Stroke effects on cognition, mood and movement: Implications for practice

1
Stroke effects on cognition, mood and movement
Implications for practice

• Pamela W Duncan Ph.D., P.T, FAPTA, FAHA
• Duke University

Thinking, Moving and Feeling September 6, 2007
2
Funding Sources

• NIA Claude D Pepper Center University of Kansas
• NINDS/NCMRR LEAPS Trials
• American Heart Association

3
Walking recovery post stroke

• Of stroke survivors living in the community, 40
  require assistance with walking, of those who are
  independent, 60 are limited in community
  ambulation-60 to 80 walk less than .8ms
• Limitation in walking ambulation is among the
  most debilitating aspects of stroke sequelae

4
Range of Steps Taken 2 months Post Stroke
(Individuals independently walking but lt.8m/sec
from the Leaps Trial)
5
Walking Recovery Post-Stroke

• Macko- Topics in Stroke Rehabilitation Mar-April
  2007
• 79 Chronic Stroke
• Daily steps ( 1389 /- 797)
• Very few steps at high intensity gt 30/steps per
  minute
• Peak Oxygen Consumption was consistent with
  profound aerobic activity

6
Consequences are huge

• 73 incidence of falls
• 4-fold increase in falls risk
• Of those who fall, stroke survivors experience a
  10-fold increase in hip fracture compared to
  non-stroke
• Limited mobility leads to social isolation and
  depression

7
Whitson, et al JAGS 2006

• Increase fractures rates in FRG 4-7 ..first year

8
Kaplan-Meier Results Time to first fracture
2.7
4.7
Estimated 1-Year Fracture Rate 2.7 (95 CI
2.3-3.1) Estimated 2-Year Fracture Rate 4.7
(95 CI 4.1-5.3)
9
Results Total FIM Score and Fracture Risk after
Stroke
Discharge FIM Score lt54
Discharge FIM Score gt90
Discharge FIM Score 54-90
Time to first fracture (years)
10
Results Total FIM Score at Discharge and
Subsequent Fracture Risk
Relative Hazard of Fracture
FIM Score At Discharge
11
Conclusions

• Fracture rates in this stroke cohort are 2-7
  times higher than expected population rates
• Characteristics associated with lower fracture
  risk after stroke
• - high cognitive FIM scores
• - black race
• - male gender
• Stroke patients with intermediate functional
  impairment are more likely to fracture than those
  with severe or minimal impairment

12
Predictors of Recovery of Walking

13
Kaplan-Meier Estimates of Cumulative Probability
of Achieving FIM Walking Independence Over 6
Months

M (n122)
MS (n111)
MH (n 35)
MSH (n 92)
p lt 0.0001
Months From the Initial Assessment
14
Percent of stroke patients with stationary gait
function and leg motor strength recovery during
conventional rehabilitation.
N804 95 get no better after 11 weeks with
routine care.
Jorgenson et al. Arch Phys Med Rehabil 1995
15
Current Model
Healthy Mobility
Activity Participation
Mobility Limitation (Gradual Onset)
Mobility Limitation (Sudden Onset)
Age in Years
16
Determinants of Gains in Walking Are
Multifaceted and Depends on Severity

• Poor Performers 16 of variance in gains
  attributable to improvements in balance
• High Performers 28 of variance in gains
  attributable to improvements in peak VO2 and LE
  Fugal-Meyer
• Pohl, Perra, Duncan et al Neurorehabilitation
  and Neural Repair March 2004

17
Determinants of Limitations in Walking Are
Multifaceted and Depends on Severity

• Determinants of walking function after stroke
  differences by deficit severity. Patterson et al
  Archives of PMR 2006
• Long-distance walking is mostly explained by
  balance in those who walk slowly (lt .48m/sec)
  but in those who walk faster
• ( gt.48m/sec) it is cardiovascular endurance.

18
Walking Recovery Following Stroke
Intervention
Mechanisms
Mobility

• Training Methods
• Parameters (dosage)
• - timing
• - duration
• - intensity
• Adjunctive therapies

• Contributions to walking
• Neural-
• Neuromuscular
• Biomechanical
• Cardiovascular
• MOOD
• COGNITIVE

• Functional role
• Community/social
• Quality of life

Abnormal Gait - Gait Deviations - Increased
energy expenditure - Increased risk of
falls
Can we map gait deficits onto the most
efficacious treatment for gait deficit to get the
most meaningful outcomes for mobility and
ultimately quality of life..
from Rose DK and Duncan PW
19
Stroke and Cognitive Deficits

• Focus of most assessements and practically all
  clinical trials have been measurement of physical
  deficits
• 65 of stroke survivors show cognitive
  impairments
• Cognitive deficits interfere with rehabilitation
  efforts and have been associated with additional
  strokes

20
Summary of Cognitive Deficits Seen in Stroke
Syndromes According to Vascular Distribution and
General Neuroanatomic Localization
Donovan NJ, Kendall, DL, Heaton, SC, Kwon S,
Velozo, CA, Duncan, PW. (Accepted)
Conceptualizing Functional Cognition In Stroke.
Neurorehabilitation and Neural Repair
21
Orpington Predicts Stroke Recovery ?
22
ORPINGTON PROGNOSTIC SCALE (CIRCLE THE
APPROPRIATE RESPONSE) A. Motor deficit in arm
Lying supine, patient flexes shoulder to 90 and
is given resistance. 0.0 MRC grade 5
(normal power) 0.4 MRC grade 4 (diminished
power) 0.8 MRC grade 3 (movement against
gravity) 1.2 MRC grade 1-2 (movement with
gravity eliminated or trace) 1.6
MRC grade 0 (no movement)
23
B. Proprioception (eyes closed) - Locates
affected thumb 0.0 Accurately 0.4 Slight
difficulty 0.8 Finds thumb via arm 1.2
Unable to find thumb C. Balance 0.0 Walks 10
feet without help 0.4 Maintains standing
position (unsupported for 1
minute) 0.8 Maintains sitting position 1.2
No sitting balance
24
D. Cognition - Hodkinson's Mental Test Score
one point for each correct answer 1. Age of
patient 2. Time (to the nearest hour) I am
going to give you an address, please remember
it and I will ask you later 42
West Street 3. Name of hospital 4.
Year 5. Date of birth of patient 6. Month
25
7. Years of the Second World War 8. Name of
the President 9. Count backwards
(20-1) 10. What is the address I asked you to
remember? 42 West Street 0.0 Mental test
score of 1 0 0.4 Mental test score of 8-9 0.8
Mental test score of 5-7 1.2 Mental test
score of 0-4
26
Barthel Recovery gt 90 at 3 Mos
27
Get to Places Out of Walking Distance at 3 Months
()
28
Performance in Complex Environments

• Yang et al Gait and Posture, Feb 2007
• Even among highly recovered community ambulators
  post stroke, introducing divided attention tasks
  significantly changes gait variables and
  stability compared to healthy age matched
  controls.

29
McDowd J et al J of Gerontology 2003

• 55 individuals with stroke ( mean MMSE of 27) and
  39 health older adults with no history of stroke
• Stroke subjects have higher incidence of divided
  attention deficits and these deficits strongly
  correlated with limitations in physical
  functioning ( SIS) and social participation

30
Kemper et al Aging, Neurpsychology and Cognition
2005

• Baseline language compared to language collected
  while performing concurrent motor tasks in stroke
  and age matched controls.
• Healthy adults few costs to language in
  concurrent tasks, stroke survivors language was
  disrupted during concurrent tasks.

31

• Stroke decreases cognitive reserve ..
• Post-stroke motor, visual, impairments require
  increasing dependence on cognitive reserve in
  order to compensate
• Post-stroke individuals may be unable to draw
  upon sufficient cognitive reserve to successfully
  maintain balance and mobility

32
Post Stroke Depression

• Occurs in approximately one third of stroke
  survivors
• Associated with diminished recovery, lower
  recovery trajectories, even when adjusting for
  other important covariates, including stroke type
  and severity.

33

34

35

36
Jorgensen et al , Stroke 2002

• Concluded that falls are more frequent among
  noninstitutionalized long-term stroke survivors
  than among community control subjects and that
  the risk of falling and depressive symptoms are
  related in stroke patients.

37
A Randomized Trial of Therapeutic Exercise in
Sub-Acute Stroke

• Funded by NIA- Claude D Pepper Center
• Duncan, Studenski et al
• Stroke, September 2003

38
Purpose of the Post-Stroke Intervention Study

• To determine the effect of a reproducible,
  physiologically based, progressive exercise
  program on strength, balance, endurance, and
  upper extremity function after stroke.

39
Methods

• Prospective, randomized, single-blind clinical
  intervention trial

40
Sample Inclusion Criteria

• Age gt 50 years old
• Stroke onset within 30-120 days of randomization
• Expected to live 6 months
• Able to care for themselves prior to stroke
• Lived within 50 miles of participating facility
• Controlled blood pressure
• Folstein Mini-Mental Status Exam score gt 16

41
Sample Inclusion Criteria

• Ambulate independently for 25 feet
• Mild to moderate stroke deficits
• Fugl-Meyer Score within 27-90 for total upper and
  lower extremity score
• Palpable or more wrist extension
• Orpington Prognostic Scale score within 2.0-5.2

42
Control Group

• Received usual care as prescribed by their
  physicians
• Visited by research assistant every 2 weeks
• those in therapy got educational materials about
  stroke and community resources
• those without or d/cd from therapy had blood
  pressure, heart rate, and O2 saturation checked
• Those receiving therapy
• treating therapist completed log of content of
  program (intensity, duration, and activity type)

43
Intervention Characteristics

• Protocol based structure with defined progression
  for each component
• Therapist supervised, in-home exercise program
• Frequency 3 times/week for minimum of 32 visits
  or 12 weeks
• Session duration 90 minutes

44
Components of Intervention

• Flexibility
• Strengthening
• PNF
• Theraband
• Functional Activities
• Balance
• Sitting
• Standing Static Dynamic
• Gait Challenge
• Endurance Stationary Bike

45
Therapy Received
46
Therapy Received
47
Therapy Received
48
Change in Balance Mobility Primary Outcomes
49
Change in Endurance Primary Outcomes
50
Studenski, Duncan et al Stroke 2005Program to
improve strength, balance and endurance improve
depression

• The intervention group improved more than usual
  care in
• Emotion 5.6 points P0.0240
• CONCLUSIONS This rehabilitation exercise program
  led to more rapid improvement in aspects of
  physical, emotional, social, and role function
  than usual care in persons with subacute stroke..

51
Lai SM et al JAGS 2006

• Exercise may help reduce poststroke depressive
  symptoms. Depressive symptoms do not limit gains
  in physical function due to exercise. Exercise
  may contribute to improved quality of life in
  those with poststroke depressive symptoms.

52

• Cognition/Depression Influencing Mobility and
  Balance and Mobility may Influence Language
  Fluency and
• other Cognitive tasks

53
Recovery and maintaining walking abilities post
stroke is Complex

• It is beyond simply the neurobiological of
  physical recovery of mobility walking.
• Interactions with cognition, depression and
  mobility

54
What is needed?

• Comprehensive Risk Assessments for Cognition,
  Depression, and Mobility/Balance/Walking
• Targeted Interventions- for combined cognitive
  tasks, complex environments, and mobility

55
(No Transcript)