 2002) - Repeated injection: Effective& safe (Nauman M et al , 2006) - Amount of saline : *No difference for dilution of Botox (Franisco GE et al , 2002) * Greater amount (ie , 5 cc) is superior. (Gracies JM et al, 2002) - Role of adjunctive therapy modalities after BTX-A injection: No any systematic review

10. Central post-stroke pain- pain associated with vascular lesions of CNS. - Following lesions at any level in the spino-thalamo-cortical pathway(i.e., lateral medulla oblongata , thalamus, posterior limb of internal capsule , …)- Incidence: 2%- 11% - onset: 20% immediately. 50% within first month 30% until 3 years

11. Affected area varies, ranging from the entire of the involved side - of body, to a small anatomic area (Depends on the location of the lesion)- The area with sensory loss > The area of pain - Burning sensation : most common (60%) - Even pruritis can be seen- Most common abnormality in physical exam: Dysesthesia- Hallmark : Allodynia(in about 50%) - Hypoesthesia: Near all of them have to temperature- similar lesion in the same area : Different pain symptoms

12. Treatment- Antidepressants: * Amitriptyline is the most effective followed by nortriptyline * caution in patients older than 65 - antiepileptics: * Gabapentine: - High dose - Just clinical experience - opioid: Ineffective

13. Migraine: Is it an etiology?- Controversial: (change of definition of migraine, migraine- like features due to large vessel dissection, Difficulty to obtain true history) -Migrainous infarction: - Fixed , focal neurologic deficit following an attack - 0.5%- 1.5% of all ischemic strokes and 10-14% of ischemic stroke in young patients (Bousser MG et al , 2005)- More often in migraine with aura- Mechanism: unusually severe cortical hypoperfusion. - 30% of infarction in occipital lobe - 2.7 times increased the risk of ischemic stroke in women. (Etminan M et al , 2005)- Rise in the risk who smokes or uses OCP. (Lampl c et al , 2006)

14. “ OCP”- No risk with current low- dose in women without Vascular risk factors. - Even low dose OCP with caution in : - Migraine - smoker - HTN ( American college of OB & Gyn, 2006)

15. Hypertension and stroke - Important for an initial than a recurrent stroke- stroke occurrence: Depends more on the duration of hypertension than on the current level of blood pressure - Treatment of only severe hypertension in a patient with stroke: Reduces the rate of recurrence significantly- optimal drug regimen: * uncertain * with history of MI: Beta- blocker+ ACE inhibi .

16. Acupuncture and stroke - In several systematic reviews the effect is weak or nonexistent . (zhang SH et al, 2005) ( wu HM et al , 2006) - Other outcomes rather than motor recovery: * postural control * Improvement of walking speed * Improvement of dysphagia ( seki T et al , 2005)- Conclusion: In the absence of any specific medical contraindications , it is safe and well- tolerated . So , in some situations try of this is recommended.

17. “Task- oriented Training to promote upper extremity Recovery” - A dominant approach to motor restoration.- Definition: - As a Top- Down approach in “WHO” definition - Motor learning , Goal- directed training - patient as an active problem-solver and focus of rehabilitation on acquisition of skills. - Task: * challenging to achieve, involve real objects and activities, goal- directed in nature. * Distinct from exercise- based movements that can be abstract and without functional goal - skill: - Desired outcome of a task- oriented program - Ability to achieve a goal (task) with consistency , flexibility and efficiency. (Q uinn L etal , 2003)

18. “Ottawa panel evidence-based clinical guidelines (EBCPG)” - Dividing ADL into component parts - practice of individual components then combine them- NOT consistent with supporting evidence & misses the essential outcome of Task-oriented approach (skill).

19. Task-oriented Training VS. Neuromuscular Re- education - For example: Brunnstrom, Bobath, Rood, knott and Doman- Delgado. - Their bases never externally validated. - Very few outcome measures existed. - Focus just on the impairment without attention to voluntary participatory behaviors or quality of life.

20. What are the active ingredients? 1- Challenging : * should be enough to require new learning with attention to solve the motor problem (plautz EJ et al , 2000) 2-Progressive and optimally adapted: optimally adapted to the patient’s capability and the environmental context , not too simple or repetitive to challenge and not too difficult to cause a failure of motor learning (Lee TD et al , 2005) 3-Interesting enough to invoke active participation: * to engage a “ particular type of repetition “ referred to as “problem- solving” * Voluntary movement elicits motor learning more than passively induced movement. (Lotze M et al , 2003)