The Key Elements of Stroke Rehabilitation: Mark Bayley MD FRCPC 1
Presenter Disclosure Information Presenter: Mark Bayley Associate Professor, University of Toronto and Medical Director, Neuro Rehabilitation, Toronto Rehabilitation Institute FINANCIAL DISCLOSURE: I have no conflicts of interest to declare with this material UNLABELED/UNAPPROVED USES DISCLOSURE: None 2
Some Miracle Happens Understanding the Black Box of Stroke Rehabilitation 3
Objectives for Presentation By the end of this presentation participants will be able to 1. Name main mechanisms of recovery after stroke 2. Identify important elements of Continuum of Stroke Care 3. To identify some important gaps in care particularly for those with severe stroke and for community based survivors 4
Objective 1 Mechanisms for Recovery after stroke 5
Mechanisms of Recovery Resolution of Temporary Factors Central Nervous System Reorganization 6
Resolution of Temporary Phenomena Resolution of edema Resolution of ischemic penumbra A focal ischemic injury consists of a core of low blood flow which eventually infarcts (Astrup et al 1981, Lyden and Zivin 2000), surrounded by a region of moderate blood flow, known as the ischemic penumbra (Astrup et al 1981, Lyden and Zivin 2000), which is at risk of infarction but is still salvageable 7
Resolution of Diaschisis 8
Crossed Cerebellar Diaschisis 9
Mechanism 2-2 Brain Reorganization Nudo (2003), based on animal research, suggested that changes occurring during motor learning, are likely the same type of changes that occur during this part of recovery from stroke 10
CNS Reorganization and Plasticity Axonal Sprouting 11
Plasticity Concepts 12
Activation of the Other Hemisphere of Brain on FMRI 13
Local Processes Resolution of edema Resolution of ischemic penumbra Resolution of remote functional depression (diaschisis) Time course of Recovery Weeks to 2 months Hours to weeks Days to months CNS Reorganization Weeks to months 14
Objective 2 Identify key elements of stroke rehabilitation system 15
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Best practice recommendation 5.2: Provision of Inpatient stroke rehabilitation All patients with stroke who are admitted to hospital and who require rehabilitation should be treated in a comprehensive or rehabilitation stroke unit by an interdisciplinary team [Evidence Level A] 17
Models of Stroke Care that have Been Studied General Medical Ward Acute Stroke Units Combined acute and subacute stroke units ( also known as Integrated Stroke Units) Subacute Stroke Rehab units Roving/Mobile Stroke Teams 18
Acute Stroke Units Geographic Unit with specialized teams. Patients on the stroke unit were treated medically more aggressively including increased use of parenteral fluids and antibiotics (Ronning) Combined Acute/Subacute Units Integrated specialized interdisciplinary combined acute and rehabilitation stroke units Heterogeneous definitions of SU Variations in timing of onset and patients admitted 19
Subacute Stroke Rehabilitation Units Geographically distinct units with focus on rehabilitation sometimes in freestanding hospitals Most studies involve moderate or severe stroke patients 20
Roving or Mobile Stroke Teams Langhorne et al. (2005) conducted a systematic review of mobile stroke teams evaluating studies which compared care provided by a mobile team of specialized stroke professionals on various wards versus alternative forms of stroke rehabilitation, 21
Pooled Analysis for Death and Dependency Model of Care OR (95% CI) Acute stroke care 0.70 (0.56, 0.86) Combined acute 0.56(0.44, 0.7 and subacute Subacute Rehab 0.63 (0.48,0.83) Mobile stroke team 1.00 (0.73, 1.38) Overall 0.68 (0.60-0.77) 22
Stroke Rehab Units Stroke rehab units discharge stroke patients with fewer neurological deficits, improved ADL, reduced mortality and greater chance of being at home NB: For Every 13 patients treated in a stroke rehab unit, 1 patient is saved from death or dependence 23
Best practice recommendation 5.2 ( Cont d): Provision of Inpatient stroke rehabilitation i. Post acute stroke care should be delivered in a setting in which rehabilitation care is formally coordinated and organized [Evidence Level A] ii. All patients should be referred to a specialist rehabilitation team on a geographically defined unit as soon as possible after admission [Evidence Level A] (RCP). 24
PSROP (Post-Stroke Rehabilitation Outcomes Project) Study of 7 stroke rehab centers (6 in United States, n=1161; 1 in New Zealand, n=130) Comprehensive study of stroke rehabilitation examining the black box PSROP study, Archives of PM&R Dec 2005 suppl 25
What did the more efficient Stroke centers do? Admitted to specialized inter-disciplinary stroke rehab units Admitted earlier and more disabled More intensive therapy (incl. W/E) Less time in assessments Move to high level tasks early Well developed outpatient services 26
The Earlier the Better 27
The Earlier the Better Brain is primed to recover early in poststroke period Animal studies suggest there is a time window when brain is primed for maximal response to rehab therapies Delays are detrimental to recovery Clinical association between early admission to rehab and better outcomes 28
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 29
Benefit of Early Therapy in Animals- Results: All received 5 weeks of enriched environment Day 5 admission marked improvement Day 14 moderate improvement Day 30 no improvement vs. controls Corresponding cortical reorganization in brain around stroke 30
Therapy Intensity 31
% D/C 100 90 80 70 60 50 40 30 20 10 0 SRU GMU 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Weeks 32
20 10 0 * OT PT SRU GMW 33 Mean hrs/pt
In German and Swiss centers, the rehabilitation programs were strictly timed (therapists had less freedom), while in UK and Belgian centers they were organized on an ad hoc basis (therapists had more freedom to decide)! No differences were found in the content of physiotherapy and occupational therapy More formal management in the German center may have resulted in the most efficient use of human resources, which may have resulted in more therapy time for the patients De Wit et al. Stroke 2007:38:2101-2107 34
In a therapeutic day >50% time in bed 28% sitting out of bed 13% in therapeutic activities Alone for 60% of the time (Inactive and alone, Bernhardt et al, Stroke 2004) Contrary to the evidence that increased activity and environmental stimulation is 35 important to neurological recovery
Reality Check: Therapy is Cheap; LOS is Not Therapists are not replaced when sick or absent Laissez-faire attitude towards rehab therapies even though it is what we are supposed to be doing At least 60% of stroke rehab budget costs are nursing (versus <20% of core therapies) which have better developed accountabilities Stroke rehab patient gets an average of a little over one hour of therapy per day 36
Task-Specific Directed Stimulation 37
Stroke Rehab Must Be Task-Specific To be most effective rehab needs to be task-specific, focusing on tasks important and meaningful to the patient e.g. Obstacle Courses Sit-to Stand Training Aerobic Training 38
Best practice recommendation 5.3: Components of inpatient stroke rehabilitation All patients with stroke should begin rehabilitation therapy as early as possible once medical stability is reached [Evidence Level A] (ASA). i. Patients should receive the intensity and duration of clinically relevant therapy defined in their individualized rehabilitation plan and appropriate to their needs [Evidence Level A]. ii. Stroke patients should receive, through an individualized treatment plan, a minimum of 1 hour of direct therapy by the interprofessional stroke team for each relevant core therapy, for a minimum of 5 days per week based on individual need and tolerance [Evidence Level A] with duration of therapy being dependent on stroke severity [Evidence Level C]. iii. The team should promote the practice of skills gained in therapy into the patient s daily routine in a consistent manner [Evidence Level A]. iv. Therapy should include repetitive and intense use of novel tasks that challenge the patient to acquire necessary motor skills to use the involved limb during functional tasks and activities [Evidence Level A] 39
Best practice recommendation 5.3: Components of inpatient stroke rehabilitation v. Stroke unit teams should conduct at least one formal interdisciplinary meeting per week at which patient problems are identified, rehabilitation goals set, progress monitored and support after discharge planned [Evidence Level B] vi. The care management plan should include a predischarge needs assessment to ensure a smooth transition from rehabilitation back to the community. Elements of discharge planning should include home visit by a health care professional, Determine equipment needs and home modifications, begin caregiver training NB Care Pathways do not seem to improve outcomes 40
First Story 41
Objective 3 To identify some important gaps in care particularly for those with severe stroke and for community based survivors 42
Should More Severe Strokes be Rehabilitated? 43
Rehab of Severe Strokes Patients with severe strokes improve to a lesser degree and at slower rate Multiple trials demonstrated severe strokes receiving rehab are more likely to be discharged home, have shorter LOS and reduced mortality rates Benefit of rehab more prevention of complications and improved discharge planning 44
Jorgensen et al. (2000) Comparative trial N = 1241 consecutive stroke patients Group 1 (n = 305) - general and neurological wards Group 2 (n = 936) - single stroke unit Patients similar in two groups 88% of all strokes admitted to hospital 45
Jorgensen et al. (2000) Relative risks of poor outcome (mortality or nursing home discharge) reduced by 47% on stroke unit For severe strokes poor outcome reduced by 86%; relative risk of 1 and 5 year mortality reduced by 40% and 70% Authors attributed it to an interdisciplinary rehab approach 46
Rehab of Severe Strokes 196 nonambulatory stroke patients with mean FIM 46 at day 56, avg age 72 admitted to a special stroke rehab unit Received daily therapy all disciplines in an interdisciplinary setting FIM increased from 46 to 70 in mean rehab stay of 88 days (FIM efficiency =.27) 43% were discharged home; savings were $4 for every $1 spent on rehab and home care Teasell et al. 2005 47
Should there be Slow Stream? Also Known in Toronto as Low Tolerance Long Duration Typically occurring in Complex Continuing Care Typical Maximum amount of therapy is 150 minutes per week 48
Severe Strokes Admission Motor FIM 12-38 (RPG 1100, 1110) Fiscal 09/10 100 95 90 80 70 60 50 48 Mean Acute LOS Mean Rehab LOS 40 30 20 10 0 18 32 26.5 26 Mean FIM change E-Stroke Data HTSD 49 LTLD
Story 2-2 Milder Stroke 50
Outpatient Therapy Outpatient therapy improves short-term functional outcomes Hospital same as home-based Outpatient therapy is relatively inexpensive (1 PT/1 OT/0.5 SLP/0.5 SW = cost of 1 rehab inpt bed) Reduces rehospitalization and allows earlier discharge home Estimated savings is $2 for every $1 spent on outpatient therapies 51
Cochrane Review of Outpatient Rehab 14 RCTs of 1,617 patients (Outpatient Trialists 2003) involved in home based, day hospital and outpatient clinic Therapy reduced the odds of a poor outcome (death, deterioration or dependency) (OR 0.72; 95% CI 0.57-0.92; p=0.009) Number needed to treat in order to spare one person from experiencing a poor outcome was 14 52
Best practice recommendation 5.4: Outpatient and community-based rehabilitation After leaving hospital, stroke survivors must have access to specialized stroke care and rehabilitation services appropriate to their needs (acute and/or inpatient rehabilitation) [Evidence Level A] 53
Best practice recommendation 5.4: Outpatient and community-based rehabilitation iii. Multifactorial interventions provided in the community including an individually prescribed exercise program, may be provided for people who are at risk of falling, in order to prevent or reduce the number and severity of falls [Evidence Level A]. iv. People with difficulties in mobility should be offered an exercise program and monitored throughout the program [Level B] v. Patients with aphasia should be taught supportive conversation techniques [Evidence Level A] vi. Patients with dysphagia should be offered swallowing therapy and opportunity for reassessment as required [Level A] 54
Best practice recommendation 5.5: Follow-up and community reintegration People with stroke living in the community should have regular and ongoing followup assessment to assess recovery, prevent deterioration and maximize functional outcome. 55
Summary Stroke Rehabilitation improves outcomes Key elements- Geographically distinct specialized unit Early onset Intensity of therapy Task Specific Therapy Outpatient Therapy 56
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Acknowledgements Robert Teasell MD FRCP University of Western Ontario Canadian Stroke Network Heart and Stroke Foundation of Canada 58
www.srebr.ca References www.canadianstrokenetwork.ca Look for tools menu for SCORE guidelines and Canadian stroke Strategy Guidelines 59
Thanks for Listening! Questions? 60