Post-Stroke Rehabilitation

Joseph  Vick Roy MD

Epidemiology of Stroke (US Data)

Incidence: 700,000 strokes per year    

Incidence doubles for every decade after 55 years of age.                                            

Recurrence rate = 7-10% per year

Mortality: 155,000 deaths per year

3rd leading cause of death

Prevalence: 3 million survivors living

Disability: #1 cause adult disability

Cost of Stroke  (US Data)

Annual Cost:     30 - 40 billion dollars

57% direct medical costs

43% indirect costs, (lost productivity)

Annual Cost to Medicare: 6 billion dollars

Average Cost per Patient in the first 90 days after a stroke: $15,000                             

>$35,000 in about 10%

Disability After Stroke (Frenchay  Study,  UK,  1981‑83)

Very severely dependent           Acute 38%       6 months 4%

Severely dependent                  Acute 20%       6 months 5%

Moderately dependent              Acute 15%       6 months 12%

Mildly dependent                      Acute 12%       6 months 32%

Physically independent              Acute12%        6 months 47%

Independent walking                 Acute 27%       6 months 85%

Treatment of Stroke: Acute care vs. Rehabilitation

Acute Care

Establish diagnosis

Emergency management

Identify & treat comorbidities

Identify & reduce risk factors

Prevent & treat acute medical complications, “stabilize the patient”

Acute Stroke Care is a “Hot Topic” today due to TPA and multiple acute interventions which are likely to become available soon.

Clot‑busters and drugs to limit thrombosis

Strategies to augment cerebral blood flow

Neuroprotective agents to protect ischemic neurons

Rehabilitation

Rehabilitation is a restorative and learning process which seeks to hasten and maximize    recovery from stroke.

Rehabilitation attempts to reduce levels of disability and facilitate return to active and productive lives through a combination of educational, counseling, physical and technology-based interventions.

Research on Rehabilitation after Stroke

Not as “hot” - but equally important

3 million survivors - majority have disability

Clinical research offers opportunity for advances that may profoundly improve the quality of life for survivors. (eg, constraint‑induced therapy)

Basic research offers opportunity for breakthroughs in our understanding of higher brain functions and injury recovery mechanisms.

Recent neuroscientific studies have identified considerable evidence of cerebral plasticity following injury.

Stroke provides an excellent model for studies regarding focal brain injury.

A Conceptual Framework of Health and Disablement, (Nagi, 1965)

Pathology (disease):  the interruption or interference of normal bodily processes or structures.

Impairment:  the loss or abnormality of mental, emotional, physiological or anatomical structure or function.

Functional limitation:  a restriction or lack of ability to perform an action or activity in the manner or within the range considered normal.

Disability:  the inability or limitation in performing socially defined activities and roles expected of individuals within a social or physical environment.

Rehabilitation Treatment Approach

In the rehabilitation care phase of patients with stroke, evaluation and treatment takes place on each of Nagi’s 4 levels.

The primary task is to recognize and reduce functional limitations so as to minimize disability and allow the stroke survivor to regain the highest level of independence and   quality of life possible.

Most health care provided by physicians today is focused at the disease level.

Issues related to functional impairment and disability are often overlooked during acute treatment.  Yet, it is these areas that define the experience of a stroke to the patient and create major barriers preventing a return to his or her pre‑morbid “normal life”.

Rehabilitation is both a philosophy and a set of tasks.

A rehab program is comparable to a school in which the patient is provided an opportunity for education, support, protected practice, reassurance, direct assistance and feedback.

The patient and family must be involved in setting goals and in planning and implementing treatments.

Rehab involves the systematic withdrawal of assistance  and return of control to the patient.

Rehabilitation is done with the patient rather than to the patient.

Rehabilitation: A Key Part of Stroke Care

One result of DRG’s and managed care has been shorter acute hospital lengths of stay for patients with stroke.

This has resulted in a trend toward sicker (less stable), patients being admitted to rehab     programs.

Much of the work‑up and treatment for comorbidities  and stroke risk factors takes place  in the rehab hospital setting.

The Interdisciplinary Care Team

Rehab Physician

Other Medical Specialist

Rehabilitation Nurse

Physical Therapist

Occupational Therapist

Speech Therapist

Case Manager

Social Worker

Neuropsychologist

Recreation Therapist

Respiratory Therapist

Dietitian

Vocation Counselor

Orthotist or Rehab Engineer

Initial Assessment of Patients  Following Stroke

Medical History which includes:

Acute treatments provided

Extent and time-course of deficits

Results of imaging studies and work-up already done

Comorbidities

Stroke risk factors

Medical complications encountered since the stroke

Pre-morbid functional status

Family support and living arrangement

Potential barriers to improvement

Medical Complications of Stroke

DVT and pulmonary emboli

Pneumonia

Hypertension or postural hypotension

Skin decubiti

Urinary retention or incontinence

Malnutrition

Constipation or bowel obstruction

Spasticity

Joint contractures

Shoulder pain

Seizures

Dysphagia

Osteoporosis

Sleep disturbances

Sexual dysfunction

Extremity edema

Hydrocephalus

Depression

Renal calculi

Cardiac arrythmias

Heterotopic ossification

Initial Assessment of Patients  Following Stroke

Examination includes:

General physical exam: cardiac, extremities, skin, etc.

Neurologic exam: motor, sensory, coordination, vision, etc.

Mental status exam: alertness, orientation, attention, language function, perceptual deficits, memory, problem solving, etc.

Functional exam: (look for Functional limitations) gait and mobility, self‑care, elimination, communication, social cognition, swallowing

Impairments After Stroke (2 weeks post‑onset)

Hemiparesis                  70 - 85%

Ambulation                   70 - 80%

Visuoperception            60 - 75%

ADL dependent            40 - 65%

ADL assisted                20 - 60%

Dysarthria                     55%

Sitting Balance              45%

Urine incontinence        45%

Depression                   40%

Proprioception              40%

Bowel incontinence       30%

Hemianopia                  20%

Aphasia                        20 - 35%

Dysphagia                    15 - 35%

Hemineglect                  10 - 35%

Memory loss                10 - 20%

Estimation of Rehabilitation Potential

Medical stability and concurrent medical problems

Can the patient tolerate the level of physical activity required?

Nature and extent of functional limitations

severity of stroke, (radiologic findings )

L-hemiparetic > R-hemi > L-hemi  with hemispatial neglect

Patients with moderate disability benefit most

Mental Status, including ability to communicate and learn

Pre‑stroke functional status

Emotional status and motivation to participate in rehab

Family support / living situation

Age

Recovery Mechanisms, The Scientific Basis for Rehab

Many animal and human studies have demonstrated adaptive plasticity in the brain

Neuronal Plasticity, examples include:

Axonal and dendritic regeneration

Altered efficacy of synaptic activity

Activity-dependent changes in synaptic strength

Unmasking of previously ineffective synapses

Synaptogenesis

Increased neuronal responsiveness from denervation hypersensitivity

Recovery Mechanisms, The Scientific Basis for Rehab

Network Plasticity, examples include:

Recovery of neuronal excitability

Resolution of edema or diaschisis

Mutability of neuronal assemblies

Expansion of representational maps

Recruitment of cells not ordinarily involved in an activity

Recruitment of parallel and subcomponent pathways

Altered activity of the distributed functions of cortical and subcortical neural networks

Activation of pattern generator circuits

Plasticity has been demonstrated, in sensory and motor cortex

Animal studies

Direct cortex electrical stimulation mapping

Human studies

Positron emission tomography (PET)

Functional magnetic resonance imaging (FMRI)

Transcranial magnetic stimulation (TMS)

Other recovery mechanisms in rehabilitation

Compensatory strategies

Adaptive equipment

Does Rehabilitation Work? The Bad News

Scientific data supporting the effectiveness of rehabilitation programs and interventions in improving patient outcomes is limited.

Most clinical studies have focused on short-term changes in impairment or function during inpatient rehabilitation.

Results have been inconsistent, and where they favor the experimental group, the difference is generally small.

Distinguishing rehabilitation effects from spontaneous neurological recovery after a stroke is difficult.

Does Rehabilitation Work? The Good News

A growing scientific basis for rehabilitation now exists.

The value of early mobilization has been amply demonstrated.

Multiple studies have shown that better clinical outcomes are achieved when moderately impaired stroke patients are treated in a more intensive and specialized rehab unit as compared to a general medical ward.

Ottenbacher and Jannell published a meta-analysis in 1993 of 36 clinical studies of stroke rehab involving 3717 patients with acute and chronic stroke.  The average patient who received a program of focused stroke rehabilitation performed better than about 65% of the patients in the comparison group.

Neither research evidence or expert consensus adequately supports recommendations concerning the superiority of one type of exercise regimen over another.

Is there a Critical Period for Recovery Following a Stroke?

Neurologic and functional recovery occurs most rapidly in the first 1 to 3 months after a stroke.

It used to be said that significant motor and sensory recovery rarely occurs beyond 6 months.

More recent studies have shown that neural and functional recovery can continue beyond 6 months, perhaps for several years especially with respect to language and visuospatial functions.

Constraint-Induced Movement Therapy

A recent study of constraint-induced movement therapy (12 day treatment), in 10 chronic hemiparetic stroke patients (5 years post-stroke average) showed motor improvement in all subjects.

6 of the subjects showed 50 - 75% improvement in motor activity - ADL log scores (MAL).

Transcranial magnetic stimulation brain mapping showed a 40% increase in the cerebral forearm-hand area contralateral to the paralysis.