Transcript REHABILITATION OF THE STROKE SURVIVOR

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
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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
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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
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Venous Thromboembolism
Pneumonia
Dysphagia
Ventilatory Dysfunction
Cardiac Disease
Seizure
Central Post-Stroke Pain Syndrome
Spasticity
Medical Complications of Stroke
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Bladder Dysfunction
Bowel Dysfunction
Pressure Ulcers
Malnutrition and Dehydration
Depression
Falls and Injuries
Shoulder Pain and Dysfunction
Medical Complications of Stroke
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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
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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:
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Graded Levels of Task Difficulty
Opportunities for Repetition of Skill
Performance
Professional Supervision and Feedback
“Protected Practice”
Principles of Stroke Rehabilitation
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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
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Functional Skills Training
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Personal Care Skills
Mobility Activities
Instrumental Activities of Daily Living
Stroke Rehabilitation Interventions
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Therapeutic Exercises
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Flexibility
Strength
Coordination
Fitness
Stroke Rehabilitation Interventions
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Spasticity Management:
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Positioning and Orthotics
Stretching and Other Exercises
Medications
Injections
Surgical Release
Stroke Rehabilitation Interventions
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Aphasia Treatment:
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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:
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Professional Counseling and Psychotherapy
Peer Relationships and Family Involvement
Medications
Stroke Rehabilitation Interventions
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Patient Education
Family and Caregiver Education
Behavioral Techniques
Supportive Counseling
Recruit Community Resources
Other Quality of Life Issues
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Sexuality
Spirituality
Driving
Employment
Education
Recreation
Family Involvement
New Rehabilitation Interventions
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Partial Body Weight-Supported Treadmill
Training
Pedaling
Biofeedback
Electrical Stimulation
Constraint-Induced Muscle Training
Robotic-Assisted Therapeutic Exercise
Stroke Rehabilitation Outcomes
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80% Independent Mobility
70% Independent Personal Care
40% Outside Home
30% Work
Factors Affecting Outcomes
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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 wellorganized interdisciplinary teams…”
-Great Britain Dept. of Health 1992