Cerebrovascular Disorders Part 2:

Author(s): Rani Haley Lindberg, MD, Mustafa Khan, MD

Originally published:10/3/2012

Last updated:05/05/2016

1. DISEASE/DISORDER:

2. ESSENTIALS OF ASSESSMENT

See Cerebrovascular Disorders Part 1.

3. CUTTING EDGE/EMERGING AND UNIQUE CONCEPTS AND PRACTICE

Cutting edge concepts and practice

Constraint-induced movement therapy (CIMT)7,11: This therapy traditionally involves restricting the unaffected limb for 90% of waking hours for 14 days, while intensively training the use of the affected arm. A number of studies have shown that CIMT induces a use-dependent increase in cortical reorganization of the areas of the brain controlling the more affected limb.8,9 Studies have demonstrated significant improvements in motor and functional outcomes, although there have been mixed results. CIMT is shown to be effective in patients who have active wrist extension (at least 20 degrees), active finger extension (at least 10 degrees),10 good cognition, limited spasticity, and preserved balance. There are a number of non-standardized modified versions of CIMT which have arisen in response to critiques of traditional CIMT, including poor patient tolerance and feasibility in clinics. CIMT has shown effectiveness in improving motor function, but studies have been limited by small sample sizes.

Bilateral upper extremity training: This training is a recent stroke rehabilitation technique that has been applied to patients in both acute and chronic post-stroke phases. Investigators have recommended that patients in the chronic phase poststroke who retain at least a minimal degree of corticospinal integrity (as reflected by, e.g., active finger movements) should receive unilateral training, and those with little or no distal movement might benefit more from bilateral training. For those stroke patients without corticospinal tract integrity, targeting the contralesional hemisphere using bilateral training is expected to be more appropriate, although the functional gains are expected to be small.5

Body-weight-supported (BWS) therapy21: This modality allows gait impaired stroke patients to safely participate in task-specific gait training. A harness provides support of body weight over a treadmill or other surface, while a therapist can observe and correct any unwanted gait pattern. BWS gait training has been shown to improve ambulation in hemiparetic stroke patients producing a more symmetric, efficient hemiparetic gait pattern. However, superiority of BWS therapy over conventional post-stroke gait training therapies has not been established.

Robotics: Robotic assisted gait devices have generally not been shown to be superior to traditional physical therapy of the same intensity.23Lightweight, motorized exoskeletons have become available very recently, but they are very expensive and slow. Studies are needed to show if they can be used as an augment to standard therapy.

Brain-computer interface25: The brain computer interface is one of the most promising research avenues, which involves developing neuroprosthetic devices and brain-computer interface (BCI) technologies to bypass brain damage via adaptive neuroplasticity of uninvolved distal brain areas. Parts of the nervous system not involved in specific tasks can be harnessed to reconstruct the neural substrate that interacts with a neuroprosthesis or BCI-driven devices. A brain-machine interface uses brain signals to drive external devices without the use of peripheral physiologic activities. Patients with locked-in syndrome from brainstem stroke benefit the most from these devices. There are issues with cost and reliability.

Noninvasive Brain Stimulation (NIBS) – Transcranial magnetic and direct current stimulation:7,14 This therapy involves applying mild magnetic or electric stimulation to the scalp. The benefit is achieved through neuromodulation of plasticity and cortical excitability. A growing number of studies support its therapeutic potential and safety in stroke rehabilitation, however a meta-analysis showed the effects to be inconsistent for motor recovery. NIBS has been shown to improve motor function, gait, language (aphasia) and cognitive (neglect) deficits, and mood.

Mental Practice(MP)/Motor Imagery7: This refers to mental rehearsal of a movement. Imaging studies have shown that this motor imagery stimulates overlapping cortical areas as the actual movements. Most studies have shown a positive effect on upper extremity function. A recent Cochrane Review found MP in combination with routine rehabilitation is more effective in restoring arm function compared to rehabilitation alone.16

Mirror Therapy7,15: Initially applied to amputation patients, this therapy involves placing a mirror in the mid-sagittal plane, allowing the patient to visualize the reflection of the non-paretic limb as if it were the paretic limb. Studies have generally shown statistically significant gains in motor function. The underlying theory is that the visual illusions of the limb induce beneficial brain plasticity and counteract maladaptive neuroplastic changes.

Virtual reality (VR): Virtual environments and objects provide the user with visual feedback and repetitive skills practice. The interface may be through a head-mounted device, projection systems, or involving sensations of hearing, touch, movement, balance, or smell. The user interacts with the environment by devices, such as a mouse or joystick, or more complex systems using cameras, sensors, or haptic feedback devices. A 2015 Cochrane review17 found evidence that VR and interactive video gaming may be beneficial in improving upper limb function and ADL function as an adjunctive therapy or when compared with the same amount of standard therapy. There was insufficient evidence to make conclusions about the effect on grip strength, gait speed or global motor function. Other 2015 review studies have shown efficacy of VR in improving neglect18, balance and mobility19.

4. REHABILITATION MANAGEMENT AND TREATMENTS

Current treatment guidelines

The American Heart Association (AHA) & American Stroke Association have published guidelines for the management and rehabilitation of stroke.1-6

Acute stroke management:

  • Emergency computerized tomography (CT) scan of the head is performed to differentiate between ischemic and hemorrhagic stroke.
  • Intravenous thrombolysis with recombinant tissue plasminogen activator (rTPA) is indicated for adults with diagnosis of ischemic stroke in the absence of contraindications, provided it can be administered within 3 to 4.5 hours of symptom onset.1
  • Endovascular techniques (e.g., thrombectomy or intra-arterial fibrinolysis) are recommended for selected patients.1,6,7 rTPA should still be administered in eligible patients.1,6 Noninvasive intracranial vascular imaging (CT angiogram) is recommended if endovascular therapy is contemplated.6
  • Initiation of aspirin within 24-48 hours is indicated for ischemic strokes.1
  • Initial management of intracerebral hemorrhage (ICH) includes reversal of any identified coagulopathy and monitoring/lowering of intracranial pressure, if increased. Surgical evacuation is generally not indicated for supratentorial hemorrhage, but is recommended for cerebellar ICH with brainstem compression or hydrocephalus.2
  • Comprehensive stroke centers and stroke systems of care improve outcomes through prevention and treatment of stroke, as well as post-stroke rehabilitation.1

Acute and post-acute stroke management and rehabilitation3:

Early initiation of rehabilitation after acute stroke is associated with improved functional outcome at discharge and shorter rehabilitation length of stay.24

The primary goal of rehabilitation is to prevent complications, minimize impairments, and maximize function. Initial rehabilitation efforts should start as soon as possible in the acute care setting then transition to the inpatient rehabilitation setting. Other levels of post-acute care include sub-acute inpatient rehabilitation, day rehabilitation programs, outpatient programs, and home therapy programs.

Rehabilitation involves a multidisciplinary team, often led by a rehabilitation physician. Depending on impairments and functional deficits, the team often includes:

  • Physical therapy: rehabilitation efforts including stretching, range of motion, strengthening, balance, endurance, transfers, standing, and ambulation
  • Occupational therapy: rehabilitation efforts include treatment of impairments related to activities of daily living and upper extremity impairments
  • Speech and language pathology: evaluation and rehabilitation of cognitive, language, and swallowing impairments
  • Neuropsychology: Psychological support and cognitive assessment and interventions
  • Nursing: Assistance with bed mobility and positioning, bowel and bladder management, skin care, education
  • Recreational therapy: community integration, functional cognitive tasks (games, music, social interaction, etc)
  • Social work/Case management: Discharge planning, resource and benefits counseling, and guidance/education
  • Other disciplines: vocational rehabilitation specialist, dietician, pharmacist

The rehabilitation physician and team play a significant role in minimizing complications:

  • Early mobilization: Minimize deconditioning and its associated effects on fatigue, orthostatic hypotension, and endurance.
  • Evaluation and treatment of dysphagia: Dysphagia is common and is a risk factor for pneumonia. A formal swallowing assessment is essential for determination of appropriate diet to minimize risk of aspiration; aspiration is missed on bedside swallow study in 40-60% of patients. Screening should be performed before any oral intake. Dynamic instrumental assessment with a videofluoroscopy swallowing study (VFSS) or fiberoptic endoscopic evaluation of swallowing (FEES) can help guide rehabilitative techniques.
  • Nutrition status: Adequate nutritional status, including adequate hydration, should be ensured by monitoring daily intake assessment, body weight, calorie count, and laboratory tests, such as albumin or prealbumin.
  • Blood glucose levels: Monitor for at least 72 hours post-stroke. Hyperglycemia or hypoglycemia should be treated adequately. Blood glucose should be maintained between 110-180 mg/dl with a mean of 140 mg/dl.
  • Blood pressure management1,12,13: There is controversy about optimal blood pressure levels in the acute stage and concern about adverse effect on collateral circulation in the brain with excessive, rapid lowering of blood pressure. Malignant hypertension needs to be treated.
  • Spasticity: Prevention and early detection are important. Prevention measures include early mobilization, range of motion, proper positioning, and use of braces, if needed. Medications include tizanidine, dantrolene, and baclofen. Botulinum toxin or intrathecal baclofen should be considered for selected patients. Contractures can be treated using splinting, serial casting, or surgical correction. Diazepam and other benzodiazepines should be avoided during the stroke recovery period because their cerebral effect may delay recovery.
  • Deep vein thrombosis (DVT) prophylaxis: Preventative measures include early mobilization, pharmacological prophylaxis with subcutaneous heparin or low molecular weight heparin (unless contraindicated), and pneumatic compression devices or graduated compression stockings. An inferior vena cava filter may be considered in patients at risk for pulmonary embolism if anticoagulation is contraindicated.
  • Shoulder pain: Prevention of post-stroke shoulder pain and subluxation is done through careful monitoring, proper positioning, shoulder harness/sling or taping, trauma prevention, avoidance of uncontrolled abduction and overhead pulley use, and precautions during transfers. Shoulder subluxation and pain may be treated with oral medications, intra-articular steroid injections, shoulder support, arm trough or lap tray, stretching, thermal modalities, and functional electrical stimulus.
  • Bladder management: Urinary incontinence is a common post-stroke complication but often resolves over time. Accurate measurement of intake and output is important. Urinary retention can be assessed with use of a bladder scanner or an in-and-out catheterization. Timed voids and temporary use of external or intermittent catheterization may be helpful. Indwelling catheters increase risk of urinary infection and prolonged use should be avoided whenever feasible.
  • Bowel management: Incontinence is less common than constipation or fecal impaction. A bowel regimen involving the use of laxatives, stool softeners, and bowel training should be initiated.
  • Skin: Skin integrity should be assessed on admission and monitored daily. Skin breakdown risk may be assessed with standardized tools, such as the Braden Scale. Preventative interventions include special mattresses, frequent turning, proper positioning, transfers, lubricants, barrier sprays, and protective dressings.
  • Medication considerations: Central nervous system (CNS) depressants, such as neuroleptics, benzodiazepines, and barbiturates, may be associated with poorer outcomes and should be avoided whenever feasible.
  • Post-stroke depression: Early diagnosis and treatment is recommended. Approximately 40% of stroke patients experience depression; depression may be related to neurotransmitter depletion from stroke lesions and/or psychological response to physical/personal losses associated with stroke. Selective serotonin reuptake inhibitors are the preferred medications. Several studies suggest neural mechanisms of recovery may be facilitated by certain antidepressants26. Other emerging treatment approaches include electroconvulsive therapy, acupuncture, music therapy, and nutraceuticals27. Further studies are needed in these emerging areas.
  • Fall risk: Fall risk should be assessed using established tools and prevention strategies utilized. Strategies include low beds, bed alarms, wheelchair belts, and patient/caregiver education.
  • Infection: Fever should be reduced promptly. Pneumonia and urinary tract infections should be prevented and promptly identified and treated if they occur.

 

  • Specific rehabilitation interventions: Rehabilitation interventions are based on comprehensive, standardized assessments for impairments (motor, sensory, cognitive, communication, swallowing, psychological, and safety awareness) and prior/current functional status (e.g. with Functional Independence Measures – FIM).
    • Motor assessment should be at both the impairment and functional level. Components should include strength, active and passive range of motion, tone, gross and fine motor coordination, balance, apraxia, and mobility. Motor function is addressed with strengthening, balance and gait training, orthoses, transcutaneous electrical nerve stimulation (TENS), robot-assisted movement therapy, constraint-induced movement therapy, and body-weight-supported treadmill training, and upper extremity interventions in order to improve activities of daily living.5 Functional electrical stimulation may help facilitate movement or compensate for lack of voluntary movement.
    • Sensory assessment should include an evaluation of different sensations (sharp/dull, temperature, light touch, vibratory and position), a vision exam, and a hearing exam if hearing impairment is suspected. Compensatory techniques for sensory impairments should be included in the stroke patient’s individualized rehabilitation program.
    • Cognitive assessment should address arousal, attention, visual neglect, learning, memory, executive function, and problem solving.
    • Psychosocial assessments should be made of psychological factors (e.g., pre-morbid personality, level of insight, loss of identity concerns, sexuality), psychiatric illnesses, available resources, social support, patient goals, life situation, and social roles. A home assessment may be needed.
    • Management of dysphagia includes postural changes, increased sensory input, modified swallowing maneuvers, active exercise programs, and diet modifications. Non-oral feeding may be required in some instances, including consideration of percutaneous endoscopic gastrostomy feeding.3
    • Aphasia management includes efforts to increase gains during spontaneous recovery and use of compensatory techniques for persistent communication problems. Dysarthria treatments include interventions to improve articulation, fluency, resonance, and phonation, compensatory techniques, and use of alternate/augmentative communication (AAC) devices.
    • Cognitive deficits are common. Memory deficits can be managed through teaching compensatory strategies. Measures to address visual and spatial neglect should be integrated with other therapies, and may include prism glasses, increased awareness of deficits, and compensatory techniques. Neuropsychiatric sequlae should be identified and treated. Acetylcholinesterase inhibitors or the NMDA receptor inhibitor, Memantine, can be considered for patients with vascular dementia or vascular cognitive impairment.3Amphetamines are not recommended to enhance motor recovery.3
    • Patient, family, and caregiver education is an integral part of rehabilitation, as are appropriate advocacy and identification and help with securing of available support and resources. Assessment findings and expected outcomes should be discussed with the patient and family/caregivers.

Chronic stroke management:

  • Rehabilitation team members should provide adequate support as the patient transitions from inpatient rehabilitation to home. Team can provide assistance with ordering functionally appropriate durable medical equipment (DME), instructions for home exercise programs, arranging for home health or outpatient therapy services, scheduling follow up medical appointments, and providing information on local stroke support groups.
  • Ongoing management may include a regular exercise program, walking aids and/or wheelchair, adaptive devices for activities of daily living, home modifications, addressing return to work, driving, sexual dysfunction, and ongoing management of stroke risk factors and comorbid conditions. Appropriate safety measures (e.g., fall prevention) should be instituted.9
  • Secondary prevention of stroke3,4: Appropriate treatment of hypertension, anticoagulation for atrial fibrillation thrombo-embolic prophylaxis, use of antiplatelet therapy in cerebral ischemia, prevention of coronary heart disease, lipid lowering therapy, exercise, and smoking cessation are all important. Blood sugar maintenance of near-normoglycemic levels (80-140 mg/dl) is recommended for long-term prevention of microvascular and macrovascular complications.

Coordination of care:

Coordination of treatment care plans should include all involved medical specialists, home care services, outpatient therapists, as well as the patient and their families. A multidisciplinary team is essential for success.

Patient & family education:

Education must focus on management of risk factors, maintenance of rehabilitation gains, preventing complications, community support and resources, home modifications, and community reintegration.

Key topics for stroke prevention education (also see “Secondary prevention of stroke” section above):

  • Modifiable risk factors include: hypertension, heart disease, diabetes, obesity or being overweight.
  • Recommend: smoking cessation, avoiding excess alcohol consumption, having a balanced diet, and exercise participation.

Key topics for post stroke complication education and prevention:

  • Maintain regular follow up with a primary care physician, who can help prevent and monitor for complications.
  • Monitor for signs and symptoms of post stroke complications: depression, spasticity or contractures, shoulder pain/subluxation, DVTs, pressure ulcers, pneumonias, seizures, osteoporosis, UTIs and/or bladder control.
  • The following treatment or preventative techniques may be employed:
    • Counseling, psychotherapy, local stroke support groups, and antidepressant medications may be utilized for depression.
    • Range of motion exercises and physical therapies can help prevent limb contractures and shoulder pain.
    • Good nutrition and frequent pressure relief, including turning while in bed, will help prevent pressure ulcers.
    • Swallowing exercises and precautions, deep breathing exercises, and respiratory therapy can minimize risk of pneumonia.
    • Bladder training programs may be helpful for poor bladder function control.

Outcome Measures:

Number of hospital readmissions, functional status, community dwelling, and mortality are important indicators to measure in the post-discharge period.

Common scales:

  • Functional Independence Measure Scale (FIM): Assesses physical and cognitive function focusing on burden of care. There are a total of 13 motor items and 5 social-cognitive items. Each item is scored from 1-7, with 7 indicating complete independence.
  • Modified Rankin Scale: A global outcome scale that runs from 0-6, with 0 being perfect health without symptoms, and 6 being death. It is commonly used for measuring the degree of disability, or dependence, and has become a widely used clinical outcome measure for stroke clinical trials.

5. GAPS IN THE EVIDENCE-BASED KNOWLEDGE

Gaps in the evidence-based knowledge

  • Although several different forms of rehabilitation techniques have been proven effective, these studies often involve small and highly selective populations and are not generalizable to the stroke population.
  • Further studies are needed to develop optimal treatment protocols for many of the cutting edge therapies, including constraint-induced movement therapy, indirect brain stimulation, and mirror therapy. There are questions on timing, intensity, ideal patient populations, and combinations with other therapies, etc.
  • Blood pressure management during early stroke management continues to be an area of conflict. Larger trials with well-defined criteria are needed and appear to be forthcoming. Current guidelines should be followed until such time.1,12,13
  • The most recent AHA guidelines suggest further study is needed in specific areas of early acute ischemic stroke management, including in intravenous fibrinolysis, endovascular interventions, anticoagulants, antiplatelet agents, and induced hypertension. 1
  • The use of complementary and alternative medicine (CAM) in cardiovascular disease and stroke patients has gained in popularity over recent years and appears common. These include biological therapies such as dietary supplements, herbal medicine, and aromatherapy; mind-body therapies such as deep breathing, meditation, yoga, tai chi, and praying; manipulative and body-based therapies such acupressure, chiropractic manipulation, massage, osteopathic manipulation, and reflexology; whole medical systems which include acupuncture, Ayurveda, homeopathy, and naturopathy; and finally energy medicine which includes healing touch, light therapy, magnetic therapy, Reiki, and sound energy therapy. Biologic, mind-body therapies, and acupuncture (especially among stroke patients) are the most commonly used. Potential interactions and adverse effects may exist for biological CAM therapies. CAM is poorly studied and there are conflicting results. Further sound and rigorous studies are needed, especially in regard to effects of CAM therapies on clinical outcomes and safety. Further studies are also needed in regard to CAM as it applies specifically to stroke patients.28,29

REFERENCES

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  5. Wells, George A., et al. “Ottawa Panel Evidence-Based Clinical Practice Guidelines for Post-Stroke Rehabilitation.” Topics in Stroke Rehabilitation 2006; 13(2), 1-269. DOI: 10.1310/3TKX-7XEC-2DTG-XQKH
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  12. Saver JL. Blood Pressure Management in Early Ischemic Stroke. JAMA. 2014;311(5):469-470. doi:10.1001/jama.2013.282544.
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  15. Park J-Y, Chang M, Kim K-M, Kim H-J. The effect of mirror therapy on upper-extremity function and activities of daily living in stroke patients. Journal of Physical Therapy Science. 2015;27(6):1681-1683. doi:10.1589/jpts.27.1681.
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  18. Pedroli E, Serino S, Cipresso P, Pallavicini F, Riva G. Assessment and rehabilitation of neglect using virtual reality: a systematic review. Frontiers in Behavioral Neuroscience. 2015;9:226. doi:10.3389/fnbeh.2015.00226
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  22. Kwakkel G, Kollen BJ, Van der Grond J, Prevo AJ. Probability of regaining dexterity in the flaccid upper limb: impact of severity of paresis and time since onset in acute stroke. 2003;34:2181-2186
  23. Mehrholz J, Pohl M. Electromechanical-assisted gait training after stroke: a systematic review comparing end-effector and exoskeleton devices. J Rehabil Med. 2012 Mar;44(3):193–199
  24. Maulden S.A. et al. Timing of Initiation of Rehabilitation After Stroke. Arch Phys Med Rehabil. 2005. 86 (Suppl 2): S34-40.
  25. Venkatakrishnan A, Francisco GE, Contreras-Vidal JL. Applications of Brain–Machine Interface Systems in Stroke Recovery and Rehabilitation. Current physical medicine and rehabilitation reports. 2014;2(2):93-105. doi:10.1007/s40141-014-0051-4.
  26. Hollender, KD. Screening, diagnosis, and treatment of post-stroke depression. J Neurosci Nurs. 2014 June; 46(3): 135–141. doi: 10.1097/JNN.0000000000000047
  27. Nabavi SF, et al. Post-stroke depression therapy: where are we now? Curr Neurovasc Res. 2014;11(3):279-89.
  28. Shah SH, Engelhardt R, Ovbiagele B. Patterns of complementary and alternative medicine use among United States stroke survivors. J Neurol Sci. 2008;271:180–5. doi: 10.1016/j.jns.2008.04.014
  29. Rabito MJ, Kaye AD. Complementary and Alternative Medicine and Cardiovascular Disease: An Evidence-Based Review. Evidence-based Complementary and Alternative Medicine : eCAM. 2013;2013:672097. doi:10.1155/2013/672097.

Original Version of the Topic:

Anne F. Ambrose, MD MS. Cerebrovascular Disorders Part 2 (Management and Treatment, Cutting Edge concepts in practice, Gaps in evidence based practice). Publication Date:2012/10/03

Author Disclosure

Rani Haley Lindberg, MD
Nothing to Disclose

Mustafa Khan, MD
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