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EvidenceBasedStrokeRehab
Citation preview
Evidence Based Stroke Rehabilitation
Scott Hardin MDMedical Director
of Rehabilitation Services, Aurora St. Luke’s
Clinical Safety Officer, Aurora St Luke’s
Vice Chief of Staff, Aurora St Luke’s
Evidence Based Stroke Rehabilitation
Disclosures
None
Evidence Based Stroke Rehabilitation
GoalsBriefly review the history of strokeLearn the pertinent epidemiological facts
of stroke now and into the futureGain an appreciation that, despite there being almost 1000 RCT regarding stroke outcomes, we are still in the infancy of understanding why we do what we do
Evidence Based Stroke Rehabilitation
Goals
Review data from the excellent resource Evidence Based Review of Stroke
Rehabilitation (EBRSR)
Evidence Based Stroke Rehabilitation
History
600 BC Hippocrates – 4 humours
160 AD Galen – advanced the humour theory
1599 “the stroke of God’s hand”
1732 Robinson described the typical apoplectic patient
Evidence Based Stroke Rehabilitation
History
Mid 1600s Jacob Wepfer
cerebral hemorrhage
blocked cerebral arteries
1920s cerebral angiography
1935 blood letting debunked
Evidence Based Stroke Rehabilitation
History
1950s first carotid endarterectomy
1960s Doppler ultrasound
1960s hypertension a modifiable risk
1970s aspirin
CT scanning
PET scanning
Evidence Based Stroke Rehabilitation
History
1980s
stroke prevention/risk modification
smoking identified as risk
1990s
endarterectomy proven to be effective
anticoagulants and a fib
blood pressure and cholesterol
Evidence Based Stroke Rehabilitation
History
1990s
tPA approved
combined dipyridimole and aspirin
2000s
acute cerebral artery thrombectomy
carotid artery stenting
Evidence Based Stroke Rehabilitation
Epidemiology >700,000 total strokes per year in the USMortality is still about 50% However, stroke mortality fell 12% between 1990 and 2000Men 1.25 x risk of womenBlacks have 2x risk of stroke vs white; Hispanic is in between
Evidence Based Stroke Rehabilitation
Epidemiology There are an estimated 5 million stroke survivors in the US
More than 1.1 million with some form of chronic disability
Baby boomers
Disability
Evidence Based Stroke Rehabilitation
Why does rehab work?
Neural Plasticity – the ability of the brain to reorganize and learn new functions
Evidence Based Stroke Rehabilitation
Evidence based/Outcomes based data
In its toddlerhood
Will be important to show we matter
Soon, doing things because we think it works won’t fly
Evidence Based Stroke Rehabilitation
Evidence based/Outcomes based dataIndredavik et al 1990
randomized 220 strokes to the IRF* unit or general medical unit
outcomes were home or not, mortality, BI at 6 and 52 weeks, 5 years and 10 years
*IRF = Inpatient Rehabilitation Facility
Evidence Based Stroke Rehabilitation
Evidence based/Outcomes based data
Indredavik et al 1990
Across all time frames statistically significant:
lower mortality in the IRF group
lower institutionalization in the IRF group
higher home living in the IRF group
higher BI scores in the IRF group
Evidence Based Stroke Rehabilitation
Evidence based/Outcomes based data
Ronning and Guldvog – 1998
randomized controlled trial
251 strokes
compared community care (no IRF) to IRF
outcome was dependence (BI<75) or death
Evidence Based Stroke Rehabilitation
Evidence based/Outcomes based data
Ronning and Guldvog – 1998
7 month follow up
23% IRF patients dead or dependent vs 38% community care (p=.01)
39% reduction in worse outcomes with IRF care
Evidence Based Stroke Rehabilitation
Evidence based/Outcomes based data
Foley, et al 2007 Meta analysis of IRF stroke unit trials
world wide
consistent statistical benefit of IRP units over other types of post stroke care in reductions in mortality and less dependency
Evidence Based Stroke Rehabilitation
Evidence based/Outcomes based data
EBRSR – Evidence Based Review of Stroke Rehabilitation
2001
systematically reviews all outcomes based stroke literature, summarizes and grades it
www.ebrsr.com
Evidence Based Stroke Rehabilitation
Evidence based/Outcomes based data
EBRSR reviews stroke literature relative to:
techniques
therapies
devices
procedures
medications
Evidence Based Stroke Rehabilitation
Evidence based/Outcomes based dataEBRSR
extensive and comprehensive database search strategies
3407 studies reviewed2000 in depth studies reviewed956 RCTMethodological quality assessed using the
PEDro scale
Evidence Based Stroke Rehabilitation
Evidence based/Outcomes based data
EBRSR
grading scale (based on the AHCPR)
Level 1a (strong)
Level 1b (moderate)
Level 2 (limited)
Level 3 (consensus)
Level 4 (conflicting)
Evidence Based Stroke Rehabilitation
Evidence based/Outcomes based data
EBRSR
only the data from the 956 RCTs are used for determination of evidenced based recommendations
Evidence Based Stroke Rehabilitation
Evidence based/Outcomes based dataEBRSR
Recommendations are broken into:Efficacy of Stroke Rehab Elements of Stroke RehabOutpatient Stroke Rehab Secondary PreventionMobility/Lower extremity Upper extremityPainful hemiplegic shoulder Cognitive/Apraxic disordersPerceptual disorders AphasiaDysphagia/Aspiration Nutritional interventionsMedical complications DepressionCommunity reintegration MiscellaneousYoung stroke Severe StrokeOutcome measures Stroke Triage
Evidence Based Stroke Rehabilitation
Evidence based/Outcomes based dataEBRSR
Stroke Triage
early screeningearly admission, butpatients with severe stroke better
managed in a less acute setting
younger (<55) patients with moderate to severe strokes should always be admitted to IRFs
Evidence Based Stroke Rehabilitation
Evidence based/Outcomes based dataEBRSR
Stroke Rehab Elementscare pathways don’t improve
outcomes or reduce costsgreater intensities of PT and OT
improve functional outcomesunclear intensive language therapythe greater functional improvements
from IRF care are maintained long term
Evidence Based Stroke Rehabilitation
Evidence based/Outcomes based data
EBRSRLower extremity and mobility
Bobath is as good but slower
focused balance training is beneficial
rhythmic auditory sensory stim helps
PBWS on treadmill questionable
strength training is beneficial
Evidence Based Stroke Rehabilitation
Evidence based/Outcomes based data
EBRSR
Lower extremity and mobility
cardiovascular training is good
WC self propel does not help
using canes enhances mobility
e stim with gait training improves gait
EMG/biofeedback improves gait training
Evidence Based Stroke Rehabilitation
Evidence based/Outcomes based data
EBRSR
Lower extremity and mobility
tilt table or night splinting prevent contracture
AFOs help
e stim and U/S reduce spasticity
Evidence Based Stroke Rehabilitation
Evidence based/Outcomes based dataEBRSR
Upper extremity
initial degree of motor impairment is the best predictor of motor recovery
NDT is not superioreffects of enhanced therapy, task
specific training, sensorimotor training and mental practiceunclear
Evidence Based Stroke Rehabilitation
Evidence based/Outcomes based data
EBRSR
Upper extremity
hand splinting does not help
robots help a little
CIT helps
virtual reality helps
Botox helps tone/spasticity but maybe not function
Evidence Based Stroke Rehabilitation
Evidence based/Outcomes based data
EBRSR
Upper extremity
PT may not reduce spasticity
IPC does not help edema
FES does improve function
Evidence Based Stroke Rehabilitation
Evidence based/Outcomes based data
EBRSR
Cognition
1/3 of stroke patients develop dementia
Stroke patients have 10x risk of developing dementia
Depression contributes to cognitive impairment in stroke
Evidence Based Stroke Rehabilitation
Evidence based/Outcomes based data
EBRSR
Cognition
treating hypertension in stroke patients reduces their dementia risk
gesture training is effective for treating ideomotor apraxia
Evidence Based Stroke Rehabilitation
Evidence based/Outcomes based data
EBRSR
Language therapy
is efficacious in aphasia when provided intensely for the first three months
group therapy may improve communicative and linguistic abilities
Evidence Based Stroke Rehabilitation
Evidence based/Outcomes based data
EBRSR
Language therapy
CPU-based aphasia therapy helps
forced use aphasia therapy helps
repetitive transcranial magnetic stimulation and polarity specific transcranial direct stimulation may help
Evidence Based Stroke Rehabilitation
Evidence based/Outcomes based data
EBRSR
Language therapy
piracetam, levodopa, memantidine, dextroamphetamine and donezepil may improve
language function
bromocriptine, cholinergics, dextran and moclobemide do not help
Evidence Based Stroke Rehabilitation
Evidence based/Outcomes based data
EBRSR
Dysphagia
VBMS is the only sure way to diagnose dysphagia and aspiration
Aspiration rates are high
risk of developing pneumonia is related to aspiration severity
Evidence Based Stroke Rehabilitation
Evidence based/Outcomes based data
EBRSR
Dysphagia
all stroke survivors should be npo until assessed
SLPs should see all patients who failed the swallow screen
dysphagic individuals should feed themselves
Evidence Based Stroke Rehabilitation
Evidence based/Outcomes based data
EBRSR
Dysphagia
a variety of treatments can be used to improve swallowing function post stroke
Evidence Based Stroke Rehabilitation
Evidence based/Outcomes based data
EBRSR
Medical complications
indwelling catheters should only be used in specific instances
timed voiding, biofeedback pelvic training, behavioral therapy
and weekly in home visits reduce incontinence
Evidence Based Stroke Rehabilitation
Evidence based/Outcomes based data
EBRSR
Medical complications
incidence of DVT is less than 10%
anticoagulation reduces DVT
LMW heparin is more effective than unfractionated heparin
compression devices don’t help reduce DVT
Evidence Based Stroke Rehabilitation
Evidence based/Outcomes based dataEBRSR
Medical complications
10% of post stroke patients have seizures
osteoporosis is common after stroke and can be reduced with ipiflavone, vit D + Ca, vit B12 + folate, sunlight, and bisphosphonates
Evidence Based Stroke Rehabilitation
Evidence based/Outcomes based data
EBRSR
Depression
1/3 develop depression
influence of stroke location and propensity to develop
depression not understood
depression negatively impacts recovery
Evidence Based Stroke Rehabilitation
Evidence based/Outcomes based dataEBRSR
Depression
depression is associated with cognitive impairment
early initiation of post stroke antidepressants is effective in preventing depression
various medication classes are effective in depression
Evidence Based Stroke Rehabilitation
Evidence based/Outcomes based data
EBRSR
Depression
pharmacologic treatment improves functional recovery
treatment with antidepressants improves long term survival
ECT and TCMS are effective
music therapy helps
Evidence Based Stroke Rehabilitation
Evidence based/Outcomes based data
EBRSR
Depression
exercise training does not help
Evidence Based Stroke Rehabilitation
Evidence based/Outcomes based data
EBRSR
Miscellaneous
unclear if acupuncture helps
Reikki does not help
HBO does not help
Evidence Based Stroke Rehabilitation
Evidence based/Outcomes based data
Summary
many of the treatments we provide stroke patients are proven to help them
many of the treatments we may be providing stroke patients have been shown not
to help (and yet we do them anyway!)
the EBRSR is an excellent resource to obtain data regarding the latest RCT evidence based outcomes information