Stroke Rehabilitation Triage Severe Strokes

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Maud Kelly
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1 The London Stroke Rehab Data Base Project Robert Teasell MD FRCPC Professor and Chair-Chief Department of Phys Med Rehab London Ontario Retrospective Data Bases In stroke rehab limited funding for clinical stroke rehab research Retrospective data bases are convenient and less expensive Unfortunately data collection is often incomplete and subject to a number of biases Will likely come to an end with the new privacy laws London Stroke Rehab Data Base Data-base is actually 4 separate databases collected from Funded locally ,014 pts University Hospital and St. Mary s Hospital pts from UH, SMH and Parkwood (slow-stream) Hospital pts Parkwood Hospital post merging of rehab units London Stroke Rehab Data Base 2,135 stroke rehab patients 15 peer-reviewed articles, > 40 abstracts and basis for two books Rich source of information on a number of areas 4 factors influencing stroke rehab outcomes Stroke Rehabilitation Triage Severe Strokes Mild Moderate Severe Outpatients and/or Home Rehab Unit and Home Slow-Stream or Institution 1

end with the new privacy laws London Stroke Rehab Data Base Data-base is actually 4 separate databases collected from 1986-2003 Funded locally 1986-1996 1,014 pts University Hospital and St.

2 Rehab of Severe Strokes Teasell et al. Canadian J Neurol Sci 2005 Slow-stream stroke unit pts Excluded pts > 6 mos post-stroke or ambulatory at time of admission 196 non-ambulatory stroke patients admitted to SSS rehab mean 56 (median 49) days post-stroke Median FIM admission score was 46 Rehab of Severe Strokes Median discharge FIM score was 70 Time in rehab was days (median 84 days) By discharge 28% able to ambulate independently (+/- assistive device) while 72% remained wheelchair dependent 43% were able to be discharged to their own home Rehab of Severe Stroke Patients Results from multiple logistic regression showed most powerful predictors of successful discharge home in descending order of importance: 1. Admission FIM score 2. Age 3. Male sex 4. No history of previous stroke Rehab of Severe Strokes Severe stroke patients do respond to rehab but much slower functional gains RCTs comparing specialized interdisciplinary stroke rehab with usual care for severe strokes showed benefits Main value is discharge of a substantial number home (importance of discharge planning in stroke rehab) Correctly predicted overall outcome 73.4% Age Rehab of Young Stroke Patients Teasell et al. Arch PM&R 2000 reviewed outcomes of 83 stroke rehab pts under patients with spouses % separated within 3 mos of hospital d/c 15 (18.1%) not able to return to their premorbid residence; 4 (4.8%) required institutionalization In many cases parents were caregivers 2

(median 49) days post-stroke Median FIM admission score was 46 Rehab of Severe Strokes Median discharge FIM score was 70 Time in rehab was 88 + 39 days (median 84 days) By discharge 28% able to

3 Rehab of Young Stroke Patients Rehab of Elderly Stroke Patients 64 patients were employed outside of the home or studying at time of stroke Only 13 (20.3%) able to return to work within 3 mos of discharge home Only 9.4% of those working full-time pre-stroke were able to return to fulltime employment Studied 6 stroke rehab cohorts based on age (40s to 90s) Berg balance and Brunnstrom postural control scores showed a significant (p<.05) worsening with age Impairment was worse with younger patients FIM scores did not change with age Rehab of Elderly Stroke Patients Suggests elderly patients do not do so well in rehab as younger patients with similar impairments in part because of increasing balance difficulties May be more important than comorbidities Gender Impact of Gender on Rehab Outcomes Likelihood of Returning Home Post- Stroke Based on Gender Hellings et al. - 1,109 consecutive stroke rehab pts from Greater proportion of males discharged home following inpatient rehab vs. women : 437/599 (72.8%) vs. 321/510 (62.9%), p=0.02; 5 patients died during rehab Men Women 3

4% of those working full-time pre-stroke were able to return to fulltime employment Studied 6 stroke rehab cohorts based on age (40s to 90s) Berg balance and Brunnstrom postural control scores showed

4 Impact of Gender on Rehab Outcomes Using retrospective data from 272 pts, logistic regression models were built for men and women Women discharged home were younger, had higher rehab admission FIM scores, were living with a spouse pre-stroke and less likely to have diabetes Men discharged home had higher admission FIM scores and were living with a spouse pre-stroke Impact of Gender on Rehab Outcomes Women were more likely to not be discharged home post-stroke Spousal support was important for both men and women Younger women were more likely to be discharged home; age was not a factor in men Presence of a younger spouse may have minimized the impact of age with men Time to Rehabilitation Time to Rehab Admission Retrospective review of 435 pts admitted to specialized stroke rehab unit from Stroke onset to rehab admission divided into 2 groups: < 30 days vs days Time to Rehab Admission Admit FIM D/C FIM FIM Adj FIM FIM efficiency LOS < 30 days days p Impact of Time to Rehab on FIM Change (adjusted for initial stroke severity) and LOS FIM admit FIM d/c FIM change LOS

Outcomes Women were more likely to not be discharged home post-stroke Spousal support was important for both men and women Younger women were more likely to be discharged home; age was not a factor

5 Time to Rehab Admission Both groups were similar in terms of age, gender, side of lesion and presence of risk factors Delayed admission group proportionately more hemorrhages No relationship to age Earlier admission to rehab is associated with greater functional gain, regardless of initial functional deficit Hemorrhagic Stroke Patients Hemorrhagic stroke rehab patients, when compared to ischemic stroke rehab patients, took longer to enter into rehabilitation and were more susceptible to developing medical complications (Lipson et al. Internat J of Rehab 2005) Once in rehabilitation, although there was a significant delay, functional gains were comparable The Earlier the Better Brain is primed to recover early in post-stroke period Animal studies suggest time window when brain is primed for maximal response to rehab therapies, such that delays are detrimental to recovery Teasell et al. Topics Stroke Rehab 2005 Clinical association between early admission to rehab and better outcomes Benefit of Early Therapy in Animals Methods Biernaskie et al. (2004) subjected rats to rehab x 5 weeks beginning at 5, 14 and 30 days post small strokes Control animals social housing Benefit of Early Therapy in Animals Results All received 5 weeks of enriched enviornment Day 5 admission marked improvement Day 14 moderate improvement Day 30 no improvement vs. controls Corresponding cortical reorganization in brain around stroke Summary Modestly funded retrospective stroke rehab patient database Stroke severity predicts stroke rehab outcomes severe strokes do benefit but outcomes may need to be redefined Young and elderly stroke rehab patients are different and require different approaches 5

ischemic stroke rehab patients, took longer to enter into rehabilitation and were more susceptible to developing medical complications (Lipson et al.

6 Summary Women are less likely to be discharged home than men Brain is primed for recovery early on delays in rehab can be detrimental to final outcomes Need a Stroke Rehabilitation patient registry 6

How many RCTs in Stroke Rehab?

How many RCTs in Stroke Rehab? Evidence Based Stroke Rehabilitation: Maximizing Recovery and Improving Outcomes Robert Teasell MD FRCPC Professor and Chair Chief Physical Medicine & Rehabilitation St. Joseph s Health Care London University