Stroke: Rehabilitation and Recovery
Stroke: Rehabilitation and Recovery
Executive Summary
With millions of stroke survivors in the United States, primary care physicians are often involved in providing post-stroke rehabilitation care, including recognizing common treatable and reversible conditions such as depression.
- Key components of rehabilitation include assessment, goal setting, treatment of functional and psychosocial impairments, and prevention of complications.
- A coordinated, multidisciplinary rehabilitation evaluation and treatment approach during the early post-stroke period is associated with improved clinical outcomes.
- Muscle weakness and impaired motor control are managed with various modalities such as repetitive task training, constraint-induced movement therapy, mirror therapy, and functional electrical stimulation.
- Spasticity is addressed through stretching and range of motion exercises, bracing, and medication, although benzodiazepines, if possible, should be avoided.
- Post-stroke depression and fatigue are common and underdiagnosed. Standard antidepressant psychotherapy and psychopharmacologic treatment including selective serotonin reuptake inhibitors, such as fluoxetine, have been found effective.
Rehabilitation is a critical component of stroke treatment, as most stroke survivors are left with significant neurological impairments and other sequelae, such as spasticity and pain. Approximately 40% of stroke patients are left with moderate functional impairment and 15%-30% with severe disability.1 Stroke rehabilitation aims to reverse these impairments to the extent possible, maximize functionality through the use of compensatory approaches, prevent complications, and manage comorbidities. This article will review the basic principles of rehabilitation, current practices, and evidence supporting various aspects of stroke rehabilitation.
Role of Primary Care Physician
With millions of stroke survivors in the United States, primary care physicians are often faced with providing care to these individuals and, thus, need to be able to identify common post-stroke rehabilitation issues. Post-stroke depression can occur at any time after stroke, and it is important that primary care physicians recognize this as a treatable and reversible condition, rather than a "natural" consequence of disability after stroke. Monitoring range of motion to identify developing contracture and/or spasticity is important so that referral can be made to a rehabilitation physician if these occur. Lastly, addressing the stroke survivor’s mobility, ability to perform activities of daily living (ADL), and any deterioration in functional status are critical to making timely referrals to rehabilitation services when needed. When these issues are identified early, the primary care physician can prevent the progression of debilitating consequences by initiating treatment or referring to appropriate specialists for further evaluation and management.
Rehabilitation
Functional improvement in rehabilitation is accomplished through a combination of neurological recovery and adoption of compensatory techniques and equipment. Improved functional independence may be attained by reducing impairment directly (i.e., via neural recovery using cerebral plasticity to overcome neuronal loss) or through compensation for impairment by using remaining physical and cognitive abilities and strategies. Both recovery and compensation are crucial concepts in rehabilitation and key therapeutic approaches; interventions must be balanced to address patient goals and efficiently deploy the available rehabilitation resources.2
Over the last century, a significant amount of research has been conducted to further elucidate how best to provide comprehensive stroke rehabilitation. Currently, it is comprised of several key components, including assessment, goal setting, treatment of functional and psychosocial impairments, and prevention of complications. Patients are reassessed at regular intervals to evaluate progress, and treatment plans are adjusted accordingly. Ideally, rehabilitation begins immediately following stroke and often becomes a long-term element in the lives of these patients. Assessment and treatment should begin in the setting of acute hospitalization, and depending on the needs of the individual, continued rehabilitation may transition to the appropriate inpatient or outpatient setting.
National and international guidelines have been developed to provide resources for health care providers with the latest evidence-based practices, such as the American Heart Association (AHA) Guidelines in 2005 and the National Institute for Health and Care Excellence (NICE) Guidelines in 2013.3,4 AHA guidelines incorporate the U.S. Preventive Services Task Force (USPSTF) grading system for level of evidence and are referenced in this article where applicable5 (see Table 1). AHA rehabilitation guidelines currently are being updated, with release anticipated in 2014. Adherence to stroke rehabilitation guidelines is associated with improved patient functional outcomes.6
| Table 1:USPSTF Recommendation Grading System5 |
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In an effort by the Joint Commission and the AHA, certification has been developed using current guidelines and established standards of care to identify Primary Stroke Centers and more recently Comprehensive Stroke Centers. The rehabilitation requirements for Primary Stroke Center certification include the ability to assess for rehabilitation needs and refer for appropriate post-acute care. Comprehensive Stroke Centers also must have a rehabilitation service led by a physician with expertise in neurorehabilitation, and the service must include therapists, nurses, and social workers with an expertise in addressing the rehabilitation needs of stroke patients.7,8 Complete guidelines can be found on the Joint Commission’s website.7
Services and Settings
A coordinated, multidisciplinary rehabilitation evaluation and treatment during the early post-stroke period is associated with improved clinical outcomes9,10 (USPSTF Level A1). The multidisciplinary team typically consists of physicians, physical therapists, occupational therapists, speech therapists, recreational therapists, nurses, social workers, and psychologists who work closely with patients and their family members or caregivers to achieve rehabilitation goals. If these rehabilitation services are not available in the acute hospital, then patients with moderate or severe symptoms should be referred to a facility with these services (USPSTF Level I1).
Stroke patients should be assessed for rehabilitation needs, and rehabilitation should commence during the acute hospitalization. Upon discharge, rehabilitation (if required) may continue in either the inpatient, home, or outpatient setting. For patients who require inpatient rehabilitation prior to returning home, the two main options are acute inpatient rehabilitation (often referred to as Inpatient Rehabilitation Facilities, or IRFs) or subacute inpatient rehabilitation (also known as skilled nursing facilities). IRFs typically provide 3 or more hours of therapy per day, with subacute rehabilitation facilities providing a lesser (and more variable) amount. For patients who can be safely discharged home, rehabilitation may continue either through homecare services or in an outpatient rehabilitation program. Choice of rehabilitation setting depends on the patient’s care needs, the team’s assessment, goals of care, available resources, and patient’s ability and willingness to participate in and tolerate a therapeutic exercise program (USPSTF Level I1).
Timing and Intensity
Initiation of rehabilitation during the acute hospitalization should occur once the patient is medically stable and safe to participate in therapy. Evidence supports early mobilization to prevent complications, such as venous thrombosis and contractures, and to begin the assessment and treatment process3 (USPSTF Level C1). Early mobilization is currently being studied in A Very Early Rehabilitation Trial (AVERT), which is a single-blind, multicenter, randomized, controlled trial. Results from Phase 2 of this trial have shown that mobilization within 24 hours of stroke and at regular intervals is safe, is feasible, expedites return to unassisted ambulation, and is independently associated with long-term improved functional outcomes.11,12
Currently, there is wide acceptance of the hypothesis that a higher intensity of therapy is more beneficial than a lower intensity;2,4,9,13-15 however, there is insufficient evidence to make specific recommendations regarding the optimal level of intensity of rehabilitation services (USPSTF Level B1). Ultimately, determining intensity level as well as duration of therapy is often greatly impacted by the mental and physical tolerance of the patient to participate in therapy, and therefore, programs must be individualized based on the multidisciplinary team’s assessment and plan of care.16
Motor Rehabilitation
Many stroke patients suffer from muscle weakness and impaired motor control, with resultant functional deficits. Multiple therapeutic methods have been developed to aid stroke patients with improving motor function. These methods typically involve repeated practice of movements as a foundation, and vary greatly from simple task-specific training to more complex methods, using virtual reality or advanced robotics. Additional therapeutic options have emerged recently and are still currently being studied, including pharmacotherapy to facilitate plasticity and the use of non-invasive brain stimulation (see Figure 1). These novel therapies are likely to serve an adjunctive role to conventional physical and occupational therapy.
Figure 1: Transcranial Magnetic Stimulation
This technique is used both as a tool for investigating brain physiology during stroke recovery, and also as a potential therapy to enhance motor recovery.
Photo courtesy of Dr. Joel Stein.
Conventional stroke rehabilitation includes repetitive task training; however, effects of specific interventions may generalize poorly to related tasks and emphasis should be placed on task- or context-specific training, which may be referred to as meaningful task-specific training.17,18 This type of therapeutic exercise has been found effective in improving upper and lower extremity motor function.18
Constraint-induced movement therapy (CIMT) is another type of repetitive task training, involving forced use of the affected limb by "constraining" use of the non-paretic limb. A randomized trial found benefit in upper limb use after CIMT training.19 The durability of this benefit is unknown, however, and additional research is required to define optimal dosing and timing of CIMT.20,21,22
In mirror therapy, a mirror is placed in the patient’s midsagittal plane while performing bilateral exercises, providing the patient with the visual illusion of successfully moving the affected limb. In a Cochrane review, mirror therapy was shown to improve upper extremity motor function, ADLs, and pain; however, data are limited.23,24 Mirror therapy may be used as an adjunct to conventional therapy.24
More than half of stroke patients are unable to walk independently during the acute phase of recovery and may benefit from intensive gait training, which can significantly improve gait function.25,26 Gait training may include assisted ambulation, treadmill training, and body-weight-supported treadmill training (BWSTT).27,26 A recent large, multicenter, randomized trial found that BWSTT compared to a home exercise program with physical therapy found no incremental benefit for BWSTT on walking speed, motor recovery, balance, and functional status, with patients participating in the home exercise program experiencing fewer falls.28
Functional electrical stimulation (FES) involves stimulating specific muscle groups to cause a muscle contraction. FES may lead to a short-term increase in motor strength and reduction in impairment severity, but without evidence of improved function.29,30,31 This method is recommended for use in ankle, knee, or wrist motor impairment, shoulder subluxation, and for gait training (USPSTF Level B1). Several FES devices have been designed to aid in ambulation for patients with foot drop, including the Bioness L300 (Bioness Inc., Valencia, CA) and the WalkAide (Innovative Neurotronics Inc., Austin, TX). Kluding et al compared use of the FES (Bioness L300) with a traditional ankle-foot orthosis (AFO) and found that use of both FES and AFO with physical therapy training significantly improved gait speed and functional outcomes, with no significant difference between groups.32
Electrical signals also can be detected in the muscle using surface electromyographic electrodes and translated into visual or auditory signals to provide biofeedback during therapeutic exercises.33,34 The benefits of this therapy remain unproven.
Figure 2: Hand Robotic Device
The Amadeo robot (Tyromotion Inc., Graz, Austria) is one of a growing number of robotic devices for providing exercise therapy for the upper limb after stroke. This device provides finger flexion and extension training.
Photo Courtesy of Dr. Joel Stein
Robots have been used in stroke rehabilitation to provide reliable, reproducible, high-intensity exercise therapy (see Figure 2).35,36,37 A 2012 Cochrane review found that patients who received robot-assisted arm training were more likely to improve arm function and ADLs but not muscle strength.17 Overall, data regarding efficacy of robot-assisted rehabilitation are limited and its cost-effectiveness may pose a barrier to implementation.36,38 Other systems, including computer games and virtual reality, have been studied as standalone therapies to provide guidance and a motivating environment as well as in combination with robot-assisted therapy.39 Although some benefit has been demonstrated, further research is needed to optimize these treatments and determine their clinical utility and cost-effectiveness.
Multiple drugs have been studied as potential facilitators of motor recovery. The Fluoxetine for Motor Recovery in Acute Ischemic Stroke (FLAME) study found that patients with moderate-to-severe motor deficits experienced enhanced motor recovery with combined fluoxetine and physical therapy after 3 months.40 However, larger, more definitive studies are needed before fluoxetine can be routinely recommended for this indication.
Non-invasive cortical stimulation is currently being studied to assess its impact on motor recovery, but it is not yet routinely used in clinical practice.41,42 The two main types of non-invasive cortical stimulation are repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS).16 In rTMS, electric current is induced in the underlying cortex using pulses of high-intensity magnetic fields. Depending on the stimulation parameters, rTMS can either augment or inhibit cortical excitability. In tDCS, surface electrodes on the scalp deliver direct current that can similarly modulate excitatory or inhibitory effects on the underlying cortex. In a 2012 meta-analysis, Hsu et al found that rTMS had a positive effect on motor recovery, especially for those with subcortical stroke.43 Non-invasive cortical stimulation is generally safe and well tolerated and is a potentially useful future therapeutic option when paired with exercise therapy.16
Approximately one-third of stroke patients develop muscle spasticity, which may further impair motor function and quality of life. However, treatment of spasticity is not necessary unless it causes impaired function, pain, deforming contractures, or limits skin hygiene. Treatment options include stretching and range of motion exercises, bracing, oral medications, and intramuscular injections. The most frequently used oral medications include baclofen, tizanidine, benzodiazepines, and dantrolene.1 If possible, use of benzodiazepines should be avoided during the stroke recovery period because of possible deleterious effects on recovery44 (USPSTF Level D1). Intramuscular injection is most commonly performed with botulinum toxins and less commonly with phenol or ethanol, and should be considered for disabling or painful spasticity, particularly if localized (USPSTF Level B1). Occasionally, patients may require more invasive treatments, such as intrathecal baclofen (ITB) or surgical correction of contractures.
Speech and Language Rehabilitation
Disorders of communication, which may occur in as many as 40% of stroke patients, most commonly include aphasia, dysarthria, or apraxia. Aphasia results from damage to the regions of the central nervous system that affect language reception, expression, or both. Apraxia is caused by impairment in the patient’s ability to plan and organize commands for muscle movement. Dysarthria results from neuromuscular damage, causing impairment in muscle movement and subsequent alterations in speech production. Speech and language rehabilitation involves careful assessment of the patient’s abilities and deficits, as many patients suffer from a complex combination of these communication disorders. Therapy includes working on the affected system (e.g., phonation, articulation, prosody, etc.) along with use of compensatory strategies and potential use of augmentative or alternative communication devices.1 Patient and caregiver education is a critical component of speech therapy. Currently, no guidelines exist for use of specific therapeutic modalities in speech and language therapy. Nonetheless, treatment can aid in recovery and prevent ineffective or inappropriate compensatory behaviors45 (USPSTF Level A, B1). Several novel therapeutic approaches are currently being investigated and include constraint-induced aphasia therapy, where use of compensatory strategies (such as communicating using gestures) is not permitted; use of non-invasive brain stimulation; and use of medications, such as memantine, an NMDA receptor antagonist.46
Dysphagia
Figure 3: Modified Barium Swallow (MBS) Study
Static images from MBS studies show laryngeal penetration (A) and aspiration of barium into the trachea (B)
Reprinted with permission. Matsuo K, Palmer JB. Anatomy and physiology of feeding and swallowing: Normal and abnormal. Phys Med Rehabil Clin N Am 2008;19:691-707, vii.
Dysphagia is seen in approximately 45% of hospitalized stroke patients; therefore, early assessment is critically important due to the risk of aspiration.1 Bedside dysphagia screening assessment should be performed before initiating oral intake for all stroke patients (USPSTF Level B1). If the bedside screening assessment is abnormal, then a complete bedside swallow evaluation is warranted (USPSTF Level I1). Additional measures, including modified barium swallow studies (see Figure 3) and flexible endoscopic evaluation of swallowing and sensory testing, also may be necessary in evaluating patients at high risk for aspiration. Treatment of dysphagia includes use of dietary texture modification, compensatory strategies, exercises, and postural advice.4,47,48 In some cases, a feeding tube may be needed temporarily or long-term to support a patient's nutrition. Malnutrition affects approximately 30% of stroke patients during the first week of hospitalization and nutritional status should be carefully monitored and appropriate supplementation provided when necessary.1
Cognitive Rehabilitation
Cognitive deficits are very common after stroke, may be quite complex, and may affect multiple aspects of cognition such as attention, executive function, memory, and insight. Screening for alterations in cognition is important, as sustained cognitive deficits may result in poor outcomes. These deficits may impact a patient’s ability to perform therapeutic exercise, and may affect one’s ability to recognize one’s own impairments, known as anosognosia. When possible, sedating medication that may exacerbate cognitive difficulties should be avoided, such as benzodiazepines, neuroleptics, barbiturates, and anticonvulsants. Severe cognitive impairments may pose significant obstacles in community and home reintegration.
Spatial neglect and visual deficits may result from damage to the non-dominant parietal lobe or to various areas of the visual system. Patients should be screened for visual deficits and spatial neglect. Use of prisms, education, functional training, compensatory strategies, and sensory stimulation may be employed in the treatment of spatial neglect or visual deficits.4,49,50,51
Psychological
Psychological disorders after stroke, including depression and fatigue, are very common and under-diagnosed, and can have a negative impact on rehabilitation. Signs or symptoms of depression warrant thorough assessment by a specialist and frequently require treatment. Standard antidepressant therapeutic modalities, including psychotherapy and psychopharmacologic treatment (e.g., selective serotonin reuptake inhibitors, such as fluoxetine),4 have been found effective for post-stroke depression.52
Psychosocial Issues
Rehabilitation not only should assess and treat motor, sensory, and cognitive deficits, but also should address issues of social support and caregiver stress early and at regular intervals. Living with disability after stroke is a lifelong challenge and adequate support from family and caregivers is critical to successful outcomes.
Conclusion
Stroke is one of the most common causes of acquired disability worldwide. The field of stroke rehabilitation is ever changing and evolving to better meet the needs of stroke survivors. Novel techniques and technology are being developed and studied with the ultimate goal of improving patient function and quality of life.
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- Van Wijk R, et al. An early mobilization protocol successfully delivers more and earlier therapy to acute stroke patients: Further results from phase II of AVERT. Neurorehabil Neural Repair 2012;26:20-26.
- Cumming TB, et al. Very early mobilization after stroke fast-tracks return to walking: Further results from the phase II AVERT randomized controlled trial. Stroke 2011;42:153-158.
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