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Stroke Rehabilitation
Aaron Hauptman, MD
Jordan Eisenstock, MD
Robert A. Baldor, MD, FAAFP
image BASICS
DESCRIPTION
  • Stroke is a compromise in blood supply to an area of the nervous system, secondary to hemorrhage or occlusion, with resultant infarction of nervous tissue.
  • 3rd leading cause of death and the leading cause of long-term disability in the United States (1)
  • Rehabilitation refers to the process of restoring a debilitated person toward baseline functionality.
  • Specific rehabilitation techniques should be used depending on the individual and based on particular deficits and brain regions impacted.
  • Rehabilitation involves cycling through the following (2):
    • Assessment of patient with the goal of identification and quantification needs of the individual
    • Setting of objectives that are realistic, concrete, and attainable
    • Repetition of assessment to gauge changes in status, with subsequent alteration of techniques as necessary
  • Motor impairment is the most commonly recognized impairment secondary to stroke.
  • Speech and language, swallowing, vision, sensation, and cognition are also commonly impaired.
EPIDEMIOLOGY
Incidence
  • Each year, ˜795,000 people suffer stroke; ˜610,000 are first attacks, and 185,000 are recurrent attacks (3).
  • ˜14% of stroke survivors reach full recovery in physical function; 25-50% need assistance poststroke (1).
  • According to the WHO, 15 million people suffer stroke worldwide each year. Of these, 5 million die and another 5 million are permanently disabled.
Prevalence
  • ˜7 million Americans ≥20 years old have had a stroke (˜3%) (3).
  • ˜50 million stroke survivors worldwide (4)
  • >1/2 of strokes in people <65 years result in death within 8 years (1).
ETIOLOGY AND PATHOPHYSIOLOGY
Stroke involves a compromise in blood supply to an area, usually by either rupture or blockage of a vessel. Of all strokes, 87% are ischemic, 10% intracerebral hemorrhage, and 3% subarachnoid hemorrhage (3).
Neural Mechanisms of Remodeling
Poststroke remodeling changes provide some degree of recovery that varies considerably between individuals. Outcomes are greatest when remodeling mimics normal organization to the greatest degree possible. Neurophysiologic changes involved in spontaneous recovery include the following (5)[B]:
  • Augmented excitability in areas of cortex functionally connected to injured brain
  • Increased activity contralateral to traumatized cortex
  • Changes in somatotopic map in other regions
Research suggests a critical window for neurophysiologic changes, further understanding of which may facilitate neurorehabilitation by augmenting endogenous healing. Animal studies suggest promising strategies for enhancing rehabilitative efforts including growth factors, hormones, proteins, cytokines, stem cells, and so forth. Studies are ongoing exploring combinations of plasticity-promoting factors, rehabilitative training, and imaging/biomarker modalities together with carefully timed neurorehabilitation that takes advantage of endogenous plasticity timing. Such work is complicated by the vast heterogeneity of stroke insults but offers promising options for future multimodal treatments.
RISK FACTORS
Risk factors for stroke are discussed in the topics “Stroke, Acute” and “Atherosclerosis.”
GENERAL PREVENTION
See “Stroke, Acute.”
image DIAGNOSIS
PHYSICAL EXAM
  • Neurologic manifestations should be examined based on location of stroke when known but should include investigation of the following:
    • Sensory or motor deficits, especially unilaterally (i.e., hemiparesis/hemiplegia)
    • Dysarthria or aphasia
    • Visual field deficits (i.e., hemianopsia)
    • Dysphagia
    • Apraxia
    • Unilateral facial palsy
  • Neuropsychiatric evaluation should be undertaken to assess cognitive, intellectual, personality, memory, psychomotor, and other system changes that may benefit from treatment during rehabilitation.
DIFFERENTIAL DIAGNOSIS
  • Differential diagnosis in stroke rehabilitation should take into account acute changes that are inconsistent with general trend in the individual patient's status.
  • New changes in motor function, mental status, and so forth could represent new stroke.
  • Subacute changes could include a wide range of neuromuscular, neuropsychiatric, or psychiatric diseases that could be related or unrelated to the initial stroke event.
DIAGNOSTIC TESTS & INTERPRETATION
A wide range of standardized, quantifiable scales have been used to track outcomes in stroke rehabilitation. These include the following (2):
  • Neurologic scales
    • Glasgow Coma scale, Mini-Mental State Examination, NIH stroke scale among others
  • Global ADL scales
    • Including, but not limited to, Barthel index, functional independence measure, modified Rankine scale, Frenchay activities index, Trunk Control Test, timed up-and-go test, Stair Climb Test, Toronto Bedside Swallowing Screening Test, and so forth.
  • Family and caretaker contextual factors are very important to stroke rehabilitation and have been shown to impact outcomes, so thorough assessment should include testing such as the following:
    • Caregiver Strain Index, Family Assessment Device
See topic “Stroke, Acute.”
Follow-Up Tests & Special Considerations
Monitor the coagulation profile of patients on anticoagulants.
image TREATMENT
  • Tailor to specific stroke-related sequelae.
  • The three major stroke rehabilitation goals are as follows (1):
    • Prevent/treat prolonged inactivity complications.
    • Prevent recurrent stroke and cardiovascular events.
    • Increase aerobic fitness.
GENERAL MEASURES
Prevention and/or treatment of the complications associated with stroke (4)[C]
  • Aspiration
    • Immediately after stroke, up to 50% of patients have dysphagia; this improves in many.
    • Remain NPO until bedside swallow assessment.
    • Prevention of aspiration involves postural changes, increased sensory input, swallowing maneuvers, active exercise programs, diet modifications, nonoral feeding (if indicated), psychological support, and supportive nursing
  • Pulmonary embolism/deep venous thrombosis
    • Risk is highest during the first 3 to 120 days poststroke.
    • Pneumatic compression devices and compression stockings
    • Ambulation as soon as possible
  • Skin breakdown
    • Increased risk due to loss of sensation, impaired circulation, older age, decreased level of consciousness, inability to move due to paralysis, and incontinence of urine or stool
    • Frequent repositioning (at least q2h) with special care to avoid excessive friction
    • Keep skin clean and dry.
  • Spasticity
    • Occurs in ˜35% of stroke survivors; treat with combination of modalities:
      • Range-of-motion exercises
      • Heat, cold, or electric stimulation
      • Splinting
      • Oral medications for spasticity of cerebral origin (e.g., dantrolene, tizanidine); phenol or botulinum toxin injections for targeting specific muscles or muscle groups
  • Malnutrition
    • Nutritional assessment with a diet history and monitoring by a dietician
  • Seizures
    • More common after hemorrhagic stroke (11%) than after ischemic stroke (9%)
    • Antiepileptic drugs and elimination of disturbances (i.e., toxins, metabolic) that may lower seizure threshold
  • P.993

  • Falls
    • Lifestyle changes
      • Avoid loose rugs; maintain a clear path without obstruction.
      • Avoid slippery surfaces (such as wet floors).
      • Maintain good lighting.
      • Shoes with nonskid soles
      • Slow down movements for transfers or walking.
  • Severe sleep apnea
    • Lifestyle changes
      • Stop smoking; lose weight.
      • Sleep on side versus back.
      • Mouthpieces and breathing devices (CPAP)
      • Surgery
  • Neurocognitive (6)
    • Wide range of deficit patterns that can be focal (e.g., aphasia) or diffuse (general cognitive slowing)
      • Most broadly effected are orientation, language, attention, and memory.
      • Common particular deficits: aphasia, neglect, cognitive slowing, memory/executive deficits
      • Assessment, treatment, and outcomes vary markedly based on stroke type, location, severity, timing, and additional factors.
      • Cognitive rehabilitation has some success in focal deficits but less in diffuse changes.
      • Pharmacology: evidence of efficacy for escitalopram and rivastigmine
      • Additional modalities under investigation: Therapies such as repetitive transcranial magnetic stimulation and prism adaptation have sown some benefit in driving plasticity and functional brain changes.
  • Depression
    • May be organic secondary to stroke or reactive to the stroke itself
    • Poststroke depression has been found to cause higher mortality, poorer functional recovery, and less activity socially (1)[C].
    • Treat with a combination of pharmacotherapy and psychotherapy:
      • Evidence suggests heterocyclic antidepressants are effective in the setting of poststroke depression but must be closely monitored in older adults due to side effects.
      • SSRIs are also effective in treating poststroke depression.
      • All stroke patients should be assessed for depression and treated with the appropriate antidepressant for 6 months.
MEDICATION
First Line
  • Management of controllable risk factors, including BP reduction, diabetes, and cholesterol (Initiate statin therapy, if history of TIA or stroke with evidence of atherosclerosis, LDL ≥100, and no CHD.)
  • Anticoagulation with warfarin for patients with mechanical prosthetic heart valves and ischemic stroke or TIA (dosage varies depending on optimum INR for patient in setting of comorbidities)
  • Note potential medication interactions (e.g., warfarin and SSRIs due to liver enzyme metabolism).
  • Antiplatelet drugs (aspirin, aspirin/dipyridamole, clopidogrel) decrease relative risk of stroke, MI, or death by ˜22% (7)[C].
ISSUES FOR REFERRAL
For stroke survivors who require 24-hour care of medical comorbidities, close physician supervision, and specialized nursing care (RN with specialized training or rehabilitation experience), an inpatient rehabilitation facility (IRF) can offer hospital-level care.
ADDITIONAL THERAPIES
Physical, occupational, speech, and recreational therapy
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
  • For stroke survivors requiring 24-hour care, close physician supervision, and specialized nursing care (RN with specialized training or rehabilitation experience), an inpatient rehabilitation facility (IRF) can offer hospital-level care.
  • Such patients must also require and receive a minimum of 3 hours daily occupational or physical therapy for no <5 days each week; this can be combined with other skilled modalities, such as speech-language or prosthetic-orthotic services) to meet the 3-hr/day requirement.
  • Either the aforementioned is required or an IRF is the only reasonable setting in which a low-intensity rehab program may be executed.
  • An alternative setting is a skilled nursing facility for residents needing daily rehabilitation or nursing care on an inpatient basis.
See “Stroke, Acute.”
IV Fluids
Avoid D5W in acute setting to avoid hyperglycemia and its secondary effects.
Nursing
An alternative inpatient setting is a skilled nursing facility that provides nursing care or rehabilitation to residents needing daily rehabilitation or nursing care on an inpatient basis.
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patient should follow-up regularly with primary care physician for management of risk factors for stroke.
Patient Monitoring
Continue to monitor risk factors. Lab studies monitored periodically may include hemoglobin A1c (and finger-stick glucose testing in diabetics), lipid panel, CBC including platelets, lipid profile, coagulation studies (PT/INR—of special importance in patients on anticoagulation).
DIET
Low salt, low calorie, low saturated and trans fat, low cholesterol
PATIENT EDUCATION
National Stroke Association: http://www.stroke.org/
PROGNOSIS
  • Strong evidence suggests an organized, interdisciplinary stroke care team of physicians, nurses, therapists, family, and patient can reduce mortality rates and the likelihood of institutional care and long-term disability. It can also enhance recovery and increase ADL independence.
  • Aggressive rehabilitation beyond the time window of the 1st poststroke months, including treadmill with or without body weight support, can increase aerobic capacity and sensorimotor functionality.
REFERENCES
1. Gordon NF, Gulanick M, Costa F, et al. Physical activity and exercise recommendations for stroke survivors: an American Heart Association scientific statement from the Council on Clinical Cardiology, Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention; the Council on Cardiovascular Nursing; the Council on Nutrition, Physical Activity, and Metabolism; and the Stroke Council. Circulation. 2004;109(16):2031-2041.
2. Langhorne P, Bernhardt J, Kwakkel G. Stroke rehabilitation. Lancet. 2011;377(9778):1693-1702.
3. Roger VL, Go AS, Lloyd-Jones DM, et al. Heart disease and stroke statistics—2011 update: a report from the American Heart Association. Circulation. 2011;123(4):e18-e209.
4. Miller EL, Murray L, Richards L, et al. Comprehensive overview of nursing and interdisciplinary rehabilitation care of the stroke patient: a scientific statement from the American Heart Association. Stroke. 2010;41(10):2402-2448.
5. Wahl AS, Schwab ME. Finding an optimal paradigm after stroke: enhancing fiber growth and training of the brain at the right moment. Front Hum Neurosci. 2014;8:381.
6. Cumming TB, Marshall RS, Lazar RM. Stroke, cognitive deficits, and rehabilitation: still an incomplete picture. Int J Stroke. 2013;8(1):38-45.
7. Furie KL, Kasner SE, Adams RJ, et al. Guidelines for the prevention of stroke in patients with stroke or transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2011;42(1):227-276.
See Also
&NA;
  • Traumatic Brain Injury (TBI)—Long Term Care; Stroke, Acute; Dementia; Delirium
  • Algorithm: Stroke
Codes
&NA;
ICD10
  • I63.9 Cerebral infarction, unspecified
  • I69.10 Unsp sequelae of nontraumatic intracerebral hemorrhage
  • I69.11 Cognitive deficits following nontraumatic intcrbl hemorrhage
Clinical Pearls
&NA;
  • Stroke is the third leading cause of death and the leading cause of long-term disability in the United States.
  • An essential part of poststroke management is the treatment of controllable risk factors, including BP reduction and cholesterol control (initiate statin therapy, if history of TIA or stroke with evidence of atherosclerosis, LDL ≥ 100).
  • Strong evidence suggests an organized, interdisciplinary stroke care team of physicians, nurses, therapists, family, and patient can reduce mortality rates and the likelihood of institutional care and long-term disability. It can also enhance recovery and increase ADL independence.