rehabilitation of the stroke survivor elliot j. roth, m.d. rehabilitation institute of chicago...
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REHABILITATION OF THE REHABILITATION OF THE STROKE SURVIVORSTROKE SURVIVOR
Elliot J. Roth, M.D. Rehabilitation Institute of ChicagoNorthwestern University Feinberg School of Medicine
The brain is my second favorite The brain is my second favorite organ” organ”
-Woody Allen-Woody Allen
StrokeStroke
Third leading cause of death in U.S. Leading cause of severe disability in U.S. Estimated one-third to one-half have
disability Most common reason for rehabilitation
The Goals of Stroke Rehabilitation
Prevent, Recognize, and Manage Comorbid Medical Conditions
Maximize Functional Independence Optimize Psychosocial Adaptation of
Patients and Families Facilitate Resumption of Prior Life Roles
and Community Reintegration Enhance Quality of Life
Rehabilitation during the Acute Phase
GOALS:Prevention of Medical
ComplicationsPrevention of Deconditioning
and ContracturesTraining of New Skills
Rehabilitation during the Acute Phase
TASKS: Range of Motion Stretching Exercises Frequent Position Changes Sitting in Upright Position to Improve
Orthostatic Tolerance Psychological Counseling Patient and Family Education
Rehabilitation during the Acute Phase
TASKS: Training Personal Care Skills, Mobility,
and Ambulation Training Bladder and Bowel Management Evaluation of Swallowing Function Initiate Nutrition and Hydration Identification and Treatment of
Depression
Medical Complications of Stroke
Venous Thromboembolism Pneumonia Dysphagia Ventilatory Dysfunction Cardiac Disease Seizure Central Post-Stroke Pain Syndrome Spasticity
Medical Complications of Stroke
Bladder Dysfunction Bowel Dysfunction Pressure Ulcers Malnutrition and Dehydration Depression Falls and Injuries Shoulder Pain and Dysfunction
Medical Complications of Stroke
Recurrent Stroke
Natural Recovery after Stroke
MOTOR CONTROL: Flaccid Hemiplegia Increasing Tone and Spasticity Emergence of Synergy Patterns Gradually Increasing Isolated Voluntary
Movements
Levels of Rehabilitation Care
Therapy during Acute Care Acute Comprehensive Inpatient
Rehabilitation Subacute Comprehensive Inpatient
Rehabilitation Comprehensive Day Rehabilitation Outpatient Rehabilitation Home Rehabilitation
Principles of Stroke Rehabilitation
Interdisciplinary Team Approach Holistic and Comprehensive Uses Learning Theory:
– Graded Levels of Task Difficulty– Opportunities for Repetition of Skill
Performance– Professional Supervision and Feedback– “Protected Practice”
Principles of Stroke Rehabilitation
Attention to Psychological Issues Involvement of Family Need to Recruit Community Resources Importance of Functional Activities Attention to Quality of Life Issues
Stroke Rehabilitation Interventions
Functional Skills Training– Personal Care Skills– Mobility Activities– Instrumental Activities of Daily Living
Stroke Rehabilitation Interventions
Therapeutic Exercises– Flexibility– Strength– Coordination– Fitness
Stroke Rehabilitation Interventions
Spasticity Management:– Positioning and Orthotics– Stretching and Other Exercises– Medications– Injections– Surgical Release
Stroke Rehabilitation Interventions
Aphasia Treatment: – Individual Supervised Practice and Training – Group Speech Therapy– Encourage Verbalizations– Conversational Coaching– Melodic Intonation Therapy– Oral Reading– Computerized Training– Medications
Stroke Rehabilitation Interventions
Treatment of Depression: Endogenous vs. Reactive Natural Recovery Interventions:
– Professional Counseling and Psychotherapy– Peer Relationships and Family Involvement– Medications
Stroke Rehabilitation InterventionsStroke Rehabilitation Interventions
Patient Education Family and Caregiver Education Behavioral Techniques Supportive Counseling Recruit Community Resources
Other Quality of Life Issues
Sexuality Spirituality Driving Employment Education Recreation Family Involvement
New Rehabilitation Interventions
Partial Body Weight-Supported Treadmill Training
Pedaling Biofeedback Electrical Stimulation Constraint-Induced Muscle Training Robotic-Assisted Therapeutic Exercise
Stroke Rehabilitation Outcomes
80% Independent Mobility 70% Independent Personal Care 40% Outside Home 30% Work
Factors Affecting Outcomes
Neurological Deficits Motivation Level Learning Ability Level of Emotional and Social Support Coping and Adaptability Medical Comorbidities Rehabilitation and Training
Stroke Rehabilitation Effectiveness
RCT; Strand et al 1985: 293 patients; mean age = 73 yrs.
Non-intensive Stroke Inpatient Rehab Unit with Team Approach, Staff Education, Early and Focused Rehabilitation Efforts, Family Participation, and Patient and Family Educationvs. General Medical Ward:
IRU Patients: More independence in hygiene, dressing, and walking; Less rehospitalization (15% vs. 39%); Less mortality; Gains persisted at one year
Stroke Rehabilitation Effectiveness
RCT; Indredavik et al 1991: 220 patients; mean age = 73 yrs.
Stroke Inpatient Rehab Unit with team approach, early rehabilitation, and education program for patient and familyvs. General Medical Ward:
IRU: More likely to live at home (56% vs. 33% at 6 weeks; 63% vs. 45% at one year); More ADL independence at 6 weeks and one year; Less mortality (7% vs. 17% at 6 weeks; 25% vs. 33% at one year)
Stroke Rehabilitation Effectiveness
RCT; Kalra et al 1993: 245 patients; stratified by prognosis as good/fair/poor
Stroke Inpatient Rehab. Unitvs. General Medical Ward:
Good prognosis patients: IRU = GMWPoor prognosis patients: IRU>GMW
IRU: Less mortality, shorter LOSFair prognosis patients:
IRU: better ADL, more home discharges, shorter LOS, less mortality
Stroke Rehabilitation Effectiveness
Meta-analysis of 10 Studies:Focused Interdisciplinary Team-Driven Stroke Rehabilitation Programvs. No Organized Rehabilitation Program1586 patients;
Rehabilitation Program Patients had reduced mortality and improved functional outcomes
-Langehorn et al 1993
Stroke Rehabilitation Effectiveness
Meta-analysis of 36 Studies:Rehabilitation Program patients performed better than 65% of patients in comparison groups.
Rehabilitation Program had greatest effects on: Personal Care Skills, Mobility Activities, Ambulation, and Visuospatial-Perceptual Functions
Improvement was more related to: Early Initiation than to Duration of Intervention
-Ottenbacher and Jannell 1993
Rehabilitation Effectiveness
AHCPR Recommendation:
“Whenever possible, patients with acute strokes should receive coordinated diagnostic, acute management, preventive, and rehabilitative services.”
(Research evidence =A;
Expert opinion=consensus)
Rehabilitation Effectiveness
“…There is some evidence that formal
rehabilitation after stroke is effective
and that it is best provided by well-
organized interdisciplinary teams…”
-Great Britain Dept. of Health 1992
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