REHABILITATION OF THE REHABILITATION OF THE STROKE SURVIVORSTROKE SURVIVOR

Elliot J. Roth, M.D. Rehabilitation Institute of ChicagoNorthwestern University Feinberg School of Medicine

The brain is my second favorite The brain is my second favorite organ” organ”

-Woody Allen-Woody Allen

StrokeStroke

Third leading cause of death in U.S. Leading cause of severe disability in U.S. Estimated one-third to one-half have

disability Most common reason for rehabilitation

The Goals of Stroke Rehabilitation

Prevent, Recognize, and Manage Comorbid Medical Conditions

Maximize Functional Independence Optimize Psychosocial Adaptation of

Patients and Families Facilitate Resumption of Prior Life Roles

and Community Reintegration Enhance Quality of Life

Rehabilitation during the Acute Phase

GOALS:Prevention of Medical

ComplicationsPrevention of Deconditioning

and ContracturesTraining of New Skills

Rehabilitation during the Acute Phase

TASKS: Range of Motion Stretching Exercises Frequent Position Changes Sitting in Upright Position to Improve

Orthostatic Tolerance Psychological Counseling Patient and Family Education

Rehabilitation during the Acute Phase

TASKS: Training Personal Care Skills, Mobility,

and Ambulation Training Bladder and Bowel Management Evaluation of Swallowing Function Initiate Nutrition and Hydration Identification and Treatment of

Depression

Medical Complications of Stroke

Venous Thromboembolism Pneumonia Dysphagia Ventilatory Dysfunction Cardiac Disease Seizure Central Post-Stroke Pain Syndrome Spasticity

Medical Complications of Stroke

Bladder Dysfunction Bowel Dysfunction Pressure Ulcers Malnutrition and Dehydration Depression Falls and Injuries Shoulder Pain and Dysfunction

Medical Complications of Stroke

Recurrent Stroke

Natural Recovery after Stroke

MOTOR CONTROL: Flaccid Hemiplegia Increasing Tone and Spasticity Emergence of Synergy Patterns Gradually Increasing Isolated Voluntary

Movements

Levels of Rehabilitation Care

Therapy during Acute Care Acute Comprehensive Inpatient

Rehabilitation Subacute Comprehensive Inpatient

Rehabilitation Comprehensive Day Rehabilitation Outpatient Rehabilitation Home Rehabilitation

Principles of Stroke Rehabilitation

Interdisciplinary Team Approach Holistic and Comprehensive Uses Learning Theory:

– Graded Levels of Task Difficulty– Opportunities for Repetition of Skill

Performance– Professional Supervision and Feedback– “Protected Practice”

Principles of Stroke Rehabilitation

Attention to Psychological Issues Involvement of Family Need to Recruit Community Resources Importance of Functional Activities Attention to Quality of Life Issues

Stroke Rehabilitation Interventions

Functional Skills Training– Personal Care Skills– Mobility Activities– Instrumental Activities of Daily Living

Stroke Rehabilitation Interventions

Therapeutic Exercises– Flexibility– Strength– Coordination– Fitness

Stroke Rehabilitation Interventions

Spasticity Management:– Positioning and Orthotics– Stretching and Other Exercises– Medications– Injections– Surgical Release

Stroke Rehabilitation Interventions

Aphasia Treatment: – Individual Supervised Practice and Training – Group Speech Therapy– Encourage Verbalizations– Conversational Coaching– Melodic Intonation Therapy– Oral Reading– Computerized Training– Medications

Stroke Rehabilitation Interventions

Treatment of Depression: Endogenous vs. Reactive Natural Recovery Interventions:

– Professional Counseling and Psychotherapy– Peer Relationships and Family Involvement– Medications

Stroke Rehabilitation InterventionsStroke Rehabilitation Interventions

Patient Education Family and Caregiver Education Behavioral Techniques Supportive Counseling Recruit Community Resources

Other Quality of Life Issues

Sexuality Spirituality Driving Employment Education Recreation Family Involvement

New Rehabilitation Interventions

Partial Body Weight-Supported Treadmill Training

Pedaling Biofeedback Electrical Stimulation Constraint-Induced Muscle Training Robotic-Assisted Therapeutic Exercise

Stroke Rehabilitation Outcomes

80% Independent Mobility 70% Independent Personal Care 40% Outside Home 30% Work

Factors Affecting Outcomes

Neurological Deficits Motivation Level Learning Ability Level of Emotional and Social Support Coping and Adaptability Medical Comorbidities Rehabilitation and Training

Stroke Rehabilitation Effectiveness

RCT; Strand et al 1985: 293 patients; mean age = 73 yrs.

Non-intensive Stroke Inpatient Rehab Unit with Team Approach, Staff Education, Early and Focused Rehabilitation Efforts, Family Participation, and Patient and Family Educationvs. General Medical Ward:

IRU Patients: More independence in hygiene, dressing, and walking; Less rehospitalization (15% vs. 39%); Less mortality; Gains persisted at one year

Stroke Rehabilitation Effectiveness

RCT; Indredavik et al 1991: 220 patients; mean age = 73 yrs.

Stroke Inpatient Rehab Unit with team approach, early rehabilitation, and education program for patient and familyvs. General Medical Ward:

IRU: More likely to live at home (56% vs. 33% at 6 weeks; 63% vs. 45% at one year); More ADL independence at 6 weeks and one year; Less mortality (7% vs. 17% at 6 weeks; 25% vs. 33% at one year)

Stroke Rehabilitation Effectiveness

RCT; Kalra et al 1993: 245 patients; stratified by prognosis as good/fair/poor

Stroke Inpatient Rehab. Unitvs. General Medical Ward:

Good prognosis patients: IRU = GMWPoor prognosis patients: IRU>GMW

IRU: Less mortality, shorter LOSFair prognosis patients:

IRU: better ADL, more home discharges, shorter LOS, less mortality

Stroke Rehabilitation Effectiveness

Meta-analysis of 10 Studies:Focused Interdisciplinary Team-Driven Stroke Rehabilitation Programvs. No Organized Rehabilitation Program1586 patients;

Rehabilitation Program Patients had reduced mortality and improved functional outcomes

-Langehorn et al 1993

Stroke Rehabilitation Effectiveness

Meta-analysis of 36 Studies:Rehabilitation Program patients performed better than 65% of patients in comparison groups.

Rehabilitation Program had greatest effects on: Personal Care Skills, Mobility Activities, Ambulation, and Visuospatial-Perceptual Functions

Improvement was more related to: Early Initiation than to Duration of Intervention

-Ottenbacher and Jannell 1993

Rehabilitation Effectiveness

AHCPR Recommendation:

“Whenever possible, patients with acute strokes should receive coordinated diagnostic, acute management, preventive, and rehabilitative services.”

(Research evidence =A;

Expert opinion=consensus)

Rehabilitation Effectiveness

“…There is some evidence that formal

rehabilitation after stroke is effective

and that it is best provided by well-

organized interdisciplinary teams…”

-Great Britain Dept. of Health 1992