The Key Elements of Stroke Rehabilitation: Mark Bayley MD FRCPC

(1)

The Key Elements of Stroke Rehabilitation:

(2)

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

(3)

Some

Miracle

Happens

(4)

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

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Objective 1

Mechanisms for Recovery

after stroke

(6)

Mechanisms of Recovery

•Resolution of

Temporary Factors

•Central Nervous

System

(7)

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

(8)

Resolution of Diaschisis

(9)

Crossed Cerebellar Diaschisis

(10)

Mechanism 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

(11)

CNS Reorganization and Plasticity

Axonal Sprouting

(12)

Plasticity Concepts

(13)

Activation of the Other Hemisphere of Brain on FMRI

(14)

Time course of Recovery

Local Processes

Resolution of edema Resolution of ischemic penumbra

Resolution of remote functional depression (diaschisis)

CNS Reorganization

Weeks to 2 months Hours to weeks Days to months

(15)

Objective 2

Identify key elements of stroke

rehabilitation system

(16)

(17)

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]

(18)

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

(19)

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)

(20)

Subacute Stroke Rehabilitation Units

Geographically distinct units with focus on

rehabilitation sometimes in freestanding

hospitals

Most studies involve moderate or severe

stroke patients

(21)

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,

(22)

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)

(23)

Stroke Rehab Units

Stroke rehab units discharge stroke patients with fewer neurological deficits, improved

ADL, reduced mortality and greater chance of being at home

(24)

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).

(25)

PSROP (Post

PSROP (Post--Stroke Rehabilitation Outcomes Project)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”

(26)

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

(27)

(28)

The Earlier the Better

Brain is “primed” to “recover” early in post-stroke 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

(29)

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

(30)

Benefit of Early Therapy in Animals

Benefit of Early Therapy in Animals-

-Results:

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

(31)

Therapy Intensity

(32)

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 0 10 20 30 40 50 60 70 80 90 100 SRU GMU % D /C

(33)

10 20 PT OT * M e a n h rs /p t

(34)

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”

(35)

In a therapeutic day

>50% time in bed

28% sitting out of bed

13% in therapeutic activities

Alone for 60% of the time

(36)

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

(37)

Task

(38)

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

Stroke Rehab Must Be Task

(39)

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

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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

(41)

First Story

(42)

Objective 3

To identify some important gaps in care

particularly for those with severe stroke

and for community based survivors

(43)

Should More Severe Strokes be

Rehabilitated?

(44)

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

(45)

Jorgensen et al. (2000)

Comparative trial

N = 1241 consecutive stroke patients

Group 1 (n = 305) - general and

neurological wards

(46)

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

(47)

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)

(48)

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

(49)

Severe Strokes Admission Motor FIM 12-38 (RPG 1100, 1110) Fiscal 09/10

48 95 32 40 50 60 70 80 90 100

Mean Acute LOS Mean Rehab LOS Mean FIM change

(50)

Story 2

(51)

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)

(52)

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

(53)

Outpatient and community

Outpatient and community--based rehabilitationbased 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]

(54)

Outpatient and community

Outpatient and community--based rehabilitationbased 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]