Treating Post Stroke Mobility Problems

Treating Post Stroke
Mobility Problems
Mya C. Schiess,
Schiess, MD
Director UT Move, UT Houston Medical School
Movement Disorders Clinic & Fellowship
June 11, 2007
Post Stroke Mobility Problems
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Stroke is the number one cause of serious adult
disability in the United States.
Moving around safely and easily is not
something you may think about, until you have
had a stroke.
Each year more than 750,000 Americans suffer
strokes.
Post Stroke Mobility Problems
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As a result, many of these survivors have paralysis
and/or balance problems.
Statistics show that 40 percent of all stroke
survivors suffer serious falls within a year after
their stroke.
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Post Stroke Mobility Problems
Let’
Let’s focus on:
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Common post stroke mobility problems
Treatment options
Other ways we can improve safety and
mobility such as home adaptations and
lifestyle changes.
New treatments
PostPost-Stroke Movement Problems
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Weakness or Paralysis
Balance or coordination problems
Spasticity
PostPost-Stroke Movement Problems:
Weakness or Paralysis
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Paralysis is one of the most common
disabilities resulting from stroke.
Paralysis is usually on the side of the body
opposite the side of the brain damaged by
stroke.
Paralysis may affect the face, an arm, a leg, or
the entire side of the body.
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PostPost-Stroke Movement Problems:
Weakness or Paralysis
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OneOne-sided paralysis is called hemiplegia
OneOne-sided weakness is called hemiparesis.
hemiparesis.
Stroke patients with hemiparesis or hemiplegia
may have difficulty with everyday activities
such as walking or grasping objects.
PostPost-Stroke Movement
Problems: Ataxia
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Occurs with damage to a lower part of the
brain, the cerebellum
Affects the body's ability to coordinate
movement
Leading to problems with body posture,
walking, and balance.
PostPost-Stroke Movement
Problems: Spasticity
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Tight, stiff muscles that make movement,
especially of the arms or legs, difficult or
uncontrollable.
Characteristics may include any of the
following: a tight fist, bent elbow, arm pressed
against the chest, stiff knee and/or pointed foot
that can interfere with walking.
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PostPost-Stroke Movement
Problems: Spasticity
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Long periods of forceful contractions in major
muscle groups can cause painful muscle
spasms.
Spasms produce a pain similar to athletic
cramping.
Spasticity
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Identify early
Initiate treatment
Several therapeutic options
Improve community and physician awareness to
identify and refer patient to appropriate
Subspecialist.
Subspecialist.
What are the Symptoms or
Effects of Spasticity?
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Stiffness in the arms, fingers or legs
Painful muscle spasms
A series of involuntary rhythmic contractions
and relaxations in a muscle or group of
muscles that lead to uncontrollable movement
or jerking, called clonus
Increased muscle "tone"
Abnormal posture
Hyperexcitable reflexes
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Spasticity
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If you have any of these symptoms, be
proactive
Ask your physician about treatment options or
for a referral to a physician who specializes in
treating spasticity
Considerations in Treatment Decisions
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Chronicity
„ acute vs. chronic
Severity
Distribution
„ diffuse vs. focal
Locus of CNS injury
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Oral medications
Focal
NeurolysisNeurolysis- phenol
ChemodenervationChemodenervationBotulinum toxin
Local Anesthetic
Multi –limb, axial, general
Intrathecal Baclofen
Remove Noxious Stimuli
Rehabilitation
Gait Therapy
Constraint Therapy (CIMT)
Splinting/Stretching
Focal electrical stimulation
Surgery
Comprehensive Management
of Spasticity
General
Oral
Anti-Spasmodics
SDR
ITB
Rehabilitation
Reversible
Irreversible
Phenol
Surgery
Botox-A
Focal/Segmental
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Spasticity
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Treatment is often a mix of therapies and
drugs.
This approach is used to achieve the best
results possible.
It’
It’s important to note that all therapies and
drugs have potential risks and side effects.
Be sure to weigh the risks and side effects
against the benefits.
Spasticity: Treatment Options
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Stretching
Full rangerange-ofof-motion exercises at least three times
a day
„ Gentle stretching of tighter muscles
„ Frequent repositioning of body parts.
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Spasticity: Treatment Options
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Oral Medicines: treat the general effects of
spasticity, act on multiple muscle groups in the body.
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TizanidineTizanidine- temporarily reduces spasticity by blocking
nerve impulses. Has been shown to decrease spasticity
without a loss in muscle strength. Due to the short period of
time the drug is effective, treatment should be saved for
activities and times when relief is most important.
Baclofen:
Baclofen: acts on the central nervous system to relax
muscles. Also decreases rate of muscle spasms, pain,
tightness and improves range of motion.
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Spasticity: Treatment Options
Benzodiazepines (Valium®
(Valium® and Klonopin®
Klonopin®)group of drugs that act on the central nervous
system to relax muscles and temporarily decrease
spasticity.
®)- acts directly on
„ Dantrolene sodium (Dantrium
(Dantrium®
the muscle by blocking the signals that cause
muscles to contract. Can lessen muscle tone.
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Spasticity: Treatment Options
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Injections: botulinum toxin (Botox
® or Myobloc®
(Botox®
Myobloc®)
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Relax stiff muscles by blocking the chemicals that make
them tight.
Target only specific limbs or muscle groups affected by
spasticity.
Helps control side effects to other areas of the body.
When side effects are present they may include mild
soreness where you received the shot and a lack of energy.
A single shot of Botox usually takes full effect within two
to four weeks after injection. Treatment may need to be
repeated as often as every three months.
Spasticity: Treatment Options
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Injections: Phenol
Gets rid of the nerve pathways that are involved
with spasticity of a specific muscle group.
„ Benefit is that you see the effects right away.
„ Relief can last from six to 36 months.
„ Side effects may include pain during injection, a
burning/tingling sensation and swelling of the
injected area.
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Spasticity: Treatment Options
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While these injections have been effective in
treating spasticity, their use for this disorder
has not yet received approval by the Federal
Drug Administration.
These treatments are ongoing to treat the
symptoms of spasticity and are not a cure.
Spasticity: Treatment Options
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Intrathecal Medication: Intrathecal
baclofen™
baclofen™ (ITB) therapy delivers Lioresal
Intrathecal®
Intrathecal®
A liquid form of the drug baclofen,
baclofen, directly
into the spinal fluid.
A programmable pump is surgically placed
just below the skin near the abdomen.
Spasticity: Treatment Options
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The pump constantly delivers small doses of
medicine.
Side effects are minimal because the drug is
delivered to only those areas affected by the
stroke and does not circulate throughout the
body.
However, possible side effects may include
drowsiness, nausea and headache.
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ITB therapy
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Beneficial effect on upper and lower
extremities and small and large muscle groups
Beneficial in reducing dynamic spasticity and
spastic dystonia
Does not lead to weakness of unaffected
muscles.
Documented Outcomes from
Established Investigators
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ITB Therapy significantly reduced spastic tone in
hemiplegic patient, especially lower extremity
(Meythaler et al, 1999)
ITB Therapy significantly reduced painful spasms
in hemiplegic patient (Meythaler et al , 1999)
¾ ITB Therapy improved gait and ambulation speed
in postpost-stroke spastic hemiplegia patients
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(Francisco, 2001,2003, and RemyRemy-Neris et al 2003)
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ITB Therapy does not effect motor strength in
the unaffeted or affected limbs, above authors
(Grissom et al 2000)
ITB Improves Ambulation
Speed in Stroke Patients
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Ambulatory stroke patients (n=10) with ITB implants
and physical therapy improved walking speed,
functional mobility and spasticity.
FollowFollow-up interval averaged 8.9 months.
Mean walking speed over 50ft improved from 36.6 to
52cm/s.
Mean Modified Ashworth Scale scores in the muscles
of the affected lower limb improved from 2.0 to 0.4.
Normal muscle strength (5/5) was preserved in the
unaffected limbs.
(Francisco GE, 2003)
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Spasticity: Treatment Options
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Not all treatments are suitable for everyone.
Doctors will try to tailor spasticity treatments
to each person, by looking at the extent of the
problems, individual symptoms and personal
lifestyle goals.
Your doctor will also help you understand how
much medicine you need and the side effects.
Treating Post Stroke
Mobility Problems
Elizabeth A. Noser, MD
CoCo-Director UT Houston Stroke Program
Medical Director, Neurorehabilitation
Mischer Neuroscience InstituteInstitute-Memorial Hermann
June 11, 2007
Home Safety Evaluation
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HSE and modification is critical to make the
home safe to move around in, allowing stroke
survivors to regain some independence.
Will decrease risk of falls and injuries in the
home.
Physician can prescribe a home safety
evaluation.
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Home Safety Evaluation
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Clear paths to the kitchen, bedroom and
bathroom
Wear non-skid shoes and avoid slick surfaces
Remove loose carpets and runners in hallways
and stairwells, or fasten them with non-skid
tape to improve traction
Install handrails for support in going up and
down stairs
Modifying the Home to
Improve Safety
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Modifying stroke survivor’s home with assistive
devices, will improve safety and allow for easier
movement around the home. Useful devices may
include:
Raised toilet seat
Tub bench
Hand-held showerhead
Modifying the Home to
Improve Safety
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Plastic strips that adhere to the bottom of a tub or
shower
Long handled brushes and washing mitts with
pockets for soap
Electric toothbrushes and razors
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Mobility Aids
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Braces, canes, walkers and wheelchairs may help
stroke survivors gain strength and improve
mobility.
Only use braces or other devices as recommended
by a therapist.
Foot drop is a common problem during stroke
recovery.
Caused by weak leg muscles that cause the ankle
to drop down when lifting a leg to take a step.
Mobility Aids
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Foot drop may cause a person to trip and fall if
the foot and ankle are not supported by a brace at
all times.
Most common brace for this problem is an anklefoot orthosis (AFO).
It is placed below the knee and supports the ankle
and foot. Comes in many styles and can be
customized.
Mobility Aids
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Support adjustments on the AFO can also
influence knee movement.
Other variations and adjustments can be made to
braces to fit specific needs.
A physical therapist or orthotist can suggest the
appropriate device.
Understanding safety procedures and proper use
of orthotics, including proper fit and
maintenance, is essential.
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Lifestyle Modifications to
Improve Mobility Safety
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Lifestyle changes to diet and exercise should be tailored
to meet a person’s individual needs.
Address your patient’s weak leg muscles, poor vision,
dizziness and medicines that may compromise balance
and put the stroke survivor at higher risk for falls.
Lifestyle Modifications to
Improve Mobility Safety
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Counsel the stroke survivors and caregivers they can
reduce or prevent falls by:
Remaining active
Strengthening leg muscles and balance through weight
training or tai chi classes
Wearing flat, wide-toed shoes
Eating calcium-rich foods and taking calcium
supplements, if necessary to increase bone strength
Lifestyle Modifications to
Improve Mobility Safety
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Stroke survivor’s should follow therapists’
recommendations about limitations and walking needs
Not relying on furniture for support while walking. Use
the assistive device prescribed by your therapist
Recognizing that certain medicines may make them
drowsy, and taking precautions
Limiting walking when distracted
Never walking without prescribed aids such as braces or
canes
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New Treatment and
Technology Options
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Treadmill Training
Lokomat, AutoAuto-Ambulator,
Ambulator, WalkAide,
WalkAide,
Bioness, Korebalance
Treadmill Training:
Treatment Options
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Partially supported treadmill training helps
survivors learn to walk again even though their
legs and upper body cannot support them.
The therapist places the survivor in a harness
with their legs suspended over a treadmill.
Harness eliminates the risk of falling.
Treadmill Training: Treatment Options
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A therapist stands by the survivor and moves their
affected leg forward on the treadmill to keep pace
with the unaffected leg.
A second therapist operates the treadmill.
The hope is this therapy will help wire the brain so
survivors can eventually make these movements on
their own.
A drawback is that this therapy requires two
therapists, making it more expensive than
conventional therapy.
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Robotic Treadmill Training:
Lokomat
WalkAide System
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Functional electrical stimulation (FES) device
Geared to combat foot drop due to stroke, spinal cord injury,
traumatic brain injury, multiple sclerosis, cerebral palsy.
No external wires or footplate
Employs a patented sensor technology called an accelerometer
and transmits information via a Bluetooth®
Bluetooth® connection
Study published in the September 2006 issue of
Neurorehabilitation and Neural Repair reported the walking
speed of patients wearing the WalkAide increased by:
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15% after three months
32% after six months
47% after twelve months
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Bioness
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The NESS L300™
L300™ system is a statestate-ofof-thethe-art,
wireless Functional Electrical Stimulation system
Designed to help patients with upper motor neuron
injuries resulting in foot drop (the inability to lift
foot/toes while walking).
Its design allows it to span from inpatient to
outpatient easily.
Helps facilitate a more normal gait.
Stimulate muscle rere-education, prevent/retard disuse
atrophy, maintain or increase joint range of motion
and increase blood flow.
Korebalance™
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Korebalance™ -interactive rehabilitation
device for balance training.
System exercises the Visual (eyes), the
Vestibular (inner ear), and Proprioception
(where you are in space).
Stimulating the brain and the nervous system
to improve balance, stability, coordination, and
posture.
Korebalance™
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REFERENCES
1. www.ninds
.nih.gov
www.ninds.nih.gov
2. www. stroke.
stroke. org
3. www.americanheart
.org
www.americanheart.org
RESEARCH:
EVEREST Study
EVEREST
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Prospective, randomized, multimulti-center study.
Main goal: targeted cortical (brain) stimulation
delivered along with rehabilitation activities to
increase motor recovery in stroke survivors
with arm weakness.
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EVEREST
Second goal: assess safety of study procedures,
neurosurgical interventions and cortical
stimulation delivered with rehabilitation
activities.
Electrode placed between skull and dura on top
of affected area in the brain. Lead is tunneled
down past clavicle and attached to subclavicular
implantable pulse generator (IPG).
IPG activated by programming wand.
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EVEREST
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Includes survivors with an ischemic stroke
At least 4 months post stroke
Moderate to moderate/severe arm weakness,
and active wrist extension of at least 5 degrees
or ability to perform a repetitive grasping task
EVEREST
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