Stroke Rehabilitation. Kenten Wang, DO HS Clinical Associate Professor Dept of Physical Medicine & Rehabilitation April 9, 2014

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1 Stroke Rehabilitation Kenten Wang, DO HS Clinical Associate Professor Dept of Physical Medicine & Rehabilitation April 9, 2014

2 Definition Stroke: cerebrovascular event with rapidly developing clinical signs of focal or global disturbances of cerebral function lasting 24 hrs or longer (or leading to death) with no apparent cause other than vascular TIA: symptoms lasting less than 24 hrs World Health Organization, 2013

3 Statistics 795,000 strokes yearly in U.S. Every 40 seconds, someone has a stroke Every 4 minutes, someone dies from stroke 4th leading cause of death in U.S. 150,000+ stroke deaths annually 17%-34% mortality in first 30 days Greatest number deaths occur in SNFs American Heart Association/American Stroke Association, 2013

4 Statistics A leading cause of adult disability 4.4M stroke survivors with disabilities 25%-50% partially/totally dependent in ADLs Costs $45.3 billion/year in care and lost earnings Source: American Heart Association/American Stroke Association

5 Rehabilitation.. Process of helping a person to reach the fullest physical, psychological, social, vocational, avocational and educational potential consistent with his or her physiologic or anatomic impairment, environmental limitations, and desires and life plans (DeLisa, et al 1998)

6 Who benefits from stroke rehab? 10% of patients have complete spontaneous recovery 10% of patients do not benefit due to severity of stroke symptoms Remaining 80% will make functional and neurologic gains with rehab National Stroke Association:

7 Key Elements for Stroke Rehabilitation Prevention of secondary complications Treatment to reduce neurologic impairment Compensation to adapt to residual deficits Maintenance of long term function Reintegration to community/work

8 REHABILITATION DURING ACUTE HOSPITALIZATION

9 Clinical Evaluation Where: setting that has coordinated services By whom: Acute care physician Rehabilitation consultants (PM&R physicians) Nursing staff Therapy staff (PT, OT, SLP)

10 Clinical Evaluation For what purposes: determine etiology, pathology, & severity assess comorbidities document clinical course When: admission & during acute hospitalization

11 Physiatric Consultation Clinical medical summary/co-morbid conditions Premorbid educational/work status Premorbid emotional status/substance use Family support system Home physical barriers Premorbid and current level of functioning Assessment for: presence of pressure ulcers Contractures/bracing Spasticity DVT prophylaxis pulmonary issues nutritional status bowel/bladder dysfunction prognosis/rehabilitation potential Need for therapy services Discharge Planning: recommend most appropriate next level of care

12 Early Mobilization Within hours, if possible Daily active/passive ROM exercises Progressively increase activity Changes of position in bed limb positioning & support

13 Secondary Stroke Prevention Carotid endarterectomy in patients who have 70%-99% carotid artery obstruction. Anticoagulants in patients with atrial fibrillation and other nonvalvular cause of embolic stroke. Antiplatelet agents in patients who have had transient ischemic attack (TIA).

14 DVT How common after stroke, if no prophylaxis? 20-75% of untreated stroke survivors Diagnostic signs and symptoms? Swelling, Pain Elevated WBC SOB, CP, tachycardia may be PE

15 DVT Prophylaxis Heparin low molecular weight (LMWH), or low-dose unfractionated (LDUH) Other effective measures intermittent pneumatic compression (SCD) elastic stockings (TED hose)

16 Dysphagia Overall incidence of 30-45%, but occurs in 67% of all brainstem strokes Predictors of aspiration on bed-side swallow exam Abnormal cough Dysphonia Abnormal gag reflex Dx: Bedside swallow evaluation Modified barium swallow FEES -- Cough after swallow -- Dysarthria --Voice after swallow

17 Dysphagia Management Goals prevent dehydration and malnutrition prevent aspiration and pneumonia restore ability to chew and swallow safely

18 Dysphagia Management Compensatory treatments changes in posture for swallowing (ie. Elevation of head of the bed, feeding in the upright position) learning new swallowing maneuvers (ie. Chin tuck, turning the head to the paretic side) changes in food texture and bolus size (ie. thickened fluids, pureed or soft foods in smaller boluses)

19 Dysphagia Management Fallback measures parenteral or tube feeding gastrostomy for longterm tube feeding

20 Prognosis of Dysphagia Swallowing function regained within 2 weeks in 86% of pts with unilateral stroke Recovery of swallowing function in most brainstem strokes occurs in the first 3 weeks post-stroke

21 Maintaining Skin Integrity Daily inspection Routine cleansing Protection from moisture Frequent position changes Maintenance of adequate hydration/nutrition Individual mobility-improvement measures

22 Bladder Dysfunction How common is urinary incontinence during 1st month after stroke? 50-75% 6 mo after stroke? 15% Causes CNS damage, UTI, impaired mobility, confusion, communication, decreased awareness of bladder fullness

23 Bowel Dysfunction Inability to inhibit urge to defecate: incontinence Incidence? 31% Usually resolves in first 2 weeks May be associated w/infectious diarrhea or impaired mobility, communication impairment Impairment of intestinal peristalsis: constipation Management: adequate fluid intake, modify diet, bowel management, allow commode/bathroom privileges

24 Bladder & Bowel Management Timed voiding Clean intermittent catheterization Indwelling catheter as last resort NO DIAPERS NO DIAPERS NO DIAPERS

25 Fall Prevention At-admission and periodic risk assessment High-risk factors visual neglect slowness in performing tasks impulsive movements older age history of falls multiple transfer situations

26 Depression At least 1 in 3 stroke pt will experience depression Risk factors Female Previous hx of depression Functional limitations Cognitive impairment

27 Diagnosing Depression Symptoms and history diminished interest in activities loss of energy/appetite/concentration sleep disturbances/agitation feelings of worthlessness/suicidal thoughts history/observed behavior changes

28 Diagnosing Depression Causes to rule out medications, e.g., sedatives environmental factors Confirming diagnosis: clinical interview by mental health professional

29 Treating Depression Mild depression attention/encouragement, therapeutic activities simple environmental changes Severe depression antidepressant medications (SSRI) psychotherapy

30

31 Rehabilitation after Acute Care

32 Rehabilitation Settings 1. Inpatient Rehab Facility (IRF) - 3 hrs therapy/day 2. Subacute/Skilled Nursing Facility (SNF) - about 1 hr/day 3. Home Health therapies Most Intensive 4. Outpatient Rehab Services Least Intensive

33 Mortality 1yr Post Acute Care Discharge, N=18,656 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% IRF SNF HH OP NONE *Acute hospital mortality averaged 12% **Post Acute Care mortatlity averaged 22.6%

34 Effectiveness of Stroke Rehab (1) Indredavik et al (1991) conducted RCT of 220 acute stroke pts, 1/2 assigned to stroke unit with other 1/2 assigned to general medical wards. Max tx time is 6 weeks. At 6 weeks, 56% of stroke unit pts vs. 33% of the general medical ward pts were living at home. At 1 yr, 63% of stroke unit pts vs. 45% of the general medical ward pts were living at home. Functional status levels were significantly greater for stroke unit pts at 6 wks & 1 yr Indredavik B, Bakke F, Solberg R, et al. Benefit of a stroke unit: a randomized controlled trial. Stroke 1991;22:

35 Effectiveness of Stroke Rehab (2) Kalra et al (1995), conducted RCT of 71 pts with severe disability after stroke and poor prognoses 34 pts to stroke rehab unit & 37 pts to gen med Pts who got stroke rehab had significantly better mortality rates, home discharge placement rates, LOS, & trend toward significantly better improvement in functional scores Kalra L, Eade J. Role of stroke rehabilitation units in managing severe disability after stroke. Stroke :

36 Effectiveness of Stroke Rehab (3) Metaanalysis done by Ottenbacher & Jannell, reported results of 36 clinical trials, involving 3717 pts. Stroke pts who underwent a focused stroke rehab program had improvement in Personal care skills Mobility activities, ambulation Visuospatial perceptual functions Improvement in performance was related more to early initation of tx than duration of intervention Ottenbacher KJ, Jannell S. The results of clinical trials in stroke rehabilitation research. Arch Neurology 1993;50:37-44.

37 IRF vs Subacute (Deutsch, 2006) Retrospective review Community discharge more likely in IRF for: Mild motor and cognitive disabilities Moderate motor disabilities Significant motor disabilities Severe disabilities younger than 82

38 IRF Regulatory Risk Medicare 13 Admitting Inpt Rehabilitation Diagnosis 1. Stroke 2. Spinal Cord Injury 3. Congenital Deformity 4. Amputation 5. Major Multiple Trauma 6. Femur Fracture 7. Brain Injury 8. Neurological Disorders: Multiple Sclerosis, motor neuron disease, polyneuropathy, muscular dystrophy and Parkinsons 9. Burns 10. Active polyarticular rheumatoid arthritis, psoriatic arthritis and seronegative arthropathies 11. Systemic vasculidities with joint inflammation 12. Severe or advanced osteoarthritis (osteoarthritis ordegenerative joint disease) involving two or more major weight bearing joints 13. Bilateral Knee or hip joint replacements 60% rule

39 Screening for Rehabilitation Setting Identify patients who will benefit Identify problems needing treatment Determine appropriate rehabilitation setting as soon as patient is medically stable

40 Poor Rehabilitation Outcomes Severe functional/motor/cognitive deficits Persistent urinary/fecal incontinence Severe visual/spatial deficits Sitting imbalance Severe aphasia

41 Poor Rehabilitation Outcomes Altered level of consciousness Major depression Severe co-morbidities Disability before stroke Older age

42 Criteria for Rehabilitation Program Medically/moderately stable One or more persistent disabilities Able to learn Physical endurance sufficient to: sit at least 1 hour per day participate in rehabilitation

43 Criteria for Interdisciplinary Inpatient Rehabilitation Disabilities in two or more of the following: Mobility Swallowing Pain management Cognition Bowel/bladder control Communication Performance of ADLs Emotional function

44 Interdisciplinary Rehabilitation Team Members Patient/Family Physiatrist Rehabilitation Nurse Physical Therapist Occupational Therapist Speech Language Pathologist Neuropsychologist/Psychologist Recreational Therapist Social Worker Case Manager Dietician

45 Stroke Survivor/Family Active participation Communicate goals with team members Give as accurate information as possible Tell care providers when they are not clear/you don t understand

46 Physiatrist Physician specialist in rehabilitation medicine Manages medical care and rehabilitation care Recommend appropriate level of care post-hospital discharge

47 Rehabilitation Nursing Provides care directed at prevention, maintenance and/or restoration of function and adaptation of different lifestyle Carries over therapeutic strategies (ADL, mobility, cognitive strategies) Discharge planning: identifies impact of daily care and potential hardships for next care provider

48 Setting Rehabilitation Goals Both short- and long-term Realistic Agreed upon by all team members Specific about roles, tasks, and activities

49 Develop a Treatment Plan Identify significant impairments and disabilities measures to prevent recurrence treatments for co-morbidities rehabilitation interventions plans for periodic monitoring

50 Continuity of Care & Family Involvement Multiple care settings during recovery Patient and family must: be fully informed & participate in decisions participate actively in rehabilitation

51 Rehabilitation is a lifelong process Outpatient Rehabilitation Acute Care Home Exercise Program Inpatient Rehabilitation

52 Outcomes

53 Predicting Functional Outcome Many Functional Outcome Scales National Institutes of Health Stroke Scale The Rankin Scale Barthel Activities of Daily Living Index Functional Independence Measure (FIM) Stroke Impact Scale The Orpington Prognostic Scale

54 Predicting Functional Outcome 80% of patients reach their best level of activities of daily living (ADL) function within 6 weeks Mild Stroke best functional level may be achieved at 8.5 weeks, and can be predicted in 80% of patients within 3 weeks. Moderate Stroke best level is achieved at 13 weeks, and can be predicted at 7 weeks Severe Stroke best level may be achieved at weeks, and can be predicted within 11.5 weeks

55 Factors for Improved Functional Outcome Increased functional skills on admission to rehabilitation Early initiation of rehabilitation services Rehabilitation in an interdisciplinary versus a multidisciplinary setting

56 Poor Prognostic Indicators Proprioceptive facilitation (tapping) response > 9 days Traction response (of shoulder flexors/adductors) > 13 days Prolonged flaccid period

57 Poor Prognostic Indicators Onset of motion > 2-4 weeks Severe proximal spasticity Absence of voluntary hand movement > 4-6 weeks Unilateral spatial neglect or hemineglect Depression

58 Cognitive/Psychologic Factors Associated with Better Outcomes Higher scores for Attention Calculations Judgment Better performance in Comprehension Short-term verbal memory Abstract thinking

59 Measures for Successful Rehabilitation Normalized health patterns Freedom from physical pain/emotional distress/impairments Retention of cognitive/communicative abilities Mobility and independence in ADL IMPROVED QUALITY OF LIFE

60 Summary: Requirements for Successful Rehabilitation In-depth assessment at all phases Appropriate patient selection Early introduction to rehabilitation Teamwork approach in multidisciplinary setting (interdisciplinary) Shared goals and management plan

61 My Stroke of Insight by Jill Bolte Taylor, PhD A neuroanatomist s personal experience with a L MCA stroke, d/t ruptured aneurysm Recounts her 8-year recovery process Recommendations for lay people and for medical professionals

62 Excerpts from her 40 Things I Needed the Most I am not stupid, I am wounded. Please respect me. Come close, speak slowly, and enunciate clearly. Repeat yourself Be patient Slow your energy down. Be aware of your body language Don t raise your voice-- I am not deaf. I m wounded. Connect with me Honor the healing power of sleep

63 Protect my energy (keep visitations brief!) Introduce me to the world kinesthetically. I am an infant again. Trust that I am trying-- just not with your skill level or on your schedule. Ask me multiple-choice questions. Avoid yes/no questions. Do not assess my cognitive ability by how fast I can think. Speak to me directly. Cheer me on. Focus on what I can do rather than bemoan what I cannot do. Show me old video footage of me doing things to remind me about how I spoke and walked.

64 That s all folks

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