Recovery Related Issues Flashcards
2 Types of Recovery
Natural/Spontaneous and Post-natural
Natural/Spontaneous Recovery
maximal, rapid, dramatic; duration of 3-12 weeks; treatment can make the patient progress even faster
Post Natural Recovery
patient continues learning, but is much slower and less dramatic 6 months is the limit
Physiology of Acute Phase
Visible microscopic changes in 24-48 hours
Edema in large infarcts
Increased intracranial pressure and tissue compression by 3rd day
Brain response to ischemia by autoregulatory mechanisms (vasodilation, diaschisis, circle of willis)
Bilateral reduction of blood circulation (depression of the neural metabolism)
Auto-regulatory Mechanisms: robbing Paul to pay Peter, if the brain needs blood it tries to find it from other areas
Acute Phase
No collateral circulation - quick loss of energy is needed to maintain the ionic balance, if this doesn’t happen it leads to cellular energy loss
Cellular Energy Loss
- Release of glutamate and aspartate
- Excitatory-toxicity to calcium channels
- Excessive calcium to many destructive enzymes
- Inflammatory changes followed by Chromatolysis and Necrosis
Chromatolysis
10-18 days Disintegration of micro-molecules, nissl bodies, and nucleolus displacement
Everything becomes liquified
After the 18 days, if the cell is healthy it will come back, if not it will die.
Second Week, post stroke
Diminished swelling
Capillaries and astrocyte invasion
Necrotic tissue liquefaction
Phagocytosis of tissue-macrophagic cells (eats up debris)
Phagocytosis - can take up to 3 months if its a large lesion.
Astrocyte Scar
Small lesion, post stroke
Cystic Cavity Formation
Occurs in 3-6 months Lg. Lesion Basis for pessimism
Sequence of Necrotic Process
Repair Process
Structure/Function/Reaction
Early & Late Reactions and the Functional Results
Core Cells
Core cells are dead and can’t be saved
Penumbra Cells
Penumbra Cells are the cells that surround the core cells.
The ischemic penumbra has idle neurons (electrically silent but metabolically ready for membrane potentials
idle neurons may survive for 20 mins without collateral circulation and 6-8 hours with collateral circulation
Means of Reperfusion
Stent
tPa (clot-dissolving medication)
Merci retrieval system (remove the clot)
Factors Contributing to Natural Recovery
Reperfusion with Collateral circulation - Collateral circulation is very closely related to the circle of Willis
Recovery from diaschisis - In the beginning the whole brain is reacting negatively, but after 2-3 weeks the swelling lowers; this is long-distance recovery
Recovery from Structural Disconnections - the pathways have been disconnected/some are broken
Intra-hemispheric reorganization
edema attenuation - reduced pressure
cell recovery in penumbra
Positive Recovery Profile
Wertz, 1987
Tx benefits patients with single LH thrombo-embolic infarct, mild-moderate loss
post-onset period of 3 or less months, if given 3 hrs/week for 5 months
intensive Tx beneficial if 8-10 hrs/week for 3 months, begin in less than 6 months post-onset
Culton Spontaneous Recovery
Found Support for natural restitution
These patients didn’t have any treatment
Non-chronic patients:
Most dramatic difference in results between the first and second tests
Chronic patients:
Testing between all the different times are very similar
This tells us that something is happening within the brain even without treatment
Vignolo, 1965
Developed the Token Test
Pts with mild-moderate loss will do better than those with profound loss
People who are young (under 50) improved the best
VA Cooperative Study on Aphasia
Wertz 1981
Patients randomly assigned to individual or group therapy
both groups improved beyond 26 weeks post-onset
recovery continued beyond spontaneous recovery period
individual Tx was better overall, but both groups improved
Kertesz & McCabe Recovery Patterns
Anomics had full recovery
Broca and Conduction with best recovery
Globals with poor recovery
Wernicke bimodal recovery (little recovery in patients with jargon, better without jargon)
evolution into different aphasia types
Lomas & Kertesz
Patterns of Spontaneous Recovery
Patients divided into 4 groups: LFLC (globals), LFHC (Broca’s), HFLC (Wernicke’s), HFHC (anomics)
equal improvements noted for all language tasks for groups with high comprehension
selective improvement in comprehension and imitation for patients with low comprehension
Anna Basso
Prognostic Factors in Aphasia
Review of literature on prognostic factors, including age, sex, handedness, etiology, site and extent of lesion, severity and type of aphasia, restitution
Age relationship to recovery - Good predictor of recovery
Gender relationship to recovery - No significant difference in the severity and recovery rate across genders
Personality relationship to recovery - Pleasant and cooperative help in recovery
Basso
Initial Severity Relationship to Recovery (1-10 weeks)
good predictor of aphasia outcome
greater initial severity is a negative recovery sign
mild initial aphasia has good recovery (95% plateaued within 2 weeks)
moderate initial aphasia 95% plateaued within 6 weeks
severe initial aphasia 95% plateaued within 10 weeks
Sparing of critical cortical area - Greater prognostic significance
Basso Extent of Recovery
Good for patients with anomia and conduction aphasia
fair/good for patients with Broca and Wernicke
poor for patients with global
Basso Rate of Recovery
Fast for patients with conduction and Wernicke
intermediate for patients with Broca
slow for patients with anomia and global
Basso Recovery Pattern
Anomic aphasia is a common end-stage for both recovering fluent and non-fluent aphasics
Overview of Contributing Factors (General)
Site and Lesion Size - the larger the lesions, the poorer the prognosis
Lesion Nature - Multiple lesions render a poor prognosis
Bilateral lesions - aphsasic residuals
Silent stroke - 11% of patients with silent lesions prior to first stroke
Multiple strokes = bad prognosis
Overview of Contributing Factors in a Natural & Trained Restitution
Age - younger = better
personality - postive = better
severity - profound loss of lang. at initial eval. = bad prognosis
Motivation - education = bad candidate because you question everything. Motivation = doesn’t really translate into better results
handedness - better recovery in left handedness following LH stroke
time post onset - less than 6 months = better
gender - no effect
social milieu - Pts. who are socially active do better
general health - Someone who has only stroke has better prognosis than someone who is complicated health wise
personality - positive = better
lesion size - bigger = worse
lesion nature - poor for multiple lesions
Aphasia Recovery & Bilingualism
Synergetic patterns = Nearly 50%
1. Parallel (41%) : both languages impaired similarly in the
beginning and recovered at the same rate
2. Differential (9%) : Both languages impaired to different
degrees, but improved at the same rate
Selective Recovery = (27%) only one lang. improves
Successive = (6%) One recovers after the other
Antagonistic = (4%) one lang. progressed whiel the other regressed
Alternate antagonistic = Different lang. prevails at different periods
If you provide tx in mother language it doesn’t generalize to L2, but if you provide tx in L2 it generalizes to L1.
Aphasia Recovery & Bilingualism
Robot’s and Pitre’s Rules
Robot’s Rule = Primary Language
Pitre’s Rule = Most frequent language
