Monday, March 22, 2010

Sensory deficits post stroke

CSM revisit: Sensory deficits post stroke: best practice treatment
Jane E. Sullivan, PT, DHS from Northwestern University presented compelling evidence that Physical therapists need to be treating sensory dysfunction after stroke (Post Stroke Sensory Dysfunction, or PSSD). First, this is truly common, although it is rarely addressed by PT outside of proprioception (where is your arm? Are you sitting up straight? Where are your feet? Etc). In addition, the loss patterns do not follow motor loss patterns, and so these do need to be tested.
A study done by Connell in 2008 found that there was high agreement between different body areas for each modality, but there was low agreement between modalities in each area! This means PTs need to test each modality. Tyson et al in 2007 found that stroke severity and weakness are significantly correlated with PSSD, a finding later corroborated by Connell in 2008.
Also correlated with decreased sensory were outcomes such as increased length of stay, decreased bowel/bladder independence, decreased ability to perform ADL’s, etc. There were many studies cited in this presentation which link low sensory function with discharge placement, slow recovery of motor function, and even mortality.
The good news is this: the neurological system is moldable and trainable. We know that motor patterns can be learned; so too can sensory. There is natural recovery, anatomical redundancy, and bilateral pathways all improve the prognosis.
The reliability and validity of sensory tests were explored, and while there are some issues in this area, the following recommendations were made: 1. Screen everyone (post-stroke) for all modalities including stereognosis. 2. Formally test if linked to movement dysfunction and goals. 3. Standardize your exam.
Obviously, there is a need for more research, but there are promising studies that link improved upper extremity sensation with improved balance outcomes. Electrical stimulation studies have shown excellent potential for “waking up” the sensory system, with improvements noted in spasticity, force, perception, selective movement, as well as balance and gait. Vibration, thermotherapy, intermittent compression, graphesthesia and discrimination tasks and passive movement all show improvement (passive range of motion shows fMRI but not clinical improvement). Finally, these changes persist! There is yet to be any meaningful dose-response trial, however.
The parameters recommended at this time across interventions are: Brief (20-30 min – they will get tired!), and repetitive (3-5 days per week) for several weeks. With any of these treatments, practice mastered tasks first and last, take breaks, and aim for limbic involvement and active attention. Reduce the stress in the environment so the patient may attend to the task as well. A quiet nervous system will respond more dramatically to changes, and above all, PRACTICE!
** for references feel free to contact me at

Monday, March 1, 2010

Combined Sections Meeting: Concussions and Mild Traumatic Brain Injury

This presentation featured four speakers about a very timely topic: concussions. ESPN has even had NFL players and others as guests to discuss this issue, including self-monitoring of athletes and team policy on the return of players to the field after concussion.
The message is becoming clear very quickly: These injuries are extremely serious and need to be treated as such. Not only are they serious, but it is an injury that has the potential affect all populations and all PTs, regardless of the specialty.
The first Speaker, Kevin Guskiewicz, PhD, ATC, FACSM gave background about concussions. There are about 1.6 to 3.8 million sports-related TBIs each year (Langlois et al, 2006), and that is only sports related. They have a cumulative effect and can have enduring consequences if not managed properly. It is estimated that 50% of these injuries go unreported in this “silent” epidemic (Giza, 2001; Guskiewicz 2003, 2007; Collins, 2003, McCrea, 2005).
The basic evaluation is the same as any other injury, including cranial nerve testing, cognition, coordination, history and physical, as well as basic PT evaluation. He cautioned that return to sport should not be considered if there was any loss of consciousness or amnesia, OR if the person is young or high school age, or if they are still experiencing signs or symptoms. However, any other return to play guidelines have not been made with evidence basis. There is work being done to rectify this.
Finally, severity of the injury cannot be determined initially. Because concussions are defined as a loss of function, not damage to structure, the severity is graded by how long the symptoms last, and how severe they are.
The strategies for addressing deficits are the same as any brain injury, remembering that the nervous system is plastic and can and will be affected by practice and rich environments.

The second speaker was none other than neurosurgeon Dr. Cantu of Emerson Hospital, who has treated many famous people with traumatic brain injury. He posited that there is really no such thing as a “MILD” traumatic brain injury. His focus was technical, as one would expect from a neurosurgeon, but the gist was that multiple concussions, especially those that do not heal correctly, can result in erratic and psychotic behavior and a syndrome called Chronic Traumatic Encephalopathy (CTE).
We have seen this play out in the news: the wrestler Chris Benoit who killed his wife and child and then killed himself, or the Steelers’ player who drove his car into an oncoming tanker truck. The problem is there is no way to diagnose CTE without an autopsy, where the presence of Tau proteins is noted.
Dr. Cantu, along with several others, is at the forefront of this in the national discussion. His goals are to better define and diagnose brain injury, develop guideline for treatment and return to sport/activity, and to educate the public about the seriousness of these injuries. He and his colleagues are lobbying congress and the court of public opinion to put this issue on the priority list for public and global health initiatives.

Third was Susan Whitney, a PT from University of Pittsburg Medical Center. Her focus was clinical: describing common symptoms and treatments for balance disorders associated with concussion and post-concussion syndrome. Dr. Whitney also shared some evaluation tools that are helpful in diagnosis and planning.
She also described some of the studies the UPMC is conducting and the results of the intervention protocols they are developing. Promising results are being reported with a program of gaze stabilization and standing balance and ambulation exercises.

The fourth speaker was Chris Nowinski, a Harvard graduate whose WWE wrestling career was cut short by a concussion. His goal was to provide a patient’s perspective of TBI. He described his last concussion, stating that he had been to eight doctors when the symptoms did not subside, and that it was finally Dr. Cantu who asked “How many times have you had your ‘bell rung’ or saw stars?” not the question that the previous doctors had asked (“how many concussions have you had?” – none diagnosed!).
After his rehabilitation, Chris teamed up with Dr. Cantu and his colleagues to help spread the word about this serious injury. He wrote a book with fellow wrestler Jesse Ventura called “Head Games” to explain to athletes why this is not an injury you should play through.

The program was extremely interesting and informative on a very well-timed topic. For more information about concussion prevention and the current work by Dr. Cantu and Chris Nowinski, go to: and

Ist speaker references:
Collins MW, Lovell MR, Iverson GL, Cantu RC, Maroon JC, Field M. Cumulative effects of concussion in high school
athletes. Neurosurgery 2002;51(5):1175-9; discussion 80-1.
Giza CC, Hovda DA. The Neurometabolic Cascade of Concussion. J Athl Train 2001;36(3):228-35.
Guskiewicz KM. Assessment of postural stability following sport-related concussion. Curr Sports Med Rep
Guskiewicz KM, Marshall SW, Bailes J, et al. Association between recurrent concussion and late-life cognitive
impairment in retired professional football players. Neurosurgery 2005;57(4):719-26.
Guskiewicz KM, Marshall SW, Bailes J, et al. Recurrent concussion and risk of depression in retired professional
football players. Med Sci Sports Exerc 2007;39(6):903-9.
Guskiewicz KM, McCrea M, Marshall SW, et al. Cumulative effects associated with recurrent concussion in collegiate football players: the NCAA Concussion Study. Jama 2003;290(19):2549-55.
McCrea M, Guskiewicz KM, Marshall SW, et al. Acute effects and recovery time following concussion in collegiate
Football players: the NCAA Concussion Study. Jama 2003;290(19):2556-63.
Langlois JA, Rutland-Brown W, Wald MM. The epidemiology and impact of traumatic brain injury: a brief overview. J Head Trauma Rehabil 2006;21(5):375-8.