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Stroke Rehabilitation

The numbers are sobering. Someone suffers a stroke every 53 seconds in the United States, and someone dies of a stroke every 3.3 minutes. Stroke is the leading cause of serious, long-term disability in the United States, and for admission to nursing homes or extended care facilities. Approximately 4.5 million stroke survivors live in this country. The estimated cost of stroke totals $45.4 billion per year, of which $17.4 billion is lost in productivity due to death and disability.

Comprehensive rehabilitation may improve the function of stroke survivors, despite age and neurologic deficit, and decrease long-term patient care costs. Although motor recovery may plateau three to six months after stroke, functional recovery may continue for up to several years. Most stroke survivors may benefit from some form of inpatient or outpatient rehabilitation. Stroke survivors appear to function better after admission to acute stroke rehabilitation units rather than subacute or nursing home units where rehabilitation is offered. Yet, third-party payers still often continue to send stroke survivors to the nonacute stroke rehabilitation units.

Post-Stroke Rehabilitation

Stroke rehabilitation involves a transdisciplinary, holistic approach that addresses medical, functional, and psychosocial issues. The team may include a physiatrist (physician specializing in rehabilitation), rehabilitation nurse, physical therapist, occupational therapist, speech/language pathologist, social worker, psychologist, vocational counselor, family, and the patient. The team periodically evaluates the stroke survivor, and short- and long-term goals are set. The stroke survivor often meets with the team to review functional progress, to confirm discharge plans, and to discuss any problems. The family participates in therapy sessions in preparation to oversee patient care at home.

Functional recovery
Researchers are gaining a better understanding of the physiological basis of functional recovery. Functional imaging (e.g., fMRI, SPECT, PET)demonstrates that neurons not usually utilized during normal movement are activated when the stroke survivor receives intensive training. Medications such as dextroamphetamine, methylphenidate, and bromocriptine appear to stimulate chemicals in the brain, thus helping motor and language recovery.

Acupuncture is also emerging as a potential means to improve and maintain motor recovery and quality of life, though its usefulness in stroke rehabilitation has not been proven definitively.

Stroke Rehabilitation Priorities

Probably the most important priority of the stroke survivor is to regain his or her ability to move and walk. Prerequisites for ambulation include:

-the ability to follow commands
-adequate trunk control for sitting and standing
-minimal or no contractures (permanent contraction of muscles) of the hip flexor, knee flexor, and ankle plantarflexor muscles
-adequate muscle strength required to stabilize the hip and knee joints.

Gait training

Gait training begins by teaching transfers to the bed, mat, and wheelchair, then improving standing balance on the affected limb. The patient is taught the most optimal gait pattern in and out of the parallel bars, and on stairs, ramps, and curbs. Orthoses (braces) and other assistive devices are used to correct gait deviations, and may decrease energy expenditure during gait. Harnesses to provide partial body weight support may accelerate early ambulation.
Falls
Falls during transfers or moving may cause medical complications such as hip fractures. Falls are most common in stroke survivors with hemineglect, which is a neglect of one side of the body, or with impulsivity, which is a jerky movement that can occur in stroke survivors. Other factors such as use of sedating drugs, urinary incontinence, or decline in mental status have been associated with falls. Stroke survivors who fall at home are more likely to be depressed, less socially active, and have more stressed caregivers.

Wheelchairs
Stroke survivors who have limited or no ability to walk may require wheelchairs. The seat should be narrow enough to allow operation of the hand rim with the unaffected arm, and low enough to allow propulsion with the unaffected leg. Arm rests should be designed to permit seating at tables. Arm and leg rests should be removable to make transfers easier. Lightweight or electric chairs may be issued to patients with cardiac or other severely debilitating conditions.

Stroke survivors usually do not place the same degree of importance on activities of daily living (ADL) as they place on their ability to move. However, teaching ADLs may be more difficult than teaching ambulation. Performance of ADLs requires visual, cognitive, perceptual, and coordination skills in addition to range of motion, motor strength, and sensation. There are a number of factors that render the affected arm useless. Apraxia, or the inability to perform learned skills like shoe tying or raising a spoon to your mouth is one factor that can affect arm use. Poor memory skills, loss of use of the left side of the body, or loss of sensory function may render the affected arm useless as well. Poor prognostic factors for upper limb function include lack of upper limb movement greater than two to four weeks.

Patients can be taught one-handed techniques to perform functional activities with the unaffected limb. Adaptive equipment may help the stroke survivor to become more independent. Occupational therapists may fabricate devices customized to the needs of the patient, and are limited only by their imaginations and technical skills. Constraint-induced movement therapy, in which the unaffected arm is immobilized, may be an effective way to force the affected arm to be more active in functional activity in certain stroke survivors.

Driving
Driving may be an important goal for some stroke survivors. Pre-driving evaluations test basic cognitive skills needed for driving: memory, spatial organization, attention, concentration, and reaction times. Driving skills are tested in simulators or behind-the-wheel with licensed instructors. Adaptive aids, such as spinner knobs and accelerator extenders, may be incorporated to compensate for motor deficits.

Intellectual function
Approximately one-third of stroke survivors under age 65 are able to return to work. To return to work, vocational assessments are necessary to test intellectual function. On-site evaluations may be helpful to modify the workplace to the stroke survivor's needs.

Speech and language
Speech and language disorders may be diagnosed by both formal testing and conversational interaction. Aphasias are characterized by decreased word finding or sentence structure, word substitutions, and errors in understanding questions or statements. Cognitive-communication impairments usually are characterized by decreased concentration, attention, memory, and disorientation, confusion, lying, concrete or irrelevant thinking, or vague language. Stroke survivors also may have unilateral neglect and impairments in safety awareness and judgment. Apraxias are characterized by problems in initiating or coordinating the mouth or tongue in order to produce speech. Dysarthrias usually consist of slurred speech or problems with volume or breath control. Therapy generally focuses on facilitating alternative brain pathways, teaching compensatory strategies, and educating families about the deficits. Persistent speech-language problems may cause an otherwise independent patient to require 24-hour supervision.

Secondary stroke prevention
Every stroke survivor admitted to the rehabilitation unit must be considered for secondary prevention of stroke. Aspirin remains the standard treatment for many strokes, though there is evidence that aspirin, in combination with extended-release dipyridamole (anti-platelet medication that works like aspirin, like Aggrenox), is more effective. Warfarin, which is a type of blood thinner, is the appropriate treatment in strokes associated with atrial fibrillation, narrowing of brain arteries, or conditions in which clotting is likely. Ticlopidine (Ticlid) or clopidogrel (Plavix) may be chosen when aspirin or warfarin therapy cannot be given or is inadequate. Cholesterol-lowering and other agents also have demonstrated to have direct stroke prophylactic properties. Angiotensin converting enzyme inhibitors for instance, or ACE inhibitors, have recently been shown to have direct effects in lowering the incidence of a second stroke. Secondary prevention of hemorrhagic stroke includes control of risk factors, such as hypertension or conditions in which clotting is likely.

DVT
Clotting in the legs, or deep venous thrombosis (DVT), should be suspected in stroke survivors who have difficulty with walking. Clinical signs and symptoms, such as pain, swelling, and warmth of the leg, are at best, unreliable. Noninvasive testing, such as ultrasound, is a routine part of diagnosis. Stroke survivors at risk for DVT should be given compression stockings (tight leg stockings that prevent pooling of blood in the legs), pneumatic compression (similar to compression stockings, but air is used to compress and deflate the stockings to encourage blood circulation), and/or subcutaneous heparin 5000 units every (blood thinner that is intended to prevent blood clots) eight to 12 hours. Prevention may be discontinued once the stroke survivor is ambulating consistently in or out of the parallel bars. Treatment of DVT includes warfarin for three months or insertion of an inferior vena cava filter, which helps the body prevent migration of blood clots from the legs to the lungs.

Positioning
Proper positioning of the stroke survivor will prevent multiple complications. Positioning in the bed and wheelchair can prevent both contractures and nerve injuries. Dependent patients should be turned every two hours in bed. Wheelchair seats should be provided with appropriate cushions to decrease the incidence of pressure sores. Affected limbs can be elevated with pillows, footrests, and elevated arm rests to prevent swelling. Massage or placement of an Isotoner glove may prevent or reduce swelling of the affected hand.

Bowel and bladder problems
Strokes often cause constipation or bowel incontinence. Diets should include adequate fluids and fiber. Patients should go to the bathroom after meals to take advantage of reflex emptying of the bowels. Stool softeners and laxatives may be prescribed as necessary. Patients who remain incontinent may require a suppository or enema every one to two days to prevent incontinence at socially inappropriate times.

Bladder problems may be suspected in stroke survivors with urinary incontinence, frequency, and urgency. Urinary tract infections and fecal impaction should be evaluated and treated. Bladder volumes after urinating should be measured by ultrasound or catheterization to assess how the bladder emptys. Patients with bladder dysfunction should be referred for studies to assess bladder function and to determine appropriate treatments. Going to the bathroom every two to four hours during the day, and fluid restriction after dinner may prevent incontinence in a majority of patients. External catheters may decrease the incidence of bedwetting. Catheterization may be needed in stroke survivors who cannot urinate by themselves.

Swallowing problems
Swallowing problems should be suspected in patients with impaired cognition, nasal regurgitation, coughing, "gurgly" voice, or impaired cough associated with absence of the gag reflex. Following evaluation by a speech/language pathologist, an x-ray swallowing study can identify swallowing disorders and help to organize a treatment plan. Changes in diet, head positioning, or other strategies may help to prevent pneumonia. Feeding tubes may be needed if oral caloric intake is not adequate to meet nutritional needs.

Shoulder pain
The direct correlation between shoulder subluxation (dislocation) and pain remains controversial. Almost three-fourths of stroke survivors will experience at least one episode of shoulder pain within the first year after stroke. Shoulder pain most commonly is correlated with limited range of motion, especially external rotation. Other causes of shoulder pain include brachial plexopathy, shoulder trauma, bursitis, tendinitis, and rotator cuff tear. A diagnosis often may be determined from a physical examination alone, but x-rays, electromyography, bone scans, or magnetic resonance imaging (MRI) may support clinical findings. Pain may be relieved with appropriate use of medications, electrical nerve stimulation, muscle or nerve blocks, local injections, or surgery. Range of motion exercises and use of braces or supports have been credited with a decrease in the number of pain complaints.

Another type of post-stroke pain is known as the post-stroke central pain syndrome, which usually occurs as a result of a lesion in the thalamus. The sensation of "thalamic" pain consists of a burning or other unpleasant sensation when an area on the body is stimulated. Many types of medications or modalities may relieve post-stroke central pain.

Spasticity
Spasticity usually causes brisk reflexes, muscles with increased resistance to movement, and pain. Treatments include ice, electrical stimulation, and splinting. Certain medications like dantrolene, work to reduce spasticity in the muscle itself, while others like, tizanidine, work in the spinal cord. Phenol or botulinum toxin blocks can inhibit spasticity in individual or groups of muscles up to three to six months. If contractures inhibit function or cause significant pain, tendon releases or transfers may re-establish normal joint alignment. When surgery is performed to release contractures, treatment of spasticity must be continued post-operatively to prevent recurrence of contractures.

Depression
Depression is the most underdiagnosed and undertreated complication after stroke. Depression may be related to mourning the loss of function or to the alteration of certain brain chemicals. Post-stroke depression has not been associated with the actual site of impairment in the brain. Therapy and anti-depressant medication may be necessary to begin to reverse its effects.

Sexual problems
Sex rarely is addressed with stroke survivors. Stroke survivors and significant others generally are fearful of causing another stroke from sexual activity. Cardiac limitations should be discussed, and medications should be reviewed. Couples should be encouraged to experiment with sexual techniques and positions, and to communicate their needs to each other.

Conclusion

Rehabilitation care should be provided as long as stroke survivors have braces, canes, or other functional needs. Patients should return to their primary practitioners for routine medical care, but should be seen by a physiatrist one month following discharge and periodically thereafter. Blood pressure and weight should be taken, and medications should be reviewed. Progress of mobility and activities of daily living should be reviewed and confirmed by a family member. Psychosocial issues should be discussed. All equipment should be inspected, and the patient should be able to demonstrate his home exercise program. A neurologic examination should be performed, including gait with appropriate assistive devices and orthoses.

Most importantly, time should be allowed for questions. Good communication between the physiatrist, the patient, and the family will facilitate optimal care, and provide the patient with the opportunity to reach his maximal functional potential.

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