स्ट्रोक के बाद पुनर्वास: उम्मीद, आत्मविश्वास और नई ज़िंदगी

[00:00:00]that you know, medical management is obviously very important in stroke patients.

[00:00:04]Uh then comes what uh Dr. Anil was telling, within first 4 and 1/2 hours, if you identify a stroke, you thrombolyse them. You give it them a clot-busting drug, that is either TPA or tenecteplase.

[00:00:17]So, that's 4.5 hours window period, okay? So, then you have uh you know, mechanical thrombectomy, like uh you do within first 6 hours, you do angiogram or DSA in cath lab.

[00:00:30]If there is a large vessel occlusion, you take the clot out through aspiration or through some stent retrieval device.

[00:00:38]So, that's called thrombectomy or aspiration. So, that is permitted up to 24 hours, so 24 hours for thrombectomy or aspiration, that's extended window period, 4 and 1/2 hours for IV thrombolysis.

[00:00:52]>> [snorts] >> So, this is standard of treatment. I mean, those who are working here, they see it day in day out in neuro rehab.

[00:01:01]So, with advent of these technologies, stroke is a huge burden in our society.

[00:01:05]With advent of these technologies, we are able to, you know, open almost 2/3 of the vessels.

[00:01:14]So, there is a you know, great deal of reperfusion to brain by doing these procedures in time.

[00:01:21]Almost more than 71% patient would recanalize with these treatments.

[00:01:26]So, that means you have restored the flow to the brain.

[00:01:31]But, is that enough?

[00:01:33]And then, usually your patient is there within uh I mean, with you for next 5, 7, or 10 days. So, that's how it is in most of the stroke patients who are in stroke unit.

[00:01:44]>> [clears throat] >> So, 7 to 10 days patient is there. So, why I'm trying to make you all this to understand, those who are doctors, neurologists, physiotherapists, occupational therapists, cognitive therapists, speech therapists, >> [gasps] >> so, I'm going to brief you about some more windows which are of more use to you. So, before you understand those windows, I want to give you a background of that. Understand these first two windows, 4.5 hours, IV thrombolysis, thrombectomy, 24 hours. Okay? And patient is with you for a week or 10 days.

[00:02:16]So, over last decade or so, apart from these two things, clot busting drug, thrombectomy, you have stroke units. I mean, right now you walk This is a stroke unit here, so the So, that's how the first stroke unit, I mean, So, with this kind of organized stroke care, things have improved significantly over last decade or so.

[00:02:37]Average number of therapists in our country So, the whole problem is, okay, you're doing fantastic medical management, you're opening brain arteries. We take pride in saying we open brain arteries within first hour of arrival to our emergency department. And that's a pretty fast thing along with our radiologically they give MRI in 10 minutes. So, that's fantastic job. So, day in day out we do this.

[00:03:01]We open arteries.

[00:03:05]So, structured rehab is not received at all, I would say. I mean, literature would say 10% less than 10% receive physiotherapy. So, physiotherapy is not, you know, obviously physiotherapy makes the chunk of therapy along with their occupational therapist, speech therapist, cognitive therapist, four specialists put together along with a neurologist in the team makes a team for neuro rehab. So, these are essentially how you get neuro rehab teams.

[00:03:39]Number one, we don't have adequate trained physiotherapist. We don't have adequate number of teams in our to Why I'm saying this? Okay?

[00:03:51]So, we have never been better at saving brains with the advent of newer technologies and tools. We are able to achieve successful reperfusion to brain in almost 2/3 of the case cases with functionally less than half become functionally independent. So, they are left with some kind of deficit, be it in power, sensation, bladder bowel, pain, sleep, cognition, speech.

[00:04:20]Something is remaining and that is why rehab is so important and exciting presently and in times to come. But, you have to understand these windows what I'll be talking.

[00:04:33]So, we have increased with more and more technologies and better treatment, we are increasing survivals.

[00:04:40]But, at the same time, many patient mortality or that you death or that you but when we are increasing their survival, we are adding, you know, more burden also, more deficits, residual impairments. So, we need to address rehab also completely differently now.

[00:05:01]I have already we have mastered the clock, thrombolysis, thrombectomy, extended windows, organized stroke units, they have improved outcome, but still there is a lot of gap between reperfusion and recovery.

[00:05:13]So, that gap has to be addressed by neurorehabilitation program.

[00:05:20]You know, brain is plastic. Most of you we all heard of neuronal plasticity.

[00:05:25]Brain is plastic.

[00:05:26]It changes through cortical remapping is there.

[00:05:30]When is there some injury, stroke, head injury, any kind of insult to brain, brain starts doing cortical remapping.

[00:05:38]Whatever the area is lost, surrounding area takes over, starts functioning for that lost function.

[00:05:45]There is axonal and dendritic re-routing and sprouting >> [clears throat] >> in the brain following an insult to brain.

[00:05:52]Thirdly, there is growth gene activation like yeah, 43 and all these things they do activate.

[00:05:59]Now I come to this, whatever background I was telling you so far. Now listen this and look at this slide very carefully.

[00:06:09]At day zero you are doing your thrombectomy, sometimes you do decompression to patient if a large infarct is there. Surgeon would do hemicraniectomy within first 48 hours.

[00:06:19]There's a lot of edema in the brain. You give anti-edema drugs. You do medically treat them. So these first five, seven, 10 days are, you know, tricky period.

[00:06:28]There's a lot of edema, a lot of problem, a lot of things happening in your brain. So that is the time, obviously your therapy should start right after 24 hours.

[00:06:37]But you cannot be very aggressive at that point of time in your therapy.

[00:06:41]Because patient may be hemodynamically unstable also at that time.

[00:06:46]So this is day zero. Then 7 to 21 days, yes, there is peak molecular plasticity and gap 42 43 molecular expression. So there is, you know, recovery starting within this period. So you start therapy in this period. Obviously you do it.

[00:07:05]And then you get fatigued, patient gets fatigued.

[00:07:09]And over a period of time patient is anyway discharged within 7 to 10 days.

[00:07:13]Some of them do come for follow-up. Some of them do go to nearby rehab person if they have somebody in vicinity.

[00:07:21]But the window period for neuro rehabilitation opens between 60 to 90 days. So that's a key message you should all remember. 60 to 90 days. That is the time when you'll have maximum recovery in your brain if somebody had a stroke or trauma. So that is the window period for rehabilitation, which should not be missed.

[00:07:43]The window closes after 6 months, mostly.

[00:07:46]Some recovery could be there, but somebody who had a a small internal capsule infarct in posterior limb of internal capsule, the patient will remain lifelong upper limb. You cannot do anything about that. I mean, whatever you do in this, you have already lost the window period within 60 to 90 days.

[00:08:06]So, what is so important? You should know about these window periods in neuro rehab.

[00:08:13]So, your plan should be right when the patient is there with you in the water.

[00:08:19]You have to be able to write prescription of physiotherapy on the day one itself.

[00:08:24]When I say prescription of physiotherapy, that means adequate dose.

[00:08:28]There is a rule of 666 we talk in neuro rehab. 6 days a week, 6 hours a day for 6 months.

[00:08:36]So, that's a general rule of neuro rehab.

[00:08:40]There is another population average rule is 70% patient improves. So, that's a population average. 70% patient will improve, there's 30% would have some or other deficit. That's That's how it happens in brain. That's what our common understanding is.

[00:08:57]But, that is not the case here.

[00:09:00]Every patient is different. Every individual is different. So, there is what is today's concept of medicine is precision health. You have to tailor your approach individually according to the patient.

[00:09:16]So, why I'm saying that dose should be adequate? The dose of rehab rehabilitation should be adequate. The duration should be adequate. You should work most in your window period.

[00:09:29]Okay. So, that's what and that's not my, you know, my kind of imagination or something. This is based on these trials, CPSS trial. So, that found the windows in human being for stroke rehabilitation which is largest meaningful gain is within 60 to 90 days.

[00:09:46]And I'm not saying you don't start physio on the day one. Yes, you have to start at that time. You should be able to evaluate the patient on the bedside then and there only. You should have a plan for next 6 months at that time only.

[00:09:58]Use everything at your disposal.

[00:10:00]Spasticity should not be developed because otherwise there will be no meaning, you know.

[00:10:06]Meaningful gain in the power.

[00:10:09]So, use all the armamentarium.

[00:10:14]This is CIMT. Most of you know CIMT how you do that. Especially those who are working here. You have idea about Shalini?

[00:10:22]CIMT mirror therapy, huh?

[00:10:26]Number one, I mean these are these are the things which are, you know, easily doable.

[00:10:31]Mirror therapy, how you trick your brain for plasticity. So, that's what Dr. Zafar can teach you in detail about these techniques.

[00:10:41]Obviously, I mean most of the technology, as I said, you should be able to First of all, you should be able to make a prescription in your mind or on paper if that doesn't work with you.

[00:10:50]The adequate dose, your tools for the future for particular patient.

[00:10:55]So, you have various tools, robotics.

[00:10:56]You do have virtual reality. I mean, we also do have it here. So, most of the places does have FES. We have You have FES, right?

[00:11:06]RTMS we don't have or maybe I would say we do have in our lab but it is not functional.

[00:11:12]Brain computer interface, yes, we don't have that.

[00:11:16]So, apart from this BCA, practically we have everything in our our department also. Probably these are the things available in my OPD also.

[00:11:25]So, what I'm trying to tell you here that all these things you should first of all remove your concept of population averages to precision neurorehabilitation, precision medicine, precision neurorehabilitation.

[00:11:40]Everything future belongs to not to drugs, stents. It is individual based interventions.

[00:11:48]People have even started doing it before they fall in. So, we are talking of something when somebody's already been struck by stroke here.

[00:11:54]So, this 70% rule, forget it.

[00:11:59]This is my patient. I'm going to work on this patient. Obviously, when you go, you discuss with your neurologist or with your physician, with your surgeon.

[00:12:08]If complete brain is gone, one [clears throat] side brain is gone, still you can achieve meaningful, you know, life for that patient.

[00:12:17]But, the day zero itself, what you do is, first of all, upper limb is gone, you do a very basic like Dr. Anil was showing NIHSS. You must know about NIH.

[00:12:27]This zero to 42 stroke is not a, you know, rocket science. You should know about that. Give you severity of a stroke.

[00:12:33]Then, simplest stroke for you for upper limb, you can do SAFE score. What is SAFE score?

[00:12:38]In this, SAFE is nothing but shoulder abduction, finger extension test.

[00:12:43]Shoulder abduction, finger extension.

[00:12:47]You know about MRC? Motor score zero to five, you all know that, no? Normal power, zero power, zero to five is four.

[00:12:53]So, for this, you five plus five, it's a score of 10. If your score is more than five, patient is less than 80 years of age, he's going to definitely make very good recovery.

[00:13:04]You know that.

[00:13:08]If score is less than five, then?

[00:13:12]The idea I'm telling you, these are very simple bedside evaluation things which you must know when you are standing beside your stroke patient.

[00:13:21]And this is all literature we have, I mean, the present literature does support that.

[00:13:25]Suppose score is less than five, then what you do?

[00:13:29]Then you should know about age. Age is 80, not a very good prognostic, you know.

[00:13:34]It is less than 80. Yes, you should put in your heart and soul into patient.

[00:13:39]Then comes NIH stroke scale, what you were saying. If score is less than seven, more than seven.

[00:13:44]If it is more the score, more is severity [snorts] of stroke. If it is more than seven, if it is less than seven, again you are in a very good, you know, position to make this patient independent in future.

[00:13:57]We assess patient's outcome at three months. All, you know, studies or all our practice should be aimed what is going to be like our patient three months down the line.

[00:14:07]Or to my best, you have a great chance, what I told.

[00:14:11]60 to 90 minute 90 days for the window open only at the three months. If we could not achieve that a kind of outcome, you have a still time to modify your things, and you know, do something better.

[00:14:27]Age, NIH, I'm talking of patients who have safe less than five.

[00:14:33]So, it has to be if you have electrophysiology lab, you can do TMS. If motor evoked potentials are present, like they do a motor evoked potential when they're operating to see the integrity of the corticospinal tracts. If motor evoked potentials are present in that patient, again you are in a very good zone.

[00:14:52]If it is absent, age is more than 80, no motor evoked potential, safe score is zero or one, everything is bad. Then you know that probably this patient I will have to use some assistive, you know, processes, orthosis, something of that kind for, you know, future care. My alone manual stretching and things may not work for this patient. But I would tell you most of the patients if you do it properly, in right window period, with right kind of tools, with right kind of dose, you are able to achieve good outcome, functionally independent outcome. It may not be 100%, you know, perfect, but functionally useful independent outcome can be achieved. And we have to work for 6 months. Don't forget it.

[00:15:42]So, this is what it is, SAFE score. And what I was telling, we add age, we add NIH, we add MEP. So, this is called PREP 2 algorithm, PREP 2 score. So, read about it if you have not heard of it.

[00:15:54]So, this is how you develop a personalized multimodal approach for your rehabilitation. So, these two things you should know, PREP 2, SAFE score. Upper limb, it is TWIST score. Sorry, lower limb.

[00:16:08]This is for upper limb, and lower limb you have TWIST score, okay?

[00:16:11]So, I'm talking of evaluation within first 2 to 3 days only. Ideally, after 24 hours only you should be able to evaluate your patient and plan your therapy for later part, okay?

[00:16:25]Um So, this is again I'm trying to emphasize at least you if you forget everything else, remember SAFE and PREP 2 score, because that will really help in your plan of treatment for future.

[00:16:41]Uh well, I will skip techniques, you know, you would know better than me. And maybe you can have classes um from Dr. Zafar for each of these techniques. That would be really very useful for you for stroke rehabilitation.

[00:16:57]So, this is how we do develop personalized rehabilitation. So, now, you know, this is as a neurologist, as a neuroscientist, as a colleague to you, I feel that this is how we should approach our patient.

[00:17:11]But it is very difficult in real life. I do have a good uh neuroscience department here where I have a physiotherapist, I have I can have, you know, uh a lot of resources here, but still despite of that, number one, even this kind of department is not there in most of the places. Number two, it is difficult even for us to get, you know, um a speech therapist. Yeah, we do have a full-time speech therapist now, but it is difficult to, you know, get sometimes your colleagues who can help you. A patient who is depressed, if you don't have a psychologist with you in your team, whatever you do to that patient, you will not have any results. So, the psychologist you should tell your psychologist that depression to is got to come out of that to be able to get out of that problem, otherwise it won't happen.

[00:17:52]So, it is a teamwork. It is not a It is not physiotherapy only. So, we should be out of these egos that we can do everything for one patient. You have to work in team. You have to work with neurologist, neurosurgeon, physiotherapist, occupational therapist, speech therapist, clinical psychologist. So, that's how team works. Obviously, yeah.

[00:18:12]So, but these things are not available to mass population in our country. So, this was the whole idea which I have suggested started suggesting to my team also. We started developing something called Watch Frame.

[00:18:26]Watch Frame, now, I mean, maybe we are coming with a book with this Watch Frame. So, the Watch Frame idea was it was actually we did few studies here which was for the normal population also, for normal healthy people like us, for stroke rehabilitation also, for depression patients also. So, Watch is simply it is like I'll tell you I'll just take uh how much time we have.

[00:18:52]Uh Watch V stands for Vayu, air, breathing, pranayama, what popularly known as. So, what you do, normally we breathe 6 to 12, 6 to 16, 18 breath a minute.

[00:19:05]I mean, this applies to you as well. So, Watch is a concept which is for patients, which is for caregiver, which is for doctors.

[00:19:12]>> [clears throat] >> It targets the whole human system around the disease, not only the disease.

[00:19:17]>> [sighs and gasps] >> If you can bring down to your breath to six breath per minute, if you start doing it, you take 4 seconds of inspiration, 6 seconds of expiration.

[00:19:30]What it does is a prolonged expiration, which stretches your mechanoreceptor in the lung, and through that, there's a vagal, you know, afferent pathway to your brainstem, and there is dorsal nucleus group in the vagus, which will reduce your heart rate, which will reduce your blood pressure, which will increase heart rate variability.

[00:19:54]So, which is good for all of us.

[00:19:56]For patients also.

[00:19:58]And so, you may not be able to bring it to six in a patient of a stroke, but you may try to bring it if somebody is cooperating, you That's what I'm saying, you should assess that. And if you can do that, so that's the start.

[00:20:11]Simple breath control.

[00:20:13]Trying to So, we are trying to use vagal parasympathetic dominance as a as a factor, because that will not only do this physically, you know, useful thing, it will make patient more calm, comfortable, happy, and peaceful also.

[00:20:28]And here it stands for asanas. Asanas.

[00:20:30]So, we picked up 12 asanas, 12 postures.

[00:20:33]You all know asanas.

[00:20:35]So, which will use right from your lumbrical to interossei to your glutei to your erector spinae to your latissimus to your tibialis to your quadriceps to your what not. Every muscle in the body would be used in this. It all depends how much you can do for given patient. I'm not saying you can do everything. Even a normal person cannot do everything sometimes. Some of the asana I'm not able to do. So, but try it We tried to make it in a way that everybody can do it. And these are isometric exercises.

[00:21:03]Isometric.

[00:21:04]Isometric, which uses red fibers, type one fibers, oxidative fibers. These are fatigue resistant. So, in ICU and a stroke unit or in a ward with patient So, we are trying to use oxidative fiber, not glycolytic fiber of the muscles.

[00:21:20]That means these are fatigue resistant.

[00:21:24]So, hemodynamic unstable patient, these are better exercises. So, most of these are 80% of isometric exercises in these asanas, and 20 20 20% are isotonic here.

[00:21:35]Third thing was nutrition, very important. So, ahar, nutrition.

[00:21:39]Nutrition is important because you have to have anti-inflammatory diet in all our stroke patients.

[00:21:48]You know, simply the one experiment was about turmeric milk. So, what turmeric does it is very good antioxidant. I mean, people do claim it is a antimicrobial also.

[00:21:58]But, inflammation There is a lot of inflammation going on in your brain.

[00:22:02]Or it is applies to heart attacks also, any kind of trauma also. So, anti-inflammatory diet. Obviously, the general consensus that in this book particularly, I mean, we have given North Indian diet, South Indian diet, vegetarian diet, non-vegetarian diet. I mean, there is no preference for any kind of diet. I mean, somebody's plate may have what, that's none of my business. So, but we try to do anti-inflammatory diet. We try to include turmeric milk in all these diet.

[00:22:27]Taking 500 mg of curcumin, that's around two teaspoonful of haldi along with dash of black pepper. That is piperine, which increases bio- availability of curcumin.

[00:22:39]So, again, that details we'll not go.

[00:22:41]So, and lastly was meditation. So, the meditation here I told you four components.

[00:22:47]Pranayama, then asanas, ahar, and or jog or meditation. Meditation is Why this is so important? Again, the same thing.

[00:22:56]I tell you, meditation are of different type. It is not something which is for philosophical people. This is for all of us. You all have stressed so much in your life. Nowadays, the modern lifestyle is full of stress and most of the diseases are because of stress and what we are eating.

[00:23:13]Meditation is simply it could be mindfulness. You are just It is not stoppage of thought. You are just sitting alone with eyes open or closed.

[00:23:20]You are just observing your breath. You are just observing anything what is happening in and around. You're just observing surrounding. That's it. That is mindfulness meditation.

[00:23:30]Or if you can focus to a point in front of you or God in front of you or deity in front of you, that becomes your concentration method. Even when you are focusing on breath in out, that is concentration method. Any kind of meditation.

[00:23:42]Because meditation and chanting when I was talking about pranayama, so when you are allowing your patient or yourself, that applies to both. What happens when you are chanting something, whether you are chanting during expiration, the 6-second expiration, you're chanting Om or Allah or whatever, irrespective of your religious or any other belief. Whatever.

[00:24:05]Even something you like, somebody's name you like. You're chanting something.

[00:24:08]What happens during chanting is there is a stimulation of pharyngeal and laryngeal branch of vagus nerve. Same thing. Vagal afferent going up in the brainstem, nucleus tractus solitarius in the brainstem.

[00:24:22]Adjacent dorsal nucleus of vagus goes down, reducing heart rate.

[00:24:29]Reducing pressure by 15 to 20% not significantly and increasing heart rate variability.

[00:24:37]So, that is the concept of meditation also.

[00:24:40]Then comes type of medication and meditation. It is As I told I mean so this there was a study here which was published also. So, the type of meditation is So, in this book particularly I mean everything has been described in detail. Muscles, pathways.

[00:25:00]I mean, it is from eyes of It is not a philosophical book. It's book from neuroscience background. So, the whole thing is explained why this happens, why did we do it. And we had surrogate markers at baseline and at 12 weeks. Now, this is Evolution means brain development over millions of years.

[00:25:22]Millions of years, right from fish to reptiles to earlier Homo sapiens and what we are today. And still we are developing. What we are going to be 100 years from here?

[00:25:33]We don't know.

[00:25:35]So, this is evolution.

[00:25:39]What we can do is modulation.

[00:25:41]Modulation can have happen as early as 12 weeks.

[00:25:45]Brain modulation.

[00:25:47]12 weeks.

[00:25:48]Whatever intervention you are doing through your CIMT, through your techniques, or through watch frame, or whatever you are doing. You're doing it on the baseline assessment by psychometric testing.

[00:25:59]Psychometric testing could be your some kind of stress, depression, anxiety scores. It could be intelligent quotient, IQ, spiritual quotient. Whatever you psychometric testing you do, you can do your manual muscle testing for motor component. And then you do what we did was EEG.

[00:26:20]Electroencephalogram. Because EEG picks up all brain activity. So, we were looking at whether there is a alpha build-up. Alpha wave is more of calm wave, 8 to 12 hertz. So, you know, that [clears throat] if it builds up, beta is more of thinking wave. Delta theta is more of sleep, slow waves. Okay. So, we looked at EEG also. So, and then lastly, serotonin dopamine level, which are so-called happy hormones. Serotonin dopamine level. So, once you do it on the baseline and 12 weeks, if you do 1 hour of watch module for 12 weeks consistently.

[00:26:54]So, this changes your brain.

[00:26:57]Whatever you do as a rehab person, we need to, you know, look at baseline parameters and 12 weeks down the line.

[00:27:05]And for you, never forget that you should be adequately dosing your patient. Most of the time, it is 20 minutes morning, 20 minutes evening physiotherapy.

[00:27:18]Or half an hour, somebody goes home and do home visit and do physiotherapy. It doesn't work.

[00:27:23]The dose should be adequate. 6 6 6.

[00:27:26]Uh obviously, somebody cannot do for that long. Yes, you have to curtail it and gradually try try to increase it.

[00:27:32]Okay? And this is some previous studies where they did, you know, a SPECT analysis of before and after meditation.

[00:27:39]The frontal lobe lights up, parietal lobe goes down. So, the idea is frontal lobe executive functions improve, concentration improves, parietal lobe goes down. There is loss of self-world dichotomy. So, person becomes mera tera kam ho jata hai.

[00:27:53]Becomes more peaceful and there is immense support to limbic system that gives you joy. So, meditation ka basic biological principle ye hai.

[00:28:01]Which was, I mean, demonstrated by a radiologist in US, Andrew. So, he did this Kapil SPECT study. He he he he has done a lot of work in radiology for this meditation.

[00:28:12]>> [sighs and gasps] >> These are our own papers, yoga music.

[00:28:15]I'll skip them. This is gut brain. Diet is so important. I mean, these were the first study we published. When we did this brain thrombus metagenomic sequencing, we found bacteria there which were same like in the gut, lactobacillus.

[00:28:31]So, why this commonality is there? Gut say how did it So, gut brain axis itself a big talk. I'll not go in details of that. Then this was on mental health.

[00:28:40]So, we did this psychological, electrophysiological, and biochemical dopamine serotonin over a period of 12 weeks. All these studies were over a period of 12 weeks.

[00:28:51]This is again turmeric milk published in stroke patients. There are various other studies we published.

[00:28:58]I'll So, the watch frame I'm This is one thing which is scalable.

[00:29:04]That you can do in the remotest of area.

[00:29:06]Once you understand the concept, you can do it yourself because howsoever advanced we become, none of us would be able to address a country like India.

[00:29:15]We will always have shortage of physiotherapists. We will always have shortage of neurologists. We will always have shortage of, you know, professionals for doing that. So, it's scalable.

[00:29:24]It's a scalable thing which can be done across and everywhere. And these are the various, you know, picked up, chosen. I told you about 12 asanas which we picked up from this. Contraindications are very few.

[00:29:36]So, we we need to learn from Indian classical wisdom here which was right, but now we have neuroscience to prove it.

[00:29:43]So, I would finish here.

[00:29:46]Thank you very much for your patient hearing.