1. Rehabilitation in Cerebrovascular Disease and Traumatic Brain Injury Prawit Rungcharoensak M.D. Dept. of Rehabilitation Medicine BMA Medical College & Vajira Hospital

2. Cerebrovascular disease / stroke Prevalence : 690 / 100,000 Risk factors 1. Age ( 65 yr : 5063) 2. Hypertension 3. Valvular heart disease, arrhythmia (AF) 4. D.M. 5. Previous stroke / TIA 6. Race 7. Sex 8. Smoking 9. Family Hx. 10. DM 11. Elevated fibrinogen 12. Erythrocytosis 13. LDL

3. 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

4. Pattern of neurological recovery Hypotonia / flaccidity ( 48 hr) Flexion / extension synergies ( 2-30 d.) Isolated movement ( 6-33 d.) Full recovery ( 10% of Pt.) Prognosis : ~12 weeks

5. Rehabilitation Goal : Independence Candidate : able to perceive, understand, follow command (verbal/gesture) Assessment : –pathology –site of lesion –symptoms & signs –risk factors –stage of neurological recovery – functional performance

6. Positive predictors 1. Bladder control (within 1-2 wk) 2. Recovery of trunk, hip, shoulder muscles within 2-4 wk (proximal muscle) 3. Recovery of each muscles 4-6 wk (Isolate muscles) 4. Family support 5. No depression 6. Good perception

7. Negative predictors 1. Prolonged coma 2. Prolonged flaccid (> 2 months) 3. Severe proximal muscles spasticity 4. Inability to control bladder & bowel (within 2-3 wk) 5. Severe unilateral neglect 6. Severe intellectual / memory impairment 7. Visuospatial deficit / hearing deficit 8. Previous stroke 9. Severe depression 10. Associated diseases (CAD, CHF, PVD)

8. Deficits 1. Cognitive problems –Left hemiplegia : perceptual deficit, neglect, poor insight & judgement –Right hemiplegia : aphasia 2. Behavioral / emotional problems –Depression (25-60%) : 6 m- 2 yr, 70% of right hemiplegia –Undue cheerfulness (anxiety, lability) : right frontal lobe –Apathy : right frontal lobe –Denial

9. Deficits 3. Communication disorder –Language : aphasia (spontaneous recovery 3-6 m) –Articulation : apraxia, dysarthria, dysphonia 4. Sensory deficits –Visual field deficit –Visual perceptual deficit (right hemisphere) : body image, special related disorder –Peripheral sensory deficit (propioception)

10. Deficits 5. Motor deficits –Spasticity –Incoordination –Weakness –Motor apraxia 6. Bladder, bowel, sexual deficits –Bladder : 70% of Pt. can control (PC exercise, CIC) –Bowel : diet (75% of Pt. can control, incontinence in bed ridden) –Sexual : in 70% of cases

11. 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 sensory deficits

12. Complications 1. Shoulder subluxation ( 50-80%) 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%, Mo 2-4 ) Causes : ANS disorder, increased sympathetic tone Stage 1: pain on ROM, swelling of wrist & fingers, cold skin Stage 2: swelling, joint stiffness, osteoporosis Stage 3: skin dystrophy,osteoporosis Treatment : ROM, wrist & hand splint, pain reduction (TENS, drug)

13. Complications 3. Seizure ( 10-15% ) Early seizure (2 wk) : brain swelling, cytotoxic metabolite, embolic > thrombotic stroke, no treatment Late seizure (6 m - 2 yr) : hemorrhagic stroke, medication 4. Aspiration Pneumonia (50%) Causes: - swallowing disorder, dysphagia (brainstem lesion) - cognitive function Treatment : oral hygiene, proper eating position, proper diet, swallowing training

14. Traumatic Brain Injury (TBI) Traffic accident 60% Risk factors 1. Age : 15-24 yr, 0-5 yr, >65 yr 2. Sex : male > female 3. Alcohol 4. Other : psychological, personality

15. Classification of TBI 1. Severity : Glasgow Coma Scale (GCS) Severe : 3-8 Moderate : 9-12 Mild : > 13

16. Classification of TBI 2. Pathology 2.1 Focal : o Focal cortical contusion (FCC) o Deep hemorrhage o Focal hypoxic-ischemic injury (FHII) 2.2 Diffuse : o Diffuse axonal injury (DAI) o Diffuse hypoxic-ischemic injury (DHII) 2.3 Indirect pathological condition & secondary phenomena : o extracerebral hematoma, herniation syndrome, hydrocephalus, chronic subdural hematoma, hygroma, posttraumatic seizure

17. FCC frontal polar, orbital frontal : apathy, disinhibition, IQ anterior inferior temporal : aphasia, agnosia Deep hemorrhage basal ganglion : hemiparesis, discordination, hypertonia, movement disorder, aphasia / neglect FHII posterior cerebral artery : hemianopia, amnesia DAI corpus collosum : coma (without lucid interval), confusional state, residual attention, cognitive & behavioral impairments

18. Recovery of diffuse TBI DAI : Coma Vegetative state Mute / low level responsiveness Confusional state : attention deficit, abn. behavior Evolving independence Intellectual / social competence FHII : prolonged coma & confusion, poor prognosis

19. Specific impairments after TBI Physical : 1. Movement control* 2. Abnormal tone, spasticity 3. Cerebellar incoordination 4. Involuntary movement 5. Seizure Neuropsychological : 1. Neurological : arousal, attention (memory), behavior 2. Postconcussion syndrome : headache, dizziness, insomnia, depression, fatigue 3. Psychological : depression, anxiety, posttraumatic stress

20. Rehabilitation program Acute : neurosurgery Acute rehabilitation phase : Coma : prevention of complications coma stimulation (sensory stimulation, sitting) Confused : rehab team approaching medication behavioral management

21. Rehabilitation program Postacute rehabilitation phase : (post discharge) Day care Day treatment Transitional living center Cognitive rehabilitation : Functional skill training (ADL) Process oriented rehabilitation (attention, executive function)

22. Outcome 1. Severe TBI (GCS 3-7) : dead 35-50%, cognitive impair = 21%, abn behavior = 24% 2. Mild TBI (GCS 12-15) : postconcussion syndrome 3. Focal pathology : multiple, mass effect, abn pupil = poor prognosis 4. Diffuse pathology : GCS, length of coma & posttraumatic amnesia (PTA) 5. Recovery rate