Transcript My Head Hurts What’s new with headaches

Evidence Based Stroke
Rehabilitation
Scott Hardin MD
Medical Director
of Rehabilitation Services, Aurora St. Luke’s
Clinical Safety Officer, Aurora St Luke’s
Vice Chief of Staff, Aurora St Luke’s
Evidence Based Stroke
Rehabilitation
Disclosures
None
Evidence Based Stroke
Rehabilitation
Goals
Briefly review the history of stroke
Learn the pertinent epidemiological facts
of stroke now and into the future
Gain an appreciation that, despite there
being almost 1000 RCT regarding
stroke outcomes, we are still in the
infancy of understanding why we do
what we do
Evidence Based Stroke
Rehabilitation
Goals
Review data from the excellent resource
Evidence Based Review of Stroke
Rehabilitation (EBRSR)
Evidence Based Stroke
Rehabilitation
History
600 BC Hippocrates – 4 humours
160 AD Galen – advanced the humour
theory
1599 “the stroke of God’s hand”
1732 Robinson described the typical
apoplectic patient
Evidence Based Stroke
Rehabilitation
History
Mid 1600s Jacob Wepfer
cerebral hemorrhage
blocked cerebral arteries
1920s cerebral angiography
1935 blood letting debunked
Evidence Based Stroke
Rehabilitation
History
1950s first carotid endarterectomy
1960s Doppler ultrasound
1960s hypertension a modifiable risk
1970s aspirin
CT scanning
PET scanning
Evidence Based Stroke
Rehabilitation
History
1980s
stroke prevention/risk modification
smoking identified as risk
1990s
endarterectomy proven to be effective
anticoagulants and a fib
blood pressure and cholesterol
Evidence Based Stroke
Rehabilitation
History
1990s
tPA approved
combined dipyridimole and aspirin
2000s
acute cerebral artery thrombectomy
carotid artery stenting
Evidence Based Stroke
Rehabilitation
Epidemiology
>700,000 total strokes per year in the US
Mortality is still about 50%
However, stroke mortality fell 12%
between 1990 and 2000
Men 1.25 x risk of women
Blacks have 2x risk of stroke vs white;
Hispanic is in between
Evidence Based Stroke
Rehabilitation
Epidemiology
There are an estimated 5 million stroke
survivors in the US
More than 1.1 million with some form of
chronic disability
Baby boomers
Disability
Evidence Based Stroke
Rehabilitation
Why does rehab work?
Neural Plasticity – the ability of the brain to
reorganize and learn new functions
Evidence Based Stroke
Rehabilitation
Evidence based/Outcomes based data
In its toddlerhood
Will be important to show we matter
Soon, doing things because we think it
works won’t fly
Evidence Based Stroke
Rehabilitation
Evidence based/Outcomes based data
Indredavik et al 1990
randomized 220 strokes to the IRF*
unit or general medical unit
outcomes were home or not, mortality,
BI at 6 and 52 weeks, 5 years and
10 years
*IRF = Inpatient Rehabilitation Facility
Evidence Based Stroke
Rehabilitation
Evidence based/Outcomes based data
Indredavik et al 1990
Across all time frames statistically significant:
lower mortality in the IRF group
lower institutionalization in the IRF
group
higher home living in the IRF
group
higher BI scores in the IRF group
Evidence Based Stroke
Rehabilitation
Evidence based/Outcomes based data
Ronning and Guldvog – 1998
randomized controlled trial
251 strokes
compared community care (no IRF) to
IRF
outcome was dependence (BI<75) or
death
Evidence Based Stroke
Rehabilitation
Evidence based/Outcomes based data
Ronning and Guldvog – 1998
7 month follow up
23% IRF patients dead or dependent
vs 38% community care (p=.01)
39% reduction in worse outcomes with
IRF care
Evidence Based Stroke
Rehabilitation
Evidence based/Outcomes based data
Foley, et al 2007 Meta analysis of IRF
stroke unit trials
world wide
consistent statistical benefit of IRP
units over other types of post
stroke care in reductions in
mortality and less dependency
Evidence Based Stroke
Rehabilitation
Evidence based/Outcomes based data
EBRSR – Evidence Based Review of
Stroke Rehabilitation
2001
systematically reviews all outcomes
based stroke literature,
summarizes and grades it
www.ebrsr.com
Evidence Based Stroke
Rehabilitation
Evidence based/Outcomes based data
EBRSR reviews stroke literature relative to:
techniques
therapies
devices
procedures
medications
Evidence Based Stroke
Rehabilitation
Evidence based/Outcomes based data
EBRSR
extensive and comprehensive
database search strategies
3407 studies reviewed
2000 in depth studies reviewed
956 RCT
Methodological quality assessed using the
PEDro scale
Evidence Based Stroke
Rehabilitation
Evidence based/Outcomes based data
EBRSR
grading scale (based on the AHCPR)
Level 1a (strong)
Level 1b (moderate)
Level 2 (limited)
Level 3 (consensus)
Level 4 (conflicting)
Evidence Based Stroke
Rehabilitation
Evidence based/Outcomes based data
EBRSR
only the data from the 956 RCTs are used
for determination of evidenced based
recommendations
Evidence Based Stroke
Rehabilitation
Evidence based/Outcomes based data
EBRSR
Recommendations are broken into:
Efficacy of Stroke Rehab
Outpatient Stroke Rehab
Mobility/Lower extremity
Painful hemiplegic shoulder
Perceptual disorders
Dysphagia/Aspiration
Medical complications
Community reintegration
Young stroke
Outcome measures
Elements of Stroke Rehab
Secondary Prevention
Upper extremity
Cognitive/Apraxic disorders
Aphasia
Nutritional interventions
Depression
Miscellaneous
Severe Stroke
Stroke Triage
Evidence Based Stroke
Rehabilitation
Evidence based/Outcomes based data
EBRSR
Stroke Triage
early screening
early admission, but
patients with severe stroke better
managed in a less acute
setting
younger (<55) patients with moderate
to severe strokes should always
be admitted to IRFs
Evidence Based Stroke
Rehabilitation
Evidence based/Outcomes based data
EBRSR
Stroke Rehab Elements
care pathways don’t improve
outcomes or reduce costs
greater intensities of PT and OT
improve functional outcomes
unclear intensive language therapy
the greater functional improvements
from IRF care are maintained
long term
Evidence Based Stroke
Rehabilitation
Evidence based/Outcomes based data
EBRSR
Lower extremity and mobility
Bobath is as good but slower
focused balance training is beneficial
rhythmic auditory sensory stim helps
PBWS on treadmill questionable
strength training is beneficial
Evidence Based Stroke
Rehabilitation
Evidence based/Outcomes based data
EBRSR
Lower extremity and mobility
cardiovascular training is good
WC self propel does not help
using canes enhances mobility
e stim with gait training improves gait
EMG/biofeedback improves gait
training
Evidence Based Stroke
Rehabilitation
Evidence based/Outcomes based data
EBRSR
Lower extremity and mobility
tilt table or night splinting prevent
contracture
AFOs help
e stim and U/S reduce spasticity
Evidence Based Stroke
Rehabilitation
Evidence based/Outcomes based data
EBRSR
Upper extremity
initial degree of motor impairment is
the best predictor of motor
recovery
NDT is not superior
effects of enhanced therapy, task
specific training, sensorimotor
training and mental practice
unclear
Evidence Based Stroke
Rehabilitation
Evidence based/Outcomes based data
EBRSR
Upper extremity
hand splinting does not help
robots help a little
CIT helps
virtual reality helps
Botox helps tone/spasticity but
maybe not function
Evidence Based Stroke
Rehabilitation
Evidence based/Outcomes based data
EBRSR
Upper extremity
PT may not reduce spasticity
IPC does not help edema
FES does improve function
Evidence Based Stroke
Rehabilitation
Evidence based/Outcomes based data
EBRSR
Cognition
1/3 of stroke patients develop
dementia
Stroke patients have 10x risk of
developing dementia
Depression contributes to cognitive
impairment in stroke
Evidence Based Stroke
Rehabilitation
Evidence based/Outcomes based data
EBRSR
Cognition
treating hypertension in stroke patients
reduces their dementia risk
gesture training is effective for treating
ideomotor apraxia
Evidence Based Stroke
Rehabilitation
Evidence based/Outcomes based data
EBRSR
Language therapy
is efficacious in aphasia when provided
intensely for the first three
months
group therapy may improve
communicative and linguistic
abilities
Evidence Based Stroke
Rehabilitation
Evidence based/Outcomes based data
EBRSR
Language therapy
CPU-based aphasia therapy helps
forced use aphasia therapy helps
repetitive transcranial magnetic
stimulation and polarity specific
transcranial direct stimulation
may help
Evidence Based Stroke
Rehabilitation
Evidence based/Outcomes based data
EBRSR
Language therapy
piracetam, levodopa, memantidine,
dextroamphetamine and
donezepil may improve language
function
bromocriptine, cholinergics, dextran
and moclobemide do not help
Evidence Based Stroke
Rehabilitation
Evidence based/Outcomes based data
EBRSR
Dysphagia
VBMS is the only sure way to diagnose
dysphagia and aspiration
Aspiration rates are high
risk of developing pneumonia is related
to aspiration severity
Evidence Based Stroke
Rehabilitation
Evidence based/Outcomes based data
EBRSR
Dysphagia
all stroke survivors should be npo until
assessed
SLPs should see all patients who failed
the swallow screen
dysphagic individuals should feed
themselves
Evidence Based Stroke
Rehabilitation
Evidence based/Outcomes based data
EBRSR
Dysphagia
a variety of treatments can be used to
improve swallowing function post
stroke
Evidence Based Stroke
Rehabilitation
Evidence based/Outcomes based data
EBRSR
Medical complications
indwelling catheters should only be
used in specific instances
timed voiding, biofeedback pelvic
training, behavioral therapy and
weekly in home visits reduce
incontinence
Evidence Based Stroke
Rehabilitation
Evidence based/Outcomes based data
EBRSR
Medical complications
incidence of DVT is less than 10%
anticoagulation reduces DVT
LMW heparin is more effective than
unfractionated heparin
compression devices don’t help reduce
DVT
Evidence Based Stroke
Rehabilitation
Evidence based/Outcomes based data
EBRSR
Medical complications
10% of post stroke patients have
seizures
osteoporosis is common after stroke
and can be reduced with
ipiflavone, vit D + Ca, vit B12 +
folate, sunlight, and
bisphosphonates
Evidence Based Stroke
Rehabilitation
Evidence based/Outcomes based data
EBRSR
Depression
1/3 develop depression
influence of stroke location and
propensity to develop depression
not understood
depression negatively impacts
recovery
Evidence Based Stroke
Rehabilitation
Evidence based/Outcomes based data
EBRSR
Depression
depression is associated with cognitive
impairment
early initiation of post stroke
antidepressants is effective in
preventing depression
various medication classes are
effective in depression
Evidence Based Stroke
Rehabilitation
Evidence based/Outcomes based data
EBRSR
Depression
pharmacologic treatment improves
functional recovery
treatment with antidepressants
improves long term survival
ECT and TCMS are effective
music therapy helps
Evidence Based Stroke
Rehabilitation
Evidence based/Outcomes based data
EBRSR
Depression
exercise training does not help
Evidence Based Stroke
Rehabilitation
Evidence based/Outcomes based data
EBRSR
Miscellaneous
unclear if acupuncture helps
Reikki does not help
HBO does not help
Evidence Based Stroke
Rehabilitation
Evidence based/Outcomes based data
Summary
many of the treatments we provide stroke
patients are proven to help them
many of the treatments we may be providing
stroke patients have been shown not to
help (and yet we do them anyway!)
the EBRSR is an excellent resource to obtain
data regarding the latest RCT evidence
based outcomes information