Rehabilitation in Cerebrovascular Di

sease and Traumatic Brai

n Injury

Prawit Rungcharoensak M.D.

Dept. of Rehabilitation Medicine

BMA Medical College & Vajir a Hospital

Cerebrovascular dise ase / stroke

Prevalence : 690 1/00000

Risk factors 1 45 601. Age (< yr : /

- 00000 45 65

998 65 5yr : ; > yr :063

2. Hypertension VVVVVVVV VVVVV VVVVVVVV V3

( ) 4. D.M. 5. Previous stroke / TIA 6. Race

7. Sex8. Smoking9. Family Hx.10. DM11. Elevated

fibrinogen12. Erythrocytosis13. LDL

Pathology :1. Ischemic stroke (80-90% of CVD)

Thrombotic (40%) : previous stroke, large vv.

Embolic : small vv., younger age, heart disease

Lacunar : penetrating artery in basal ganglion,

internal capsule, brainstem (good recovery)

2. Hemorrhagic stroke mortality 50-70%

Lesion : putamen, thalamus

Pattern of neurological recovery

Hypotonia / flaccidity (48 hr)

Flexion / extension synergies ( -230 d.)

Isolated movement ( -633 d.)

Full recovery (10% of Pt.) Prognosis : ~ 12 weeks

Rehabilitation Goal : Independence

Candidate : able to perceive, unde rstand, follow command (verbal/

gesture) Assessment :

– pathology– site of lesion– symptoms & signs– risk factors– stage of neurological recovery– functional performance

Positive predictors

- 1 . Bladder control (within 1 2 wk) VVVVVVVV VV VVVVVV VVVV VVVVVVVV 2

- muscles within 2 4 wk (proximal muscle) - 3 46. Recoveryofeachmuscl es wk ( Isolate muscles) 4. Fami l y suppor t 5. No depression 6. Good per cept i on

Negative predictors 1. Prolonged coma

2. (> 2 )Prolonged flaccid months 3. Severe proximal muscles spasticity 4. & (Inability to control bladder bowel with

- 23in wk) 5. Severe unilateral neglect 6. /Severe intellectual memory impairmenV 7. /Visuospatial deficit hearing deficit VVVVVVVV VVVVVV8. 9. Severe depression

10. Associated diseases (CAD, CHF, PV)

Deficits 1. Cognitive problems

– Left hemiplegia : perceptual deficit, negle ct, poor insight & judgement

– Right hemiplegia : aphasia

2 . /Behavi or al emot i onal pr obl ems– - - Depression (25 60%) : 6 m 2 yr, 70% of rig

ht hemiplegia– Undue cheerfulness (anxiety, lability) : rig

ht frontal lobe– Apathy : right frontal lobe– Denial

Deficits 3. Communication disorder– Language : aphasia (spontaneous reco

- very 3 6 m)– Articulation : apraxia, dysarthria, dysp

honia

4. Sensory deficits– Visual field deficit– Visual perceptual deficit (right hemisp

here) : body image, special related disorder

– Peripheralsensorydefi ci t (propi ocepti on)

Deficits 5. Motor deficits

– Spasticity– Incoordination– Weakness– Motor apraxia

6. , ,Bladder bowel sexual deficits– Bladder : 70% of Pt. can control (PC exer

cise, CIC)– 75Bowel:di et ( %of Pt. cancontrol , i nconti n

encei nbedri dden)– Sexual : in 70% of cases

Rehabilitation program 1. Mobility

– Bed positioning– Therapeutic exercise (ROM)– Bed mobility– Sitting balance / trunk control training– Transfer training– Wheelchair management– Standing / progressive ambulation (ROM,

propioception, sitting balance, cognition , hip extensor power)

2. Activities of daily living– UE function, good sitting balance, no sen

sory deficits

Complications 1.Shoul der subl uxat i on ( -5080%)

- Causes : paralysis of shoulder M., flaccid stage - laxity of joint capsule

Treatment : shoulder support / sling, ES, proper bed & sitting position

2 . ( ) (Shoulder hand syndrome RSD 12.5%, VV -24) Causes : ANS disorder, increased sympathetic tone

Stage 1: pain on ROM, swelling of wrist & fingers, co ld skin

Stage 2: swelling, joint stiffness, osteoporosis Stage 3: skin dystrophy, osteoporosis

Treatment : ROM, wrist & hand splint, pain reductio n (TENS, drug)

Complications 3. Seizure ( -1015% )

2Earlyseizure( wk) : brainswelling, cytotoxicmet abol i t e, embol i c >t hr ombot VVVVVVV VV VVVVVV VVV,

- V VVVVVVVVVVV VVVVVVV VVVVVVVV(62 ) : ,VV

4 . ( 5 0 %) - VVVVVVVVVV VVVVVVV: ,( )

- VVVVVVVVV VVVVVVVV VVVVVVVV VVVVVV VVVVVV VVVVVVVVV VVVVVV VVV:, ,

VV VVVVV VVV VVVVVVVV,

Traumatic Brain Inj ury (TBI)

• Traffic accident 60% Risk factors

- - 1. Age : 15 24 yr, 0 5 yr, >65 yr VVV V VVVV V VVVVVV2

3. Alcohol

4. Other : psychological, personaVVVV

Classification of TBI

1 . Severity : Glasgow Coma Scal e (GCS)

-38Severe : -: 9 1 2

13Mild : >

Classification of TBI 2. Pathology

21. Focal :o Focal cortical contusion (FCC)o Deep hemorrhageo - Focal hypoxic ischemic injury (FHII)

22. Diffuse :o Diffuse axonal injury (DAI)o - Diffuse hypoxic ischemic injury (DHII)

VVVVVVVV VVVVVVVVVVVV VVVVVVVVV V VVVVVVVVV VVVVVV VV23

V:o extracerebral hematoma, herniation syndrome, hydrocephal

us, chronic subdural hematoma, hygroma, posttraumatic seizure

FCC

frontal polar, orbital frontal : apathy, disinhibiti on, IQ

anterior inferior temporal : aphasia, agnosia Deep hemorrhage

basal ganglion : hemiparesis, discordination, hy pertonia, movement disorder, aphasia / neglect

FHII posterior cerebral artery : hemianopia, amnesia

DAI

corpus collosum : coma (without lucid interval), confusional state, residual attention, cognitive

& behavioral impairments

Recovery of diffuse TBI DAI :

Coma Vegetati ve state Mute/ l owl evel responsi veness Confusionalstate:attenti ondefi ci t,abn.behavi or Evol vi ngi ndependence Intellectual/ soci al competence

F HII : prolonged coma & confu sion, poor prognosis

Specific impairments afterTBI

Physical : 1 *. Movement control 2 . ,Abnormal tone spasticity

3. Cerebellar incoordination 4. Involuntary movement 5. Seizure

Neuropsychological : 1. Neurological : arousal, attention (memor VVVVVVVV), 2. Postconcussion syndrome : headache, diz

VVVVVVV, , , 3. Psychological : depression, anxiety, postt

VVVVVVVV VVVVVV

Rehabilitation program Acute : neurosurgery Acute rehabilitation phase :

Coma :• prevention of complications• coma stimulation (sensory stimulatio

n, sitting)

Confused :• rehab team approaching• medication• behavioral management

Rehabilitation program Postacute rehabilitation phas

e : (post discharge)• V VV VVVV• Day treatment• VVVVVVVVVVVV VVVVVV VVVVVV

Cognitive rehabilitation :• Functional skill training (ADL)• V VVVVVV VVVVVVVV VVVVVVVVVVVVVV

(attention, executive function)

Outcome - 1 37. Severe TBI (GCS ) :

- 3550 21 24dead %, cognitiveimpair= %,abn behavi or = % - 2 . ( 1 2 1 5 ) :

VVVVVVVVVVVVVV VVVVVVVV 3. Focal pathology :

multiple, masseffect, abn pupi l = poor pr ognosi s VVVVVVVVV V4 . :

VV VVV V V VVVVVVVVV VVVV VV V, & esia (PTA)

5. Recovery rate