What factors are associated with long-term ADL independence post CVA?
- Age
- Severity of CVA (e.g. by NIHSS)
- Sitting balance
- Urinary incontinence
- Severity of hemiplegia (e.g. hemiparesis vs paralysis)
- Comorbidity
- Consciousness at admission
- Cognitive status
- Depression
Factors associated with ability to walk 6 months post CVA?
- Severity of sensory and motor impairment in paretic leg (specifically muscle strength on hemiparetic leg)
- Homonympous hemianopsia
- Urinary incontinence
- Sitting balance (especially when measured 2-4 wks post stroke)
- Initial disability in ADL and ambulation
- Loss of consciousness on admission
- # of days between stroke onset and first assessment at hospital
- Better standing balance also helps!
*60-80% of pts with CVA walk independently at 6 months post stroke!
Favorable factors associated with discharge home?
Less favorable factors??
Favorable factors
- Younger age
- Good post stroke function (Barthel Index, Mobility Scale for Acute Stroke [MSAS])
- Admission to a teaching hospital
- Pre stroke statin use (as well as during hospitalization)
- Higher admission Hct
- Achieving a high level of independence in IRF
LESS Favorable factors:
- Lower level of current mobility (MSAS)
- Severity of stroke (NIHSS)
- High Charlson Comorbiditiy index
- Statin withdrawal during hospitalization
- Encephalopathy
- Respiratory failure
- Brain herniation
- Pre-stroke dementia
- High WBC
- Rheumatologic dz
- Peptic ulcer dz
- Liver or renal dz
- Diabetes
- Elevated BMI
- EtOH abuse
Older age and being uninsured also influenced discharge destination
Early mobilization post CVA:
Very early mobilization post stroke (within first 24 hrs)?
Early rehab (between 3-60 days post CVA)?
Early mobilization post CVA: goal to do it by day 3 post CVA. We know this is safe. Intensive early OOB (e.g. 2x/day <24-48h post CVA including sitting and walking) may be too much for some pts (e.g. post hemorrhage) and result in negative outcomes.
Very early mobilization post stroke (within first 24 hrs)?
- Go for more FREQUENT, SHORT duration OOB sessions, which result in improved outcomes
- POORER OUTCOMES are seen when very early mobilization sessions are more prolonged
Early rehab (between 3-60 days post CVA)? ...is STRONGLY associated with improved functional outcomes! This is the window when we should be aggressively working our patients to maximize outcomes
Goal of the AVERT studies?
Goal of AVERT was to get pt OOB within 24h post CVA with a short sitting duration (~15 mins, definitely <1 hour)
Incidence of contraversive pushing post CVA?
~10% (but one study of n=65 pts had 63% incidence!)
Pathophysiology of pushing
Posterior lateral thalamus, insular cortex, and parietal cortex are often involved…
BUT other areas likely involved too: cortical and subcortical regions. Invovlement of parietal cortex, insular cortex, and somatosensory areas or superior temporal gyrus (which might explain frequent association with aphasia, neglect or sensory impariments!)
Patients with contraversive pushing have body orientation problems in the __ plane. Patients with neglect have issues in the ___ plane.
Patients with contraversive pushing have body orientation problems in the CORONAL plane. Patients with neglect have issues in the TRANSVERSE plane.
Spatial neglect is the result of damage to the [R / L ] … [which brain parts?]
Spatial neglect is the result of damage to the RIGHT SUPERIOR TEMPORAL CORTEX, INSULA, and TEMPORO-PARIETAL JUNCTION
How to measure contraversive pushing?
Clinical Scale for Contraversive Pushing (SCP)
- Symmetry of spontaneous body posture
- Use of non-paretic extremities (leg/arm) to push by abduction and extension thrust
Resistance ot passive correction of tilted posture
ALL THREE items must be present for contraversive pushing. Scaled in sitting and standing.
Describe the Burke lateralpulsion scale
Sensitive to detect pusher behavior in standing and walking
Looks at pt’s response/resistance to being tilted 5, 10, 20, and 30 deg toward paretic side
Prognostic factors with pushing?
Influence of visuospatial neglect?
Patients with LEFT brain lesions: older age and worse admission motor status = persistent lateropulsion at discharge from rehab
Patients w/RIGHT brain lesions: older age, greater admission limb placement error, lower cognitive FIM scores = persistent lateropulsion - these patients will require special intervention strategies and longer LOS to ameliorate lateropulsion and maximize function
Pushing + motor symptoms only = did pretty well (vision & proproception intact, were helpful)
*If have RIGHT (rather than L) brain lesions + additional impairments (e.g. proprioception, vision ) will have a harder time recovering.
Patients with pushing will have a LONGER (average 3.6 wks longer) and harder recovery than those without pushing.
Visuospatial neglect did NOT Influence recovery from lateropulsion (but impaired proprioception does!)
Treatment strategies in contraversive pushing?
Visual treatment: using visual cues/structures/aides to orient to vertical midline with functional movements (obviously won’t work as well if pt has a visual deficit!) Right sided lesions will be harder and take longer to recover.
Allow pt to begin to lose balance toward that side, and reinforce visual cues! Avoid passively moving pt.
Have pt stroke their thighs -> lower legs (with assist on paretic side; they’re typically fearful to lean forward)
Transfers: transferring TOWARD the strong side is often hard because of the pushing! So start with transfers TOWARD PARETIC SIDE first, then later transfer toward the intact side.
Computer generated interactive group (using Nintendo Wii balance board) had good outcomes.
Gait training will be a useful adjunct - equipment like Lokomat may help with alignment and to reduce fear of falling, but not much research
Anatomical reasons that UE is more affected than LE in stroke?
- MCA - most common vessel with related strokes, biases areas of brain that help w/UE function
- Descending tracks: UE function is almost solely through lateral corticospinal tract (for fine fractioned movements of distal extremities), where as LE function has some redundancy via the reticulospinal tract (which splits!) as well as CPGs int he spinal cord itself which are a big piece of walking
- UE reaching requires careful management of a long lever arm with reaching tasks (less so with LEs/walking)
- Gait is more gross flexion to extension movmeent to be functional; UE requires much more skill and fine motor function to be functional
- UE: often people can compensate more with unaffected side, vs people tend to train walking more robustly for aesthetics if nothing else
Factors which predict independence with ADLs at 6 months post CVA
- Age
- NIHSS initially
- Upper limb paresis
When the ___ tract and ___ (area of brain) are spared, patients do better after stroke.
When corticospinal tract and internal capsule are spared, patients do better after stroke.
The PREP algorithm predicts recovery of [UE/LE] function at ___ weeks post CVA.
Step 1: __ days post stroke, what is their combined MMT for __ and ?
Step 2: At __ days post stroke, are ___s present on ___?
Step 3: At __ days post stroke, is the ___ score on ___ [imagine] > or < ___.
The PREP algorithm predicts recovery of UE function at 12 weeks post CVA.
Step 1: 3 days post stroke, what is their combined MMT for SHOULDER ABDUCTION and FINGER EXTENSION (“SAFE score”)
>=8 = complete recovery predicted (use it fully, via keyboarding, washing/drying hands, keyboarding)
5-7 = NOTABLE recovery predicted
(goal is to promote function; pt can use arm/hand for most ADLs within 12 weeks. Goals to use paretic UE for 90% bathing activities, eat finger foods and dress with paretic hand)
<5 = go to step 2
Step 2: At 5 days post stroke, are MEPs present on TMS? (TMS assesses the functional integrity of the corticospinal pathways originating from the ipsilesional primary motor cortex, will elicit motor evoked potential in hand muscle)
If yes = NOTABLE recovery (goal is to promote function; pt can use arm/hand for most ADLs within 12 weeks. Goals to use paretic UE for 90% bathing activities, eat finger foods and dress with paretic hand)
If no = go to step 3
Step 3: At 10 days post stroke, is the ASYMMETRY score on MRI > or < 0.15.
Asymmetry <0.15 = predict LIMITED recovery (maximize strength and ROM; expect to use limb as a stabilizer in bimanual tasks and with gross tasks)
Asymmetry >0.15 = predict NO recovery (expect pt will keep limb in line of sight, direct caregivers to optimize positioning in shoulder ABD and ER, elbow ext)
(MRI is looking at the structural integrity of the posterior limb of the internal capsule)
What are the theories behind bilateral training to improve UE function post CVA?
- Perhaps priming the crossed cortical spinal tract for recruitment later on, including involvement w/rubrospinal tract
- ?invoking the uncrossed CST
