UN is most common following damage to the right hemisphere of the brain from stroke; although illness or traumatic brain injury are also linked to the development of UN. When functioning normally, the right hemisphere of the brain is attentive to both sides of the world with a global focus and the ability for prolonged attention while the left hemisphere is attentive only to its opposite side with a centralized focus and shorter attention span.

The wide range and complexity of UN symptoms and the presence of other sensory or motor deficits due to stroke contributes to the high rate of missed diagnoses. A disorder of input and/or output, a person affected with UN will either completely ignore the side opposite to the brain injury or feel that side is totally unimportant; to the extent of not recognizing their own limbs. All deficits are more severe in those affected by UN following stroke and are more likely to be permanent than in people who do not have UN in conjunction with stroke.

People with UN are able to see, hear, and move but do not recognize, listen to, or understand their world. A person with input disorder, also called inattention, will ignore odors, sounds, touch, and sight on the side opposite to their brain lesion; this inattention may also include ignoring one side of hallucinations, dreams or memories. A person with output disorder will not use their limbs opposite to the lesion, despite having the ability to do so; or will only be able to move a limb within the recognized space, but not within the ignored space.

A person with UN will ignore the left side of their visual field, or will be able to see both sides but ignore the left half of each object within the visual field. They will only dress or care and protect one side of their body; will only eat food on one side of their plate; will only look to one side; will completely ignore objects or people on the affected side; or will walk into walls or furniture on the effected side. People are usually unaware of the presence of their deficits due to UN, unlike when other sensory and motor deficits are present following stroke.

Inpatient rehabilitation facilities receive a set amount of money from Medicare, based upon guidelines for each illness or disease. These prospective payment systems limit a patient’s length of stay regardless of their level of functioning upon discharge and have been found to have an impact upon the outcome of people with UN. A person affected with UN does not progress quickly during rehabilitation, requires a long time to recover, and is discharged with a low level of functioning. In addition, people with UN are less likely to return to their homes and live on their own following stroke, and have an increased risk for falls or other injuries.

People are now living longer; the incidence and severity of UN will continue to rise, straining an already overburdened health care system. UN has impacted the elderly today and will have an impact upon aging baby boomers in the very near future. Additional research is needed to ensure early and accurate diagnosis through appropriate testing methods; targeted and effective treatment modalities need to be developed; and the health care team must be educated to increase awareness of this often neglected complication of stroke. Modification of the prospective payment system within the current Medicare system is also needed that recognizes the increased rehabilitation requirements for this group of stoke and brain injury survivors.

References

Gillen R et al. The impact of the inpatient rehabilitation facility prospective payment system on stroke program outcomes. Am J Phys Med Rehabil. 2007 May; 86 (5): 356-63. doi:  10.1097/PHM.0b013e31804a7e2f

Gottesman RF et al. Unilateral neglect is more severe and common in older patients with right hemispheric stroke. Neurology. 2008 Oct 28;71(18):1439-44. doi: 10.1212/01.wnl.0000327888.48230.d2

Jepson R et al. Unilateral Neglect: Assessment in Nursing Practice. J Neurosci Nurs. 2008 Jun; 40 (3): 142-9.

Wee, J., & Hopman, W. (2008). Comparing Consequences of Right and Left Unilateral Neglect in a Stroke Rehabilitation Population American Journal of Physical Medicine & Rehabilitation, 87 (11), 910-920 DOI: 10.1097/PHM.0b013e31818a58bd

In mirror therapy, a mirror is placed beside the unaffected limb, blocking the view of the affected limb. This creates the illusion that both limbs are functioning properly. Mirror theory is based on evidence that action observation activates the same motor areas of the brain as action execution. Observed actions lead to the generation of intended actions, engaging motor planning and execution. Further, evidence suggests that damaged areas of the brain’s motor cortex may improve by viewing movements of intact, functioning limbs.

Strokes can cause much neurological impairment, which may lead to a reduction in the performance of activities of daily living. Current rehabilitation techniques focus on occupational and physical therapy, using guided limb manipulation and task-oriented training. These exercises combine passive and active movement in an attempt to rebuild neuronal connections damaged by the stroke. Adding mirror therapy to traditional therapy enlists visual stimulation showing proper functioning. This points to a large cognitive role in rehabilitation, rather than just physical.

In the current study, 14 stroke patients with lower-limb hemiplegia were randomized to begin traditional rehabilitation therapies with or without the addition of mirror therapy. The study was a crossover design, and patients crossed to the other treatment arm after an initial treatment period. The subjects sat in a chair with a mirrored box placed over their lower limbs. They stepped over a 3-cm high step 10 times, and the angle of the ankle joint, as well as the time required to complete the task, were calculated.

Among this group of patients, the time required to complete the task was significantly shorter in the mirror therapy group, 2.80 seconds compared with 3.19 seconds in the non-mirror group. This translates to an approximate 12% acceleration of movement in the mirror therapy group. There was no significant difference in ankle flexion between the groups.

This is not the first study to report the positive effects of added mirror therapy in stroke patients. A randomized, controlled 4-week trial of 40 stroke patients concluded that hand functioning improved more after the addition of mirror therapy compared to conventional stroke rehabilitation programs. This study measured motor functioning and spasticity using standard instruments for recording physical rehabilitation, including the Modified Ashworth Scale (MAS) and the Functional Independence Measure (FIM). Additionally, a similar study of another 40 stroke patients found mirror therapy enhanced lower-extremity motor recovery. This study measured motor functioning and spasticity using the MAS, the FIM, and measured walking ability. The study presented at the World Stroke Congress is among the first to report speed of movement as a result.

Interestingly, the principles of mirror therapy have been applied to other techniques for stroke rehabilitation and used to develop virtual-reality based therapy systems for physical therapy programs. A recent study reported positive preliminary results from such a method that combines action observation with goal-directed movement imagery.

Hemiplegia is one of the most common consequences of strokes and presents great challenges for rehabilitation. With more evidence focused on visual and cognitive techniques to enhance traditional therapies, the mental and intellectual processes involved in rehabilitation are recognized as important factors in physical recovery. Now, a simple optical illusion could reflect great strides in stroke recovery.

References

Kynan Eng, Ewa Siekierka, Pawel Pyk, Edith Chevrier, Yves Hauser, Monica Cameirao, Lisa Holper, Karin Hägni, Lukas Zimmerli, Armin Duff, Corina Schuster, Claudio Bassetti, Paul Verschure, Daniel Kiper (2007). Interactive visuo-motor therapy system for stroke rehabilitation Medical & Biological Engineering & Computing, 45 (9), 901-907 DOI: 10.1007/s11517-007-0239-1

D ERTELT, S SMALL, A SOLODKIN, C DETTMERS, A MCNAMARA, F BINKOFSKI, G BUCCINO (2007). Action observation has a positive impact on rehabilitation of motor deficits after stroke NeuroImage, 36 DOI: 10.1016/j.neuroimage.2007.03.043

S SUTBEYAZ, G YAVUZER, N SEZER, B KOSEOGLU (2007). Mirror Therapy Enhances Lower-Extremity Motor Recovery and Motor Functioning After Stroke: A Randomized Controlled Trial Archives of Physical Medicine and Rehabilitation, 88 (5), 555-559 DOI: 10.1016/j.apmr.2007.02.034

G YAVUZER, R SELLES, N SEZER, S SUTBEYAZ, J BUSSMANN, F KOSEOGLU, M ATAY, H STAM (2008). Mirror Therapy Improves Hand Function in Subacute Stroke: A Randomized Controlled Trial Archives of Physical Medicine and Rehabilitation, 89 (3), 393-398 DOI: 10.1016/j.apmr.2007.08.162

In the USA, there has been growing emphasis on documentation and maintaining good health records in the field of healthcare over the past few years. As a rehabilitation professional, I used to find summarizing the activities of a one-hour session into a paragraph of words somewhat challenging. But over the years, one tends to accept medical notes as part of one’s work, gradually getting more efficient at it. Documentation is primarily viewed as a means to communicate episodes of care to third party payers for reimbursement purposes. However, detailed documentation and well-organized records also serve to benefit the healthcare professional and the consumer. Some of the benefits of good quality documentation are:

• Maintaining records so that administrative operations may be evaluated based on the recommendations of accrediting and certifying organizations.
• Maintaining privacy and security of personal healthcare records.
• Maintaining records to keep up with the expectations of the educated consumer.
• Legal record of all communication between professional and consumer in case of disputes.

In the field of therapy and rehabilitation, the typical evaluation form has a section for goal setting. Personally, I think this is invaluable, as it gives the professional a chance to ask patients and their families what their expectations from therapy are, thereby including them in the process from the beginning. This is the foundation of the Interdisciplinary model of healthcare delivery, which places the patient and family at the center of the planning process. When goals are set early on, the rehabilitation plan is better outlined and specific to the patients’ needs. Studies have indicated that efficient goal planning and documentation improve patient compliance and participation in the program. Studies also suggest that concise and systematic goal planning has a positive effect on patient outcome.

To increase efficiency and ease of storage, hospitals and clinics are moving form the traditional pen and paper documentation toward electronic medical records (EMR). The technology boom has certainly affected healthcare; now documentation may be done on word processing software, over the Internet, or telephonically via dictation systems.

“Working from home” — a concept alien in rehabilitation — is now becoming a possibility; the EMR gives therapists the choice of completing notes at home.

Studies suggested that EMR improved reporting capabilities, and provided a standardized system to analyze and measure therapy outcomes. Studies also showed that EMR enabled individualized treatment planning for clients. Other benefits of EMR included improved efficiency of patient admission processes, decreased length of rehabilitation stay, improved communication within the team, and reduced duplication of information. Another advantage of the EMR is maintaining continuum of care, as the records are available to the entire treatment team for reference and for planning treatment sessions.

Maintaining current and accurate medical records is the responsibility of every healthcare professional. There are more advantages than disadvantages to this and timeliness of documentation benefits the consumer, the providers and companies that bear healthcare costs.

A 29 year old stroke victim in the magazine Stroke Connection provided vivid detail of his stroke pain,

Someone is ripping at my arm, hand, face and foot with razorblades constantly. My fingers are made of metal worms that move constantly. My arm and other bones are broken and sticking out of my skin… I know that’s difficult to imagine, but it’s difficult to explain the evil, horrific, non-stop ripping, clawing, beating, burning,…on and on…and it never stops, even for one second, it’s constant and will not stop and you endure it for the rest of your life!

This condition, central pain syndrome, is a neurological condition caused by damage to or dysfunction of the central nervous system (CNS), which includes the brain, brainstem, and spinal cord. It is characterized by sensory changes and nerve pain. In addition to stroke, central pain syndrome can be seen with multiple sclerosis, tumors, epilepsy, brain or spinal cord trauma, or Parkinson’s disease

Central pain syndrome is unexpected and bewildering to family members, caretakers, and even the stroke patient. Before them is a limb with little motion that is supposed to be devoid of feeling, yet these very same extremities are transmitting intense sensation. The pain is usually constant, may be moderate to severe in intensity, and is often made worse by touch, movement, emotions, and temperature changes, usually cold temperatures. Individuals experience one or more types of pain sensations, the most prominent being burning. Along with the burning may be pressing, lacerating, or aching pain; sensations of “pins and needles”; and brief, intolerable bursts of sharp pain similar to the pain caused by an exposed nerve. Individuals may have numbness and burning in the areas affected by the pain, especially in the hands or the feet. With the onset of the symptoms more than a month after the stroke, there is much confusion. The symptoms may be misinterpreted as depression or a reaction to a life jarring event. True enough, stroke is a life altering situation, but the pain described or experienced is real.

The increase in soldiers with traumatic brain and spinal cord injuries returning from the wars in Iraq and Afghanistan has focused more attention and research on the condition. Treatment at this time is limited. It includes use of antidepressants, anticonvulsants, narcotics, and anti-arrhythmics. The drug of first choice is the antidepressant amitriptyline. Newer techniques such as vestibular stimulation (introduction of water to the inner ear) have shown promising results in pain relief.

References

P. Hansson (2004). Post-stroke pain case study: clinical characteristics, therapeutic options and long-term follow-up European Journal of Neurology, 11 (s1), 22-30 DOI: 10.1111/j.1471-0552.2004.00793.x

P. D. McGeoch, L. E. Williams, R. R. Lee, V. S Ramachandran (2008). Behavioural evidence for vestibular stimulation as a treatment for central post-stroke pain Journal of Neurology, Neurosurgery & Psychiatry DOI: 10.1136/jnnp.2008.146738

For a large part of the previous century, it was believed that people with stroke would have to lead a largely dependent life, confined to the wheelchair. They were even discouraged from moving their limbs or exercising. Over the years, rehabilitation for patients with stroke has come a long way. Focus has shifted from basic interventions utilizing strengthening exercises to more advance techniques based on the theories of motor learning and neuroplasticity. This included manual techniques by skilled clinicians as well as the use of equipment such as electrical stimulation modalities, and specialized bikes and treadmill systems — all aimed at optimizing function in patients with impairments. In the past few years, a major step for the field of rehabilitation has been the integration of fields such as assistive technology, robotics and computer sciences with the science of rehabilitation. The amalgam of the above has led to potentially powerful systems that will enhance the functional outcome in patients greatly. The latest entrant into the filed of rehabilitation is virtual reality (VR) systems for rehabilitation. Many of the systems have been tested, released and are now available to hospitals and clinics for use. Clinical trials are ongoing, for upgrading existing technology and for invention of new systems for recovery and rehabilitation.

In 2002, the engineers at Rutgers University have created a VR system that included therapeutic activities aimed at recovery of function in patients with stroke. There are now many versions of this system available, and clinical trials are ongoing to evaluate the extent of efficacy of these systems in recovery of function. Like any VR gaming system, patients will see themselves in a simulated environment. Only, games will be replaced by targeted exercises that will work target various functional muscle groups in the arms and hands. Patients can complete fine motor tasks such as picking up objects, stacking objects, and gross motor tasks such as tapping balloons, catching objects and even reach for objects out of their base of support, thus encouraging balance retraining.

Of late, VR rehabilitation systems are also being evaluated for their use in decreasing neglect in patients with hemiplegia. This is achieved by the system providing visual cues from the affected side, to increase awareness and enhance adaptive relearning. A recent published case study (four participants) suggested that VR systems had the potential for decreasing neglect in patients with stroke. In addition to improvements on the objective tests that were administered, participants also subjectively reported that VR training sessions were helpful and enjoyable. VR systems can even simulate day-to-day situations like crossing a street, cooking, opening doors, etc. This will provide very specific learning of the tasks that are essential activities of daily living. The VR systems are effective as they emphasize active participation by the patient and provide varied environments for task practice while providing immediate feedback of quality. All of these fulfill the requirements of ideal motor practice and motor learning.

Stroke survivors, in my experience, are people who have the most enthusiasm to recover; their zest to go back to doing things they used to love serves as a wonderful motivator at rehabilitation sessions. Preserved cognition, high motivations levels, and a firm conviction to go back to their old routine makes patients with stroke ideal candidates for unique rehabilitation tools. I look forward to the day when these systems are available to most hospitals at an affordable price, with simpler user interfaces so that more and more patients will benefit from the systems.

Reference

Smith, J., Hebert, D., Reid, D. (2007). Exploring the effects of virtual reality on unilateral neglect caused by stroke: Four case studies. Technology and Disability, 19(1), 29-40.

Our job is to help restore function to patients with disabilities. We typically work hand-in-hand with a multidisciplinary team that may include physical therapists, occupational therapists, speech and language pathologists, recreational therapists, orthotists, prosthetists, clinical psychologists, social workers, vocational counselors, massage therapists, chiropractors, acupuncturists, or other doctors such as orthopedic surgeons, anesthesiologists, neurologists, rheumatologists, psychiatrists, or internists. Needless to say, a major prerequisite for being a physiatrist is being an excellent team player.

The physiatrist is like the conductor of an orchestra. We are the gatekeeper to a group of professionals who are good at what they do, but don’t necessarily know what the other people in the team do or how that affects the patient. The brass section doesn’t particularly care about what the strings are doing, or even know the first thing about how to play a violin. However, if the brass section is playing too loudly it can undermine what the strings are doing, and compromise the score as a whole. Only the conductor, who understands the bigger picture of the symphony, can put that whole puzzle together. In addition, the physiatrist brings their individual expertise into the picture. In particular, patients with heavily disabling injuries like traumatic brain injury (TBI) and spinal cord injury (SCI) are more or less managed exclusively by physiatrists (and the team that comes with them).

Because disability has so many faces, the field of PM&R has many facets to it. A general physiatrist is expected to know and master over a dozen disciplines including TBI, SCI, stroke, amputations, burns, musculoskeletal medicine, sports medicine, pain management, neuromuscular disorders, electrodiagnostics, cardiopulmonary rehabilitation, and pediatric rehabilitation. Since it is almost impossible to master all of these disciplines, most physiatrists end up subspecializing in 1 or 2 of them.

So what does all this mean to you? If you have any type of limitation in your activities, a physiatrist would be able to help. Not hitting that golf ball as far as you used to? Having trouble walking two city blocks when you used to be able to walk for miles? Is that pain in your knees really making it tough to climb a flight of stairs? Are you finding yourself having difficulty with swallowing foods? Any of these problems can be addressed by a physiatrist. We are here to help you function as well as your body will allow, and provide equipment and strategies to work around the things your body won’t allow.

Unlike a fracture or an elective surgery, the ordeal does not end after the medical procedures are through. When a person sustains a TBI — in most cases families face some of their toughest challenges after the immediate palliative procedures are complete. The patient goes through acute care, an inpatient rehabilitation program, and then may be discharged to their home. In some cases, if they are medically unstable they are required to stay at post-acute settings and also receive outpatient rehabilitation. Some states in the USA also offer long-term care centers for those patients who might never be able to function safely and independently in their homes. These centers usually become permanent “homes” for these patients. Caregivers are often torn between running their homes and visiting their loved one; living their own life and accompanying their loved one to various medical appointments.

The residual physical impairments are only one aspect of the injury. Patients with TBI are prone to emotional disturbances, outbursts and attacks of a myriad of emotions ranging from depression to frustration to extreme rage. Anson and Ponsford studied 33 individuals with brain injury, and found that 51% of them had clinical levels of depression and anxiety (based on their scores on various scales that were administered. They also elaborated upon two styles of coping — non-productive coping (avoidance, self-blame, resorting to drug and alcohol use, etc) and adaptive coping (accepting the problem, and taking proactive steps, incorporating humor and enjoyable activities, etc). The results of their research study suggested that there was a statistically significant correlation between the type of coping mechanism used and ability to overcome the emotional problems.

As a physical therapist, I have spent more than 10 hours a week with one patient and their families. This intense, one-on-one time gave me a glimpse into their current lives and a hint of how things were before this terrible episode dictated every aspect of their lives. I worked with moms who did not recognize their children, with professors who had completely lost the function of speech and teenage boys who would spend all of their adult lives confined to a wheelchair. I saw families attend session after session, hoping to find a fragment of the person they once knew and loved.

For families, living with someone they don’t recognize any more, being pushed suddenly into the role of a caregiver, and dealing with all the emotional ups and downs of the patient takes a physical and emotional toll. A recent literature review study that was published in the Journal of Clinical Nursing indicated that a family member’s cognitive, behavioral and psychological impairments of are greater stressors to the family than their physical disabilities after a TBI. The same study also suggested that partners of people with a TBI scored higher on stress indicator scales than parents; for the most part, women appeared to be more stressed than men.

For most people who have not been through these experiences, this information may be unfamiliar, and difficult to relate to. But the only way that people with TBI may be reintegrated into the community is increasing awareness about this complex disease. Understanding the intricate complexities in the lives of people living with brain injury will hopefully will make us more accepting of people. We can then do our part to assist patients reintegrate smoothly into the community. TBI is a disease that can be prevented by increasing awareness in the community and education with safety tips. The National Institute of Health and the Brain Injury Association are excellent resources for the entire spectrum of Brain Injury.

References

Verhaeghe, S., Defloor, T., Grypdonck, M. (2005). Stress and coping among families of patients with traumatic brain injury: a review of the literature. Journal of Clinical Nursing, 14(8), 1004-1012. DOI: 10.1111/j.1365-2702.2005.01126.x

Godfrey, H.P., Knight, R.G., Partridge, F.M. (1996). Emotional Adjustment Following Traumatic Brain Injury: A Stress- Appraisal-Coping Formulation. Journal of Head Trauma Rehabilitation, 11(6), 29-40. DOI: 10.1097/00001199-199612000-00006