REHABILITATION OF THE STROKE SURVIVOR Elliot J. Roth, M.D. Rehabilitation Institute of Chicago Northwestern University Feinberg School of Medicine

The brain is my second favorite organ” -Woody Allen

Stroke 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 Complications Prevention of Deconditioning and Contractures Training 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 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 Education vs. 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 family vs. 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. Unit vs. General Medical Ward: Good prognosis patients: IRU = GMW Poor prognosis patients: IRU>GMW IRU: Less mortality, shorter LOS Fair 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 Program vs. No Organized Rehabilitation Program 1586 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