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Stroke1
This document outlines the PM&R approach to stroke rehabilitation. It discusses the goals of stroke rehabilitation which include restoring maximum function and independence. It also emphasizes the importance of a multidisciplinary team approach involving various medical specialists. The rehabilitation process involves several phases from the acute hospitalization, to post-acute care in various settings, to managing long-term outcomes and improving quality of life. Key factors that can influence outcomes include early initiation of rehabilitation, treatment in an interdisciplinary setting, and in-depth assessment throughout the rehabilitation process.
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Stroke1
- 1. PM&R Approach to StrokeRehabilitation A Treatment Plan for Optimum Patient Recovery
- 2. Stroke Improve effectiveness ofstroke rehabilitation –identify, assess, treat –roles of PCP, PM&R, & other specialists Provide information and resources on standardized treatment Goals of Presentation
- 3.
- 4. Stroke Stroke Statistics 600,000 strokesyearly in U.S. Third leading cause of death in U.S. –150,000+ stroke deaths annually –17%-34% mortality in first 30 days
- 5. Stroke Leading cause ofadult disability –4.4M stroke survivors with disablements –25%-50% partially/totally dependent in ADL Costs $45.3 billion/year in care and lost earnings Stroke Statistics
- 6. Stroke A cerebrovascular event Focalor global disturbances of cerebral function 14+ hours duration or death Vascular in origin Definition of Stroke
- 7. Stroke Organ dysfunction (impairment) Difficultywith tasks (disability) Social disadvantage (handicap) Definition of Disablement
- 8.
- 9. Stroke Restore patient tomaximum mobilization Help patient regain functional independence and confidence Provide measures to prevent falls and ensure safety Educate patient and family about secondary prevention Facilitate psychosocial adjustment Goals of the Physical Medicine & Rehabilitation Specialist
- 10. Stroke Early treatment isessential for maximal recovery <3-hr window for TPA 3-6 hr window for thrombolytic therapy Only 40% reach hospital in 24 hrs Patients most likely to benefit are least likely to arrive in time Important Facts About Diagnosis & Treatment
- 11. Stroke 40% of olderAmericans do not know stroke occurs in brain 91% do not know sudden blurred/decreased vision is symptom 85% do not know loss of balance/ coordination is symptom Poor Public Awareness of Stroke
- 12. Stroke Only 40% wouldcall 911 if experiencing symptoms 67% are unaware of brief therapeutic window for effective treatment Poor Public Awareness of Stroke
- 13.
- 14. Stroke Medical specialties –PM&R –familypractice –geriatrics –neurology –internal medicine –psychiatry Interdisciplinary Care
- 15. Stroke Allied healthteam members –rehab nurses –psychologists –OTs –recreational therapists –PTs –speech pathologists –medical social services personnel Interdisciplinary Care
- 16. Stroke Standardized protocols –repeatedclinical examinations –full & consistent documentation throughout Patient Assessment
- 17. Stroke Assessment targets –neurologicimpairments –medical problems –disabilities –living conditions and community reintegration Patient Assessment
- 18. Stroke Multiple care settingsduring recovery Patient and family must: –be fully informed & participate in decisions –participate actively in rehabilitation Continuity of Care and Family Involvement
- 19.
- 20. Stroke Where: setting thathas coordinated services By whom: –acute care physician –rehabilitation consultants (PM&R physicians) –nursing staff Clinical Evaluation
- 21. Stroke For what purposes: –determineetiology, pathology, & severity –assess comorbidities –document clinical course When: admission & during acute hospitalization Clinical Evaluation
- 22. Stroke Within 12-24 hours,if possible Daily active/passive ROM exercises Progressively increased activity Changes of position in bed –pullsheet method –limb positioning & support Encouragement to resume self-care & socialization Mobilization
- 23. Stroke Carotid endarterectomy inpatients 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). Measures to Prevent Recurrent Stroke
- 24. Stroke Heparin –low molecular weight(LMWH), or –low-dose unfractionated (LDUH) Other effective measures –intermittent pneumatic compression –elastic stockings Preventing Deep Venous Thrombosis (DVT)
- 25. Stroke Goals –prevent dehydrationand malnutrition –prevent aspiration and pneumonia –restore ability to chew and swallow safely Management of Dysphagia
- 26. Stroke Compensatory treatments –changesin posture for swallowing –learning new swallowing maneuvers –changes in food texture and bolus size Management of Dysphagia
- 27. Stroke Fallback measures –parenteralor tube feeding –gastrostomy for long-term tube feeding Management of Dysphagia
- 28. Stroke Daily inspection Routine cleansing Protectionfrom moisture Frequent position changes Maintenance of adequate hydration/nutrition Individual mobility-improvement measures Maintaining Skin Integrity
- 29. Stroke Timed voiding Clean intermittentcatheterization Indwelling catheter as last resort Managing Bowel/Bladder Function
- 30. Stroke At-admission and periodicrisk assessment High-risk factors –visual neglect –slowness in performing tasks –impulsive movements –older age –history of falls –multiple transfer situations Preventing Falls
- 31.
- 32. Stroke Identify patients whowill benefit Identify problems needing treatment Determine appropriate rehabilitation setting as soon as patient is medically stable Screening for Rehabilitation & Setting
- 33. Stroke Severe functional/motor/cognitive deficits Persistenturinary/fecal incontinence Severe visual/spatial deficits Sitting imbalance Severe aphasia Patient Characteristics Suggestive of Poor Rehabilitation Outcomes
- 34. Stroke Altered level ofconsciousness Major depression Severe comorbidities Disability before stroke Older age Patient Characteristics Suggestive of Poor Rehabilitation Outcomes
- 35. Stroke Medically/moderately stable One ormore persistent disabilities Able to learn Physical endurance sufficient to: –sit at least 1 hour per day –participate in rehabilitation Threshold Criteria for Admission to a Rehabilitation Program
- 36. Stroke Disabilities intwo or more of the following –mobility –swallowing –pain management –caognition Criteria for Admission to an Interdisciplinary Rehabilitation Program –bowel/bladder control –communication –performance of ADL –emotional function
- 37. Stroke Both short- andlong-term Realistic Agreed upon by all parties Specific about roles, tasks, and activities Setting Rehabilitation Goals
- 38. Stroke The managementplan should identify –significant impairments and disabilities –measures to prevent recurrence –treatments for comorbidities –rehabilitation interventions –plans for periodic monitoring Developing a Management Plan
- 39. Stroke POST-ACUTE MANAGEMENT OF SPECIFICCONDITIONS
- 40. Stroke 1. Remediation/facilitation to enhancemotor recovery 2. Compensatory training to improve function 3. Adaptive devices/orthotics Managing Sensorimotor Deficits and Impaired Mobility
- 41. Stroke Cognitive/perceptual problemsrequire –goal-directed treatment plans –retraining –substitution of intact abilities –compensatory approaches Managing Cognitive and Perceptual Deficits
- 42. Stroke Symptoms and history –diminishedinterest in activities –loss of energy/appetite/concentration –sleep disturbances/agitation –feelings of worthlessness/suicidal thoughts –history/observed behavior changes Diagnosing Depression
- 43. Stroke Causes to ruleout –medications, e.g., sedatives –environmental factors Confirming diagnosis: clinical interview by mental health professional Diagnosing Depression
- 44. Stroke Mild depression –attention/encouragement, therapeutic activities –simpleenvironmental changes More severe depression –antidepressant medications –psychotherapy Treating Depression
- 45. Stroke Aphasia –language retrieval –improvedcomprehension Dysarthria/apraxia of speech –reinstate normal intelligibility –assistive devices Treating Speech/Language Disorders
- 46. Stroke Issues forpediatric patients –school re-entry –self-esteem Issues for younger adults –vocational considerations –child care –sexual relations Physiatrist’s Spectrum of Care
- 47. Stroke Issues forolder adults –aging –sexual relations –self care; inability to remain at home Physiatrist’s Spectrum of Care
- 48.
- 49. Stroke Increased functional skillson admission to rehabilitation Early initiation of rehabilitation services Rehabilitation in an interdisciplinary versus a multidisciplinary setting Factors Related to Improved Functional Outcome
- 50. Stroke Proprioceptive facilitation (tapping) response> 9 days Traction response (of shoulder flexors/adductors) > 13 days Prolonged flaccid period Poor Prognostic Indicators
- 51. Stroke Onset of motion> 2-4 weeks Severe proximal spasticity Absence of voluntary hand movement > 4-6 weeks Poor Prognostic Indicators
- 52. Stroke Unilateral spatial neglector hemineglect Abnormal illness behavior (AIB) Depression Poor Prognostic Indicators
- 53. Stroke Higher scoresfor –attention –calculations –judgment Better performance in –comprehension –short-term verbal memory –abstract thinking Cognitive/Psychological Factors Associated with Better Outcomes
- 54. Stroke Normalized health patterns Freedomfrom physical pain/emotional distress/impairments Retention of cognitive/communicative abilities Mobility and independence in ADL IMPROVED QUALITY OF LIFE Measures of Successful Rehabilitation
- 55. Stroke In-depth assessment atall phases Appropriate patient selection Early introduction to rehabilitation Teamwork approach in multidisciplinary setting Shared goals and management plan Detailed, shared record keeping Summary: Requirements for Successful Rehabilitation
- 56.
Editor's Notes
- #2 Stroke can be devastating to patients and their families. Rehabilitation is often a long, hard road with many frustrations along the way for all concerned. Because there are so many physical, mental, and emotional ramifications, optimum stroke rehabilitation depends upon interdisciplinary teamwork, where specialists contribute what they do best to complement the overall care provided by the primary care physician. Preface The AAPM&R PM&R Approach to Stroke Rehabilitation slide presentation is provided as an educational service to assist physiatrists, particularly members of the American Academy of Physical Medicine and Rehabilitation, in marketing their services to primary care physicians and other referral sources. This presentation is one of the many products developed as part of the PM&R Awareness Initiative – a multi‑year marketing and communications program addressing key audiences including: AAPM&R members, employers, primary care physicians, managed care organizations and insurers, allied health professionals, and the public. A key component of this plan is the creation of tools and resources that AAPM&R members can use to supplement marketing activities conducted at the national level. The AAPM&R PM&R Approach to Stroke Rehabilitation slide presentation is one of the tools developed specifically to help physiatrists demonstrate their ability to provide high quality specialty care to primary care physicians and other professional sources of referral. In addition to a brief overview of the PM&R specialty, the presentation illustrates the value of PM&R physicians’ approach to stroke rehabilitation. It includes case studies and examples that can be easily adapted to reflect your own practice. The Academy welcomes your feedback on the utility of this product as well as suggestions or ideas for future updates to this presentation or additional products and services that would be useful to practicing PM&R physicians. Please direct comments and suggestions to the national office. The Academy acknowledges Drs. Stephen F. Noll and Richard D. Zorowitz for their assistance in developing and reviewing content for this presentation. The Academy also acknowledges the assistance of the AAPM&R Marketing Committee in developing this program. Members of the AAPM&R Marketing Committee include: Kristjan T. Ragnarsson, MD, Chair Kurtis M. Hoppe, MD David L. Bagnall, MD, PASSOR Representative Austin I. Nobunaga, MD D. Nathan Cope, MD Ross D. Zafonte, DO (ex‑officio) Brian D. Greenwald, MD Robert D. Rondinelli, MD, PhD Stacey L. Harris, MD, RPC Representative Claire V. Wolfe, MD, BOG Liaison Steven L. Hendler, MD Thanks are also due to members of the Academy national office staff for overall management of the project and design, editing and production of this slide presentation. American Academy of Physical Medicine and Rehabilitation One IBM Plaza, Suite 2500, Chicago, IL 60611‑3604 phone: (312) 464‑9700 fax: (312) 464-0227 e-mail: info@aapmr.org http://www.aapmr.org 2000 American Academy of Physical Medicine and Rehabilitation All rights reserved. The AAPM&R PM&R Approach to Stroke Rehabilitation slide presentation is owned and copyrighted by the American Academy of Physical Medicine and Rehabilitation. The PM&R Approach to Stroke Rehabilitation slide presentation cannot be licensed, sold, or distributed to another purchaser without the express written permission of the American Academy of Physical Medicine and Rehabilitation. Information in this presentation does not represent official policy of the American Academy of Physical Medicine and Rehabilitation unless specifically stated. The purpose of this presentation is to provide information for education and communication purposes only. The information contained herein is meant to be a helpful resource for AAPM&R members, referring physicians, healthcare professionals, and the public; AAPM&R does not guarantee and thus accepts no liability relative to the content, accuracy, or use of the content of this presentation. The information in this presentation should not be considered complete, nor should it be relied on to suggest a course of treatment for a particular individual. It should not be used as a substitute for a visit, call, consultation or the advice of a physician or other qualified health care provider. The information contained in this presentation was compiled from a variety of sources, and while every effort has been made to ensure its accuracy, it is intended only as a guide and is not a substitute for specific medical opinion.
- #3 Today I’d like to share with you some of the ways in which Physical Medicine and Rehabilitation specialists--physiatrists--can contribute to the treatment plan along with other specialists to provide the standardized care that is so important to successful rehabilitation. Specifically, I’ll be discussing methods of identifying, assessing and treating disabilities due to stroke; describing roles of primary care physicians, physiatrists and other medical specialists; and giving you some information and resources on standardized treatment of stroke-related disabilities.
- #4 Let’s start with a little background information so we can see the scope of the stroke problem.
- #5 600,000 strokes occur yearly in the U.S. Of those, more than 150,000 result in death, with 17%-34% mortality in first 30 days, and 25% to 40% within one year. Stroke is the thirdleading cause of death in our country. Only heart disease and cancer kill more people than stroke.
- #6 Many of those who do survive a stroke will be left with varying degrees of disablements. There are an estimated three million stroke survivors in the U.S. today with disablements. In fact, up to half of stroke survivors are at least somewhat dependent in their activities of daily living. And stroke has a huge financial impact: annual direct medical costs alone were $29.5 billion in 1999, according to the American Stroke Association, a division of the American Heart Association. The annual cost of care and lost earnings has reached a staggering $45.3 billion a year.
- #7 We all know what a stroke is, but I thought we should have a standardized definition in mind as we talk today. This one is from the World Health Organization: “Stroke is a cerebrovascular event with rapidly developing clinical signs of focal or global disturbances of cerebral function, with signs lasting 14 hours or longer or leading to death, with no apparent cause other than of vascular origin.” This definition includes subarachnoid hemorrhage, but it excludes transient ischemic attack and hemorrhage or infarction related to infection or tumor. Impairments and disabilities are similar regardless of stroke etiology.
- #8 Some use the term “disablement” to span the gamut of problems a stroke survivor may have. We can conceptualize disablement in terms of impairment, disability, and handicap. These designations are somewhat arbitrary, but they provide common definitions that all members of the team can use.
- #9 Stroke rehabilitation is a restorative learning process that seeks to hasten and maximize recovery by treating disabilities and handicaps caused by stroke, and preparing the stroke survivor to reintegrate into community life. This is a multi-faceted process that includes working with physical, mental, and emotional problems. Elements of stroke rehabilitation are: 1. Prevention of secondary complications. 2. Remediation or treatment to reduce the effects of neurologic impairment. 3. Compensatory techniques to offset or adapt to residual disabilities/ handicaps. 4. Maintenance of long-term function. 5. Reintegration into community and/or work.
- #10 As rehabilitation professionals, our goal is to restore the patient to as normal a lifestyle as his or her condition permits. Helping patients regain functional independence and confidence is a top priority. Sometimes we can accomplish this with treatment alone, but in other cases, patients will require environmental modifications or adaptive devices to ensure their safety. Falls are a particular concern. Not only the patient, but also the family, may have to adapt to changes in lifestyle. We address all these issues as we work through the rehabilitation process.
- #11 I can’t stress enough the importance of your patients knowing the signs and symptoms of stroke. Thrombolysis may be successful if patients arrive in the hospital within the therapeutic window of three to six hours, but many times patients are not aware that they have had a stroke. This is particularly true of those with mild symptoms. If you haven’t already, I urge you to talk with your patients about stroke. Let me know how vital it is that they get medical help immediately if they even suspect stroke. Patients most likely to benefit - those with mild symptoms - are least likely to arrive in time for thrombolysis.
- #12 These are Gallup Poll results that underscore how uninformed most people are about stroke. As you can see from these statistics, the vast majority can’t identify stroke symptoms. (Read statistics on slides 11 and 12.)
- #13 Given that, it’s probably not surprising that less than half the population would consider one or more stroke symptoms an emergency. And, unfortunately, most people are unaware of the benefits of immediate treatment. We physicians have a big educational job on our hands, but it’s a really important one if we are to make inroads into the death and disability statistics.
- #14 Now that we’ve seen the statistics, let’s talk about some basic principles of rehabilitation.
- #15 Treatment by an interdisciplinary team is important to achieve the most favorable outcomes. These are the specialties that are most commonly involved – PM&R, family practice, geriatrics, neurology, internal medicine, and psychiatry.
- #16 Allied health team members may include rehabilitation nurses, occupational therapists, physical therapists, psychologists, recreational therapists, speech pathologists, and medical social services personnel. Of course, not all these people will be involved in every case. In addition to those listed, inclusion of a dietitian, rehab engineer, orthotist, vocational rehab specialist, music therapist, art therapist, and/or a chaplain or minister might be appropriate. And the patient and family are, of course, central team members.
- #17 Initial assessment should include the rehabilitation specialist with the other members called in on the basis of the assessment. Standardized protocols should be used in all clinical examinations. Through documentation is also vital throughout rehabilitation if everyone is to work together efficiently.
- #18 The patient’s assessment starts with an evaluation of neurologic impairments, including sensory and motor. Medical problems that the patient had prior to the stroke should be assessed for their impact on treatment and care. Disabilities – physical, emotional, cognitive, or speech/language – may limit rehabilitation options as well. Assessment targets should be secure to include the patient’s environment. Are the home and living conditions a help or a hindrance? What about the work environment? How does the family function together? What kind of community support is available? All these pieces fit together to form a total assessment.
- #19 Just as though documentation and frequent assessment are important to keep all members of the team on the same page, it is equally important that continuity of care be maintained through what may be a multiplicity of settings. The patient may progress from acute hospital care to an inpatient stay in a continuing care facility, to home or outpatient rehabilitation programs, and/or to follow-up visits at your office. As the patient moves through various phases of rehabilitation, he or she, along with the family, should participate in developing goals, choosing interventions and rehabilitation or residence settings. If the patient and family are informed, actively involved, and enthusiastically behind the goals and decisions, rehabilitation is much more likely to be effective.
- #20 Now let’s talk about some principles and practices of rehabilitation that come into play during acute hospitalization. By this we mean prior to transfer to an acute rehabilitation setting.
- #21 Ideally, the patient can be assessed in a setting that provides coordinated diagnostic, acute management, preventive, and rehabilitative services. Evaluators should include the acute care physician, a rehabilitation specialist, such as a PM&R physician, and members of the nursing staff.
- #22 The purpose of the clinical evaluation is to determine etiology, pathology, and severity, assess comorbidities, and document the clinical course of action. In addition to the initial evaluation at the time of admission, the patient should be reassessed throughout his or her hospital stay. Rehabilitative treatment should begin as soon as the patient can medically tolerate it.
- #23 Early mobilization – 12-24 hours, if possible – and return to self-care is highly desirable not only for the patient’s physical well being, but also for his or her psychological and mental state. Progressively increasing active and passive range of motion exercises should be started as soon as possible. For the immobile patient, changes of positioning in bed are important. They should be made in a physiologically sound manner, using a pullsheet rather than lifting the patient under the arms.
- #24 As you well know, patients who have had one stroke are at risk for having another. Measures to prevent recurrence are specific to each patient’s unique condition, and should be based on accurate determination of stroke etiology. These are commonly used measures to prevent the recurrence of strokes: (Read slide).
- #25 Deep venous thrombosis is also a threat in stroke patients. In addition to low molecular weight or low-dose unfractioned heparin, intermittent pneumatic compression and the use of elastic stockings can be effective measures to prevent DVT.
- #26 Many stroke patients have difficulty in swallowing – dysphagia. This is frightening to the patient, and it can result in malnutrition and dehydration if the patient is afraid to eat or drink. It is important to have a high index of suspicion, especially if the patient has dysarthria or “wet” vocal quality. A bedside swallowing evaluation or videofluorographic swallowing study can be used to assess function. Goals in the management of dysphagia are to: prevent dehydration and malnutrition; prevent aspiration and pneumonia; and, restore ability to chew and swallow safely.
- #27 Posture changes and new swallowing techniques may help. Thickening liquids may forestall choking. Many patients are able to manage pureed or semisolid food. Changing the size of the bolus is another strategy.
- #28 If all else fails, the physician will have to resort to parenteral or tube feeding. For long-term tube feeding, gastrostomy is preferable to a nasogastric tube, as this route may decrease problems associated with gastroesophageal reflux.
- #29 Daily systematic skin inspection and a gentle cleansing routine are basic to good skin care. Comatose, obese, or severely paralyzed patients are at high risk for pressure sores. Areas of bony prominence are particularly vulnerable to breaking down, so proper positioning and transfer techniques are imperative. The key to pressure sore prevention is pressure relief by frequent position changes. Barrier sprays and lubricants may help, as may special mattresses. Patients should also be protected from excess moisture, such as perspiration and urine. Orthotics, protective dressings, splints, and padding can lessen friction and excessive pressure. Keeping the patient hydrated and well-nourished also helps maintain skin integrity. Your consulting PM&R physician can suggest techniques that are appropriate in individual cases. Ideally, we want the patient to become more mobile to avoid the problem.
- #30 Bladder or bowel incontinence and muscle spasticity are risk factors, too. For some patients, timed voiding may be adequate, but clean intermittent catheterization is typically the method of choice. Timed voiding can enhance elimination and decrease incontinence between stooling. Because of the risk of infection and other complications, indwelling catheterization should be reserved for only those patients who cannot be managed otherwise. Early removal is the goal in these cases.
- #31 As the patient becomes more mobile, physicians should caution patients and their families about the risk of falls. Patients should be assessed at hospital admission and throughout their stay for indications of increased risk. Telltale signs include vision problems, lack of concentration, unusual slowness in performing tasks, impulsive physical movements, advanced age, a history of falls, and confusion due to multiple transfer situations. Patients can sometimes fall out of bed in hospitals, so hospital personnel need to be alert to bed-rail positioning after performing tasks. Transfer situations need to be handled carefully too. We’ll talk later about preventing falls after the patient leaves the hospital.
- #32 Rehabilitation can – and should – begin during the acute phase of a stroke patient’s care, but the work begins in earnest when the acute phase is over.
- #33 Ideally, a rehabilitation consultant will be called in to evaluate the patient within the first 24 hours after admission. A Physical Medicine and Rehabilitation specialist can identify patients who will benefit, as well as identify specific problems needing treatment. I can’t stress enough how important it is to call in a PM&R specialist as soon as possible. In addition to being medically sound, early consultation also serves to relieve anxiety for patients and their families. They can begin to plan for the future if they have some idea what to expect.
- #34 Most individuals with a stroke will benefit from rehabilitation interventions. Unfortunately, there are no clinical trials to determine who is most likely to benefit from rehabilitation. Currently, observational studies provide the criteria. We can identify some patient characteristics that may suggest poorer rehabilitation outcomes: (Read slides 34 and 35).
- #35 Most individuals with a stroke will benefit from rehabilitation interventions. Unfortunately, there are no clinical trials to determine who is most likely to benefit from rehabilitation. Currently, observational studies provide the criteria. We can identify some patient characteristics that may suggest poorer rehabilitation outcomes: (Read slides 34 and 35). While these characteristics may hint at less than an ideal outcome, they do not rule out rehabilitation interventions. Although older age is on the list, judgement as to whether that is a factor is almost entirely relative to the individual patient. Some of these characteristics – altered level of consciousness, for example – are sufficient unto themselves to auger a poor outcome. Others, like incontinence, do not by themselves warrant giving up on rehabilitation.
- #36 These criteria were developed by AHCPR and are included in their Post-Stroke Rehabilitation Guidelines. Patients who do not meet these basic standards are not candidates for a rehabilitation program. The patient must be medically/moderately stable, have one or more persistent disabilities, be able to learn, and have enough endurance to sit supported at least one hour per day and participate actively in rehabilitation. It is important to note that these criteria are not absolute, and other rehabilitation alternatives exist beyond the acute inpatient setting.
- #37 Patients who have disabilities in two or more areas – mobility, pain management, bowel/bladder control, performance of ADL, swallowing, cognition, communication, or emotional function – need an interdisciplinary rehabilitation program that includes treatment by specialists and therapists from various disciplines.
- #38 Setting rehabilitation goals should be a joint effort between the patient and family and the rehabilitation team. Short-term goals are important to give the patient a sense of achievement and to forestall discouragement, but of course there will be a long-range plan too. It’s important not to let the patient set goals he or she can’t possibly achieve. The key is to focus on the positive things the patient can learn to accomplish.
- #39 A well-developed rehabilitation management plan is an excellent tool for ensuring optimal progress. The management plan should identify: significant impairments and disabilities; measures to prevent recurrent stroke and complications; treatments for comorbidities; and, rehabilitation interventions. Interventions should be specific as to sequence, intensity, frequency, and expected duration. All members of the rehabilitation team should have input into the management plan, and everyone should have a copy. Periodic monitoring and reevaluation are important to assess the patient’s progress. The patient and significant other are key players on the team and must be involved in determining plans. When the plan is being developed it’s a good idea to be sure that all team members have the same understanding of the terms used by other members of the team. Each specialty has its own jargon and shorthand, so it doesn’t hurt to check that everybody is on the same page.
- #40 Now I’d like to talk a little bit about the management of some specific conditions.
- #41 There are multiplae treatment modalities for sensorimotor impairments that are not mutually exclusive. Facilitation may involve alternately stretching and contracting specific groups of muscles, usually with the aid of a partner. Motor control methods are task-specific. An example might be partial-weight-support treadmill training to improve ambulation. Compensatory training aims to improve function rather than motor recovery. Patients learn new approaches to performing tasks. We prefer that the patient use the affected limb to avoid learned disuse of the impaired side. Adaptive or orthotic devices may be appropriate. They can serve to promote patient safety and to make performance easier if fatigue is a problem. So far there’s insufficient evidence that any specific technique is superior to regular physical therapy, and the same is true for other methods, such as biofeedback and functional electrical stimulation.
- #42 Patients with cognitive or perceptual problems may require customized goal-directed treatment plans, along with retraining, substitution of intact abilities for those impaired, and other compensatory approaches. Like all other treatments, cognitive remediation is best provided by an interdisciplinary approach.
- #43 Nobody is happy to have had a stroke; so obviously, some blue moments are to be expected. But stroke victims are at risk for real clinical depression. You should be on the alert of this problem. Depression is the most underdiagnosed and undertreated complication following stroke, and as your patient’s personal physician, you are in the best position to spot the symptoms. Remarks from family members that the patient cries a lot or seems perpetually despondent are clues that you should investigate. Clinical depression is a serious impediment to successful rehabilitation, so the sooner the patient gets treatment the better. Diagnosis can be difficult, depending on the patient’s condition. Also, it’s important to differentiate between organic and reactive depression. A mental health professional can confirm the diagnosis and consult with you on treatment. Symptoms and history may include: diminished interest in activities; loss of energy, appetite or concentration; sleep disturbances or agitation; feelings of worthlessness or suicidal thoughts; or other significant behavior changes.
- #44 Since medications can also contribute to many of these symptoms, it is important to rule them out as a contributing factor when diagnosing depression. Environmental factors should also be evaluated. As we mentioned, it may be necessary to have the patient interviewed by a mental health professional to determine whether clinical depression is truly present.
- #45 Patients with mild depression may improve with more staff and family attention and encouragement. Therapeutic activities can help too. If these measures don’t solve the problem, an antidepressant medication may be in order, but be aware that antidepressants often cause side effects in stroke patients. The current consensus favors the SSRIs. Many practitioners prescribe sertraline or paroxetine (Zoloft, Paxil), which have few side effects. Psychotherapy is another option.
- #46 Approximately 30-45% of stroke survivors experience speech and language disorders, and if your stroke patient has speech or language problems, you will probably want a speech pathologist on the rehabilitation team. There are specific goals for treating different disorders. For aphasia, the goals are language retrieval and improved comprehension. In patients with dysarthria and apraxia of speech, the goal is to reinstate normal intelligibility. A number of strategies and techniques have been developed to manage speech and language disorders with the underlying goal being to improve a patient’s ability to speak, understand, read, and write. Non-verbal communication and assistive devices can also be used to improve quality of life for patients who do not respond well to traditional speech therapy programs.
- #47 It goes without saying that the age of the stroke patient determines the types of issues that will confront him or her. Obviously children will be concerned about school and interactions with their peers. Younger adults will have job-related issues, concerns about resuming sexual relations, and possibly child-care problems.
- #48 Older adults – who have the majority of strokes – face the same problems of aging that everyone else does but with a bigger handicap. If they live alone, as many elderly people do, they may not be able to remain at home. The physiatrist on your rehabilitation team can help patients and their families deal with these age-related issues.
- #49 After rehabilitation, what can we – and the patient – expect?
- #50 Patients with only mild functional deficits and those who have already shown functional improvement before admission to rehabilitation have a favorable prognosis. The earlier rehabilitation begins, the more likely the patient is to have a good functional outcome. This is such an important issue because patients who begin rehabilitation as soon as it is medically feasible benefit greatly from the early start. We find also that an interdisciplinary setting offers the greatest likelihood of optimum recovery.
- #51 Unfortunately, not all stroke patients are candidates for rehabilitation. Patients whose functional responses have not returned within the time frames indicated on the slide have poor prognosis. (Read slides 58 and 59.)
- #52 The focus of rehabilitation may change in response to these poor signs. However, we should note that none of these indicators contraindicates a trial of rehabilitation.
- #53 On the cognitive and psychological side, patients with spatial neglect, abnormal illness behavior, and/or depression tend to do poorly. Treatment for depression improves the prognosis in some patients.
- #54 Patients who have good attention spans and are able to calculate and make judgements will likely do well. Comprehension is a key component of successful rehabilitation. If patients don’t understand what we’re trying to do, we have little to work with. Better memory is a good sign too, and we are very hopeful if patients are able to think abstractly.
- #55 Ideally, the patient would have no residual effects from the stroke whatsoever. While this is not possible for many patients, we can use the measures listed on the slide to gauge the success of our efforts. By “normalized health patterns,” we mean such things as bowel and bladder continence, regular sleep patterns, and good nutrition. Probably the bottom line for patients is their quality of life. If our patients complete rehabilitation with a zest of life, meaningful relationships with friends and family, activities they enjoy, and a good integration with the outside world, we feel we have really added quality to their lives.
- #56 In summary, there are many factors at work in successful stroke rehabilitation: (read slide). It is often a long and complex process. At the end of the road, many people will have contributed to a successful outcome. The heart of the team is the patient’s personal physician who knows the patient best, but we – Physical Medicine and Rehabilitation specialists – also have an important role to play. I hope that my presentation today has given you a little more insight into what we do and how we can work with you. As complementary members of a team, together we can offer stroke patients and their families hope that – with a united effort – their lives will improve. (Open for Q & A)
- #57 References 1998 Heart and Stroke Statistical Update. Dallas, Tex: American Heart Association; 1998. NHLBI. The Framingham Heart Study, 1948-1998. ISFC/WHO Task Force on Standardization of Clinical Nomenclature and Criteria for Diagnosis of Ischaemic Heart Disease. Nomenclature and criteria for diagnosis of ischaemic heart disease. Circulation 59(3):607-609, 1979. Rehabilitation of Persons WithTraumatic Brain Injury. NIH Consensus Statement 1998 Oct 26-28; 16(1):1-41. Roth EJ. Medical rehabilitation of the stroke patient. Be Stroke Smart 8:8, 1992. National Institute of Neurological Disorders and Stroke. Girolami P, Emr M. NIH Experts Say Few Eligible Stroke Patients Receive Treatments That Save Lives And Reduce Disability. NINDS Office of Communications and Public Liaison, 1999. National Guideline Clearinghouse. Post-stroke rehabilitation. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, AHCPR; 248 (Clinical practice guideline, no.16), May 1995. National Stroke Association/Gallup Survey on Stroke Awareness in the United States, 1996. North American Symptomatic Carotid Endarectomy Trial Collaborators. Beneficial effects of carotid endarectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med 325:445-453, 1991. Stroke Prevention in Atrial Fibrillation Investigators. Warfarin compared to aspirin for prevention of thromboembolism in atrial fibrillation. Stroke Prevention in Atrial Fibrillation II Study. Lancet 353:687-691, 1994. Odderson IR, Keaton JC, McKenna BS. Swallow management in patients on an acute stroke pathway: quality is cost effective. Arch Phys Med Rehabil 76(12):1130-1133, 1995. Novack TA, Haban G, Graham K, et al. Prediction of stroke rehabilitation outcome from psychologic screening. Arch Phys Med Rehabil 68(10):729-734, 1987. Paolucci S, Antonucci G, Gialloreti LE, et al. Predicting stroke inpatient rehabilitation outcome: the prominent role of neuropsychological disorders. Eur Neurol 36(6): 385-390, 1996. Clark MS, Smith DS. The effects of depression and abnormal illness behaviour on outcome following rehabilitation from stroke. Clin Rehabil 12(1): 73-80, 1998. AHCPR. Post-Stroke Rehabilitation, Clinical Guideline Number 16. AHCPR Publication No. 95-0062: May, 1995.