New Approaches, Improved Outcomes in Stroke RehabilitationBy Beverly Lucas
Abstract: There is hope for stroke victims at the end of the 20th century. Mortality rates are lower. And research data from innovate therapies suggests that stroke patients will survive and have less severe long-term problems. Aggressive early rehabilitation efforts by a well-trained staff is particularly important in improving the condition of stroke victims.
The latest strategies for poststroke rehabilitation are supported by a growing body of scientific evidence. Much of it suggests that care in the acute period and the choice of a rehabilitation setting can dramatically affect outcome.
Stroke is now the leading cause of serious long-term disability in the United States. According to the National Stroke Association, 40% of stroke survivors experience moderate to severe impairments, 25% die shortly after the stroke or experience such severe impairment that they require care in a long-term-care facility, and 25% recover with minor sequelae. Only 10% experience a near-complete recovery.1 Data from the National Heart, Lung, and Blood Institute's Framingham Heart Study showed that 71% of stroke survivors had an impaired vocational capacity when examined an average of 7 years following the stroke.2 Common poststroke deficits are listed in Table 1.
The financial toll is considerable as well. According to 1998 American Heart Association estimates, the direct costs of stroke, including hospitalization, nursing home use, health care professionals' fees, drugs, and home health and other medical durables, reach $28.3 billion.3 The total exceeds $43 billion when indirect costs associated with lost productivity due to morbidity and mortality are included.
But at the dawn of the new millennium, the outlook for patients who experience stroke is improving. Mortality continues to decline. And preliminary data from studies of new therapies for the acute treatment of stroke suggest that more patients will survive and that those who do will have less severe residual deficits.*
*For more information, see "New treatments, new risk factors for acute ischemic stroke," Patient Care, March 30, 1999, page 144.
Acute Rehabilitation Advances
Evidence of improved outcomes for patients admitted to specialized stroke units for acute treatment continues to accrue. Recent findings from the Stroke Unit Trialists' Collaboration in Scotland show that organized inpatient stroke unit care reduces death from secondary complications of stroke and lessens the need for institutional care.4 Other recent studies show that stroke unit care, when compared with hospitalization on a general medical ward, improves long-term survival, functional state, and quality of life, and increases the number of patients who are able to live at home 5 years after stroke.5,6 So strong is the evidence favoring treatment in specialized units that the Agency for Health Care Policy and Research (AHCPR) poststroke rehabilitation guidelines advise physicians to seriously consider transferring patients to a stroke unit if rehabilitation services at the admitting hospital are limited and a specialized stroke center is available within reasonable proximity.7
Stroke experts believe that improved outcomes are the result of emphasis on early mobilization and rehabilitation and aggressive measures to prevent, identify, and treat medical and psychological complications. Comprehensive, coordinated, interdisciplinary care provided by a well-trained, knowledgeable staff is also believed to be a key factor in improved outcomes.
Areas of Assessment
All stroke patients require thorough clinical assessments performed on admission and throughout the acute hospitalization. These provide critical information about the course of recovery. Initially, a complete clinical evaluation is required to confirm the diagnosis and determine the cause of stroke, as well as its location and extent. The acute assessment should also determine if the patient has coexisting medical conditions that could affect participation in therapy or increase the risk of further complications. Changes in clinical status should also be documented.
A thorough neurologic examination is necessary to assess the patient's level of consciousness and to identify cognitive disorders, motor deficits, disturbances in balance and coordination, and somatosensory deficits. The neurologic exam also seeks to uncover possible vision disorders or unilateral neglect. Disabling perceptual deficits are frequently found in patients with right brain lesions and can jeopardize safety even when motor deficits are minimal. Speech-language deficits, dysphagia, affective disorders, and residual pain may also be noted during the assessment. Identifying neurologic problems is crucial. An effort to address these deficits forms the basis of devising the patient's rehabilitation program.
Another component of the evaluation is an assessment of basic health functions. While these problems and their sequelae are well-known individually, close attention to the particular constellation of problems experienced by a stroke patient can help pinpoint problems early, before a cascade of deterioration begins. Examinations should include an assessment of these areas:
This occurs frequently in stroke patients. If the problem remains undetected, however, it could result in aspiration and pneumonia. Swallowing problems can be identified by conducting a careful pharyngeal and laryngeal nerve examination and performing barium videofluoroscopy. Researchers are also looking at the blink reflex as a potential early neurophysiologic marker for determining whether a patient will be able to swallow after a stroke.
Bladder and Bowel Function
Disturbances in these systems are also common in stroke patients and may be caused by mental status changes, immobility, bladder hyperreflexia or hyporeflexia, loss of sphincter control, urinary tract infection (UTI), or sensory loss. Some causes, such as UTIs, are easily treatable. Behavioral management strategies, including pelvic muscle training and exercise, biofeedback, and bladder training may also be helpful. Biofeedback may be less so in patients who cannot focus and are unable to achieve the contraction-relaxation sequence of pelvic floor musculature.
Stroke survivors with bowel function disorders most commonly suffer from constipation and impaction. Documentation of bowel habits, along with adequate fluid intake and physical activity, can help prevent this.
Incontinent patients are at greatest risk for this problem. Other factors, such as sensory deficits and poor nutrition, compound the risk. Daily examination of the patient's skin, with close attention to pressure points, can help identify problems early on, before the development of decubitus ulcers.
Adequate nutrition reduces the risk of infection, pressure sores, and mental status changes, but a number of factors can reduce a patient's ability and desire to eat after a stroke. Swallowing disorders, perceptual deficits, and reduced mobility are just a few of the potential troublesome areas. Careful attention to caloric intake, body weight, and urinary and fecal output can help ensure that the patient is receiving sufficient vitamins, nutrients, and micronutrients.
Physical Activity Endurance
A key factor in the choice of a rehabilitation setting is the patient's physical stamina. Identifying and treating potential causes of limited endurance can help ensure that a patient is not unnecessarily denied access to an intensive rehabilitation program. The best way to identify limited endurance is by direct observation during exercise. Respiration, blood pressure, and heart rate also provide important clues.
Sluggish behavior that suggests depression or lack of interest or motivation may actually be caused by disrupted sleep. Observing and documenting sleep patterns throughout the day and night will help detect disturbances.
Psychosocial assessments should also be conducted during a poststroke evaluation. An estimated 50% of survivors suffer depression shortly after a stroke, but the true figure is probably higher. The condition may go undetected in some cases, particularly since patients may not offer complaints generally associated with this condition. The presence of aprosody, especially in patients with rightsided brain damage, or vegetative signs may suggest depression, however. As with any seriously ill patient, fear and anxiety are common. But stroke survivors are also likely to experience feelings of helplessness, frustration, irritability, and emotional lability. Identifying and treating these problems can improve a patient's chances for a successful outcome following rehabilitation.
Last, but not least, the poststroke evaluation must include a review of family and community resources. Age, income, the family's level of commitment in caring for the patient, and cultural beliefs and norms are just a few of the contextual factors to consider during discharge planning.
Experts emphasize that when possible, screening should be systematically performed using well-validated, standardized measures. Recently, the American Heart Association (AHA) developed the AHA Stroke Outcome Classification (SOC) score.8 This approach to stroke assessment classifies the severity and extent of neurologic impairments that define the disability. It also identifies the level of independence of stroke patients according to basic and more complex activities of daily living at home and in the community. Although the AHA SOC provides a comprehensive way to document stroke impairments and disabilities in a single summary stroke score, this tool is designed to be used as a complement to, rather than as a replacement for, other standardized instruments.
Stroke patients are at increased risk for recurrent stroke and venous thromboembolism. Efforts to prevent recurrent stroke should focus on modifiable risk factors. For example, aspirin and ticlopidine (Ticlid) have been shown to reduce the likelihood of stroke in patients with transient ischemic attacks (TIAs) or a minor stroke. According to one recent study, although aspirin is associated with a significant increase in the risk of hemorrhagic stroke, its overall benefit almost certainly overcomes this potential risk in patients who have already experienced a stroke.9
Anticoagulation with warfarin has been shown to reduce future cardioembolic events and mortality in patients with nonvalvular atrial fibrillation (AF). Interestingly, recent findings from the Copenhagen Stroke Study, which show that stroke recurrence is more frequently associated with a history of TIA, AF, male gender, and hypertension, also show that only 12% of patients with AF receive anticoagulant treatment before recurrence.10 Other means of reducing the risk of recurrent stroke include surgical treatment of cerebral aneurysms after subarachnoid hemorrhage and carotid endarterectomy in patients with minor acute ischemic stroke or TIA.
Management strategies to reduce the risk of venous thromboembolism include early mobilization, elastic stockings, intermittent pneumatic compression, and if there are no contraindications, prophylaxis with low-dose heparin, low molecular weight heparin, or warfarin.
Thorough assessment and documentation during the acute phase of stroke will provide you with a good basis for determining whether a patient could benefit from rehabilitation. The available evidence suggests that candidates who are likely to do well fall in the middle group of stroke survivors -- those with moderate to severe impairment that often prohibits them from returning home. These patients are still able to learn and to follow both simple and complex commands and to withstand the rigors of an intensive program. They are also more likely to be continent of urine and to have mild or moderate initial functional, motor, cognitive, and visuospatial deficits. Stroke-related major depression is not common in this group of patients.
While these and other predictors of functional recovery are useful starting points for determining prognosis, they should not be relied upon as criteria for admission to a rehabilitation program. Experts agree that the best method of selecting candidates consists of a thorough, systematized, standardized assessment. The AHCPR guidelines note, however, that patients with a number of indicators of a poor prognosis should be evaluated carefully before being referred to a rehabilitation program.
For those who are selected as candidates, it's important to identify the specific problems needing treatment to determine if an inpatient program is required-or if individual services can be provided at home or on an outpatient basis. Patients who need services can be treated in an inpatient or outpatient program, nursing facility, or at home (see "What's in a name?"). Experts emphasize the importance of selecting the setting that best meets a patient's individual needs. Some stroke experts recommend a 2- to 4-day trial of a comprehensive rehabilitation program during the acute hospitalization. Such a trial, performed under the supervision of a physiatrist or neurologist with experience in stroke rehabilitation, may help gauge the patient's suitability for a particular program.
Not to be overlooked in the decision-making process are family members' concerns and preferences. The geographic location of a facility may be an important factor. Many families will seriously consider the level of medical care provided for the patient. Still others might look for physicians with expertise in stroke rehabilitation.
The Impact of Setting on Outcome
Most stroke rehabilitation experts believe that any patient who can withstand 3 hours a day of therapy should be enrolled in a program that offers intensive therapy. For some of those patients, however subacute care may be the only option available because of insurance constraints. Cost may also come into play when a patient who is a good candidate for outpatient therapy is required to go to a subacute facility, since the expense of outpatient therapy may be greater when services are provided in the home. The bottom line, say the experts, is that you may have to fight to get some patients into the rehabilitation program that best meets their needs.
What impact does setting have on outcome? Experts note that evaluating relative effectiveness is challenging since, for the most part, patients admitted to one setting are not equivalent to those admitted to another. While good data exist showing potential outcomes after inpatient rehabilitation, it's difficult to determine whether the same patients do equally well in different settings.
Clarifying data are becoming available, however. One recent study found that rehabilitation facilities produced the best overall outcomes for stroke patients, even after adjusting for possible selection biases.11 Subacute skilled nursing facilities, when enhanced by more home health care and physician follow-up, produced better outcomes than traditional skilled Pursing facilities.
Services provided to stroke patients who were admitted to rehabilitation facilities included recreational therapy, psychological services, and physiatry; these services are rarely provided in skilled nursing facilities. Patients in rehabilitation facilities also received more visits from attending physicians and physical, occupational, and speech therapists.
Improved outcome has a higher price tag, though. The average total Medicare cost for stroke patients during the 6 months after admission to a rehabilitation facility was $23,133, compared to $15,522 for enhanced skilled nursing facility care and $11,699 for care in a traditional skilled nursing setting. The authors note that their findings are consistent with previous reports showing improved functional outcomes among patients admitted for more comprehensive and intensive rehabilitation programs for stroke.
This study and others show a trend toward better outcomes with acute care programs.12,13 But it is important to examine each program on its own merits. Some subacute rehabilitation programs are becoming more competitive and now offer intensive comprehensive rehabilitation services.
Accreditation may provide some degree of assurance that the facility meets certain basic standards. For comprehensive, integrated, inpatient rehabilitation programs, the accrediting body is the Commission on Acute Rehabilitation Facilities (CARF). Unfortunately, there is no equivalent certification for less comprehensive programs or those offered on an outpatient basis. Because subacute care encompasses tremendous variability in the quality and intensity of services provided, it's important to look for several key factors:
Experts note that if it is not possible to have either a board-certified physiatrist or a neurologist with a background in rehabilitation as the team leader, the consulting physician should have these skills. Individualized, one-on-one treatment, a continued focus on preventing recurrent stroke, and ongoing family education and involvement are also important components of a good rehabilitation program.
Continuum of Care
Managed care pressures sometimes force the premature discharge of patients from a rehabilitation program. Lengths of stay have been dramatically reduced in recent years. If a patient is in an acute program, transfer to a subacute program may be an important option. Some rehabilitation hospitals offer outpatient and home-based programs. The goal is to create a seamless continuum of care at time of discharge.
Stroke rehabilitation experts recommend that patients see the primary care provider within 2 weeks of discharge. The provider should obtain a discharge summary, which includes useful baseline information that can be used to monitor changes in the patient's medical condition. Areas of particular concern include:
Physicians should also monitor any other changes in medical care that may have been instituted while the patient was hospitalized. For example, has the patient been started on anticoagulants or some other medication that requires close monitoring? It is also important to reinforce new behaviors learned during rehabilitation. Many patients have learned to become active participants in their own care and should be encouraged to continue in this role.
Primary care physicians are also instrumental in providing medical care and support to the families of stroke survivors. Adverse effects on the health of caregivers are well-documented, and by asking the caregiver about stress, you can identify problems and help provide appropriate interventions (see "Resources,").
1. National Stroke Association. Recovery and rehab. Web site: http://www.stroke.org/NS804.
2. American Heart Association. Stroke (Brain attack.). Web site: http://www. amhrt.ort/Scientific/HSstats98/05stroke.html.
3. American Heart Association. Economic cost of cardiovascular diseases. Web site: http://www.amhrt.org/Scientific/HSstats98/10econom.html/
4. Stroke Unit Trialists' Collaboration. How do stroke units improve patient outcomes? A collaborative systematic review of the randomized trials. Stroke. 1997;28:2139-2144.
5. Indredavik B, Bakke F, Slordahl SA, et al. Stroke unit treatment improves long-term quality of life: a randomized controlled trial. Stroke. 1998;29:895-899.
6. Indredavik B, Slordahl SA, Bakke F, et al. Stroke unit treatment: long-term effects. Stroke. 1997;28:1861-1866.
7. Gresham GE, Duncan PW, Stason WB, et al. Clinical Practice Guideline Number 16: Post-Stroke Rehabilitation, Assessment, Referral, and Patient Management. Rockville, Md: US Department of Health and Human Services. Public Health Service, Agency for Health Care Policy and Research; 1995. AHCPR publication 95-0663.
8. Kelly-Hayes M, Robertson JT, Broderick JP, et al. The American Heart Association Stroke Outcome Classification: executive summary. Circulation. 1996;97:2474-2478.
9. He J, Whelton PK, Vu B, et al. Aspirin and risk of hemorrhagic stroke: a meta-analysis of randomized controlled trials. JAMA. 1998;280:1930-1935.
10. Jorgensen HS, Nakayama H, Reith J, et al. Stroke recurrence: predictors, severity, and prognosis. The Copenhagen Stroke Study. Neurology. 1997;48:891-895.
11. Kramer AM, Steiner JF, Schlenker RE, et al. Outcomes and costs after hip fracture and stroke: a comparison of rehabilitation settings. JAMA. 1997;277: 396-404.
12. Kane RL, Chen Q, Blewett, LA, et al. Do rehabilitative nursing homes improve the outcomes of care? J Am Geriatr Soc. 1996;44:545-554.
13. Kane RL, Chen Q, Finch M, et al. Functional outcomes of posthospital care for stroke and hip fracture patients under Medicare. J Am Geriatr Soc. 1998; 46:1526-1533.
What's in a Name?
Rehabilitation programs go by various names that don't necessarily clarify their function or usefulness to specific patients. Stroke rehabilitation programs are commonly classified as acute, subacute, and inpatient.
Acute rehabilitation programs meet the Medicare 3-hour rule. These programs provide intensive, multidisciplinary rehabilitation services for a minimum of 3-hours per day 5 days per week. Generally, the intensive rehabilitation is divided among 2 or 3 different disciplines: physical therapy, occupational therapy, and speech therapy.
Subacute rehabilitation programs usually offer rehabilitation services on a much lower intensify. Therapy may be as infrequent as a single, 1-hour session per day or as frequent as 3 times a day for 2 to 3 days a week. Medical monitoring may or may not be available, but nursing care is provided. Physical therapy, speech, and occupational therapy may be provided as needed.
Acute and subacute programs can be offered in full-service acute care hospitals, freestanding rehabilitation hospitals, or in a rehabilitation unit of an acute care hospital. Nursing facilities may also offer rehabilitation services, but these services vary greatly. In most instances, subacute rehabilitation is conducted in nonmedical facilities such as a skilled nursing facility.
Inpatient services refer to programs in which the patient resides at the facility during treatment. That setting can be an acute care hospital, a rehabilitation hospital, or a nursing facility. Outpatient services may be provided in a freestanding facility or an acute care or rehabilitation hospital.
A federal agency that sponsors older-American volunteer programs such as the Senior Companion Program.
National Association of Area Agencies on Aging
Provides community services for people aged 60 and older. Services provided include homemaker services, Meals on Wheels, transportation, senior center activities.
Stroke Connection of the American Stroke Association,
a division of the American Heart Association
Provides educational books, pamphlets, videos about stroke for stroke survivors and caregivers. Publishes Stroke Connection Magazine. Provides referrals to local stroke clubs and self-help groups.
National Aphasia Association
Offers educational books and pamphlets about aphasia and provides referrals to community services.
National Stroke Association
Promotes stroke prevention, treatment, rehabilitation, family support and research. Offers educational materials for stroke patients and their families. Provides training programs about stroke for health care professionals. Publishes Be Stroke Smart, a newsletter for survivors and their caregivers.
Common Neurologic Deficits Following Stroke
MARK N. OZER, M.D., is Clinical Professor of Neurology, Georgetown University School of Medicine; and Director, Program for Clinical Excellence, National Rehabilitation Hospital, Washington, DC.
ELLIOT ROTH, M.D., is The Paul B. Magnuson Professor and Chairman, Department of Physical Medicine and Rehabilitation, Northwestern University Medical School, Chicago, IL; and Medical Director, Rehabilitation Institute of Chicago.
MARK A. YOUNG, M.D., is Associate Chairman, Department of Physical Medicine and Rehabilitation, The New Children's Hospital and Bennett Institute for Sports Medicine and Rehabilitation; Assistant Professor, Physical Medicine and Rehabilitation Training Program, Sinai Hospital of Baltimore, The Johns Hopkins University School of Medicine; and Codirector, Department of Physical Medicine and Rehabilitation, Maryland Rehabilitation Center, Baltimore.
Patient Care. April 15, 1999