By Carolyn Scott, Ph.D., L.P., CBIST
Rainbow Rehabilitation Centers
Every 40 seconds, someone in the United States will have a stroke.1 That means that there are around 795,000 strokes per year with about three-quarters of these being a first-time event.1,2 Stroke kills about 160,000 individuals each year3 and a large portion of survivors require rehabilitation to return to premorbid levels of functioning.
WHAT IS A STROKE?
A stroke occurs when blood flow to the brain is disrupted. Ischemic stroke, which accounts for 80 percent of strokes,3 occurs when blood flow to the brain is blocked. Blockages may be due to a clot that forms within an artery in the brain or neck (thrombosis) or a clot or debris, like plaque, from elsewhere in the body moves to the brain or neck (emboli). Additionally, arteries in the brain or leading to the brain can be narrowed by plaque (fatty deposits). In a hemorrhagic stroke, a weakened blood vessel leaks or an aneurysm, a balloon like pouch on a vessel wall, bursts. Alternatively, an arteriovenous malformation (AVM), an abnormal tangle of blood vessels may rupture and cause a stroke. Sometimes, the cause of a stroke can’t be determined; this is called a cryptogenic stroke. Regardless of the cause, without blood flow, brain tissue begins to die rapidly leading to permanent or potentially reversible damage.
HOW DOES STROKE AFFECT AN INDIVIDUAL?
While the whole brain works together in concert, some functions can be localized to specific areas in the brain. The deficits seen after a stroke are dependent upon what part of the brain is injured. Common deficits seen after stroke may include communication difficulty such as aphasia, physical concerns such as hemiparesis or weakness on one side of the body, emotional issues, or cognitive deficits including memory problems. These newly acquired deficits are first addressed in the acute care setting, but for many survivors that is not enough care. Over two-thirds of stroke survivors receive rehabilitation after hospitalization.4
After a stroke, rehabilitation may focus on cognitive impairments, reduced mobility, emotional and behavioral changes, and deficits in activities of daily living (ADLs) amongst other concerns. To ensure the best outcomes for survivors and the most effective and efficient care, in 2016 the American Heart Association/American Stroke Association developed guidelines for adult stroke rehabilitation and recovery which the American Academy of Physical Medicine and Rehabilitation and the American Society of Neurorehabilitation endorsed. The guidelines make 227 specific recommendations on the following topics: the organization of rehabilitation programs and intervention in an inpatient setting, how to prevent and manage comorbidities, how to assess strengths and weaknesses post-stroke, the types of deficits commonly seen after stroke and how they affect daily life, and rehabilitation in the community, social supports, and transitions of care.
OVERVIEW OF FINDINGS4
Data strongly suggests that starting rehabilitation as soon as a survivor can tolerate it is beneficial. Ideally, the post-stroke rehabilitation team consists of a physiatrist or neurologist, rehab nurse, physical therapist, occupational therapist, speech therapist, social workers, psychologist, psychiatrist and counselors. Coordination amongst team members is important. Organized, inter-professional stroke care has been shown to reduce mortality rates and the likelihood of institutional care and long-term disability. It has also been shown to enhance recovery and increases independence in completing ADLs.
Cognitive impairment affects more than a third of stroke survivors three months and a year after their injury.4,5 The most common deficits seen are in orientation, memory, language, and attention. It is recommended that individuals are screened for cognitive deficits prior to returning home. If the screen is positive, neuropsychological evaluation may be beneficial. Assessment of communication skills, important for advocating for oneself should include language, pragmatics, reading, writing, and cognitive-communication skills. The results of the assessment can be used to identify targets for rehabilitation and compensatory strategies. Speech and language therapy is recommended for aphasia. Cognitive rehabilitation designed to restore or replace function through compensatory strategies or adaptive technology is generally considered reasonable practice. The guidelines detail more specific strategies that are supported or may be considered. In general, the utility of medications to address cognition was not well established.
Speech therapists, who play a role in cognitive rehabilitation, can also assist in management of dysphagia, the difficulty with swallowing that is common after stroke. Assessment of swallowing before an individual begins to eat or drink is recommended. Oral hygiene strategies should be employed to reduce the risk of aspiration pneumonia, and behavioral therapy and principles of neuroplasticity may be reasonably incorporated into treatment.
Other common deficits after stroke can be targeted in rehabilitation. Intensive, repetitive, mobility-task training is recommended for individuals with gait limitation because of their stroke. Strengthening tasks are considered reasonable to address mobility and gait issues as well as to assist in recovering upper extremity functioning. Constraint-induced movement therapy and neuromuscular electrical stimulation is reasonable for upper extremity concerns. With upper extremity paresis, deficits in instrumental activities of daily living (IADLs) are common. Therefore, practice with ADLs and IADLs should occur and functional tasks should be practiced repeatedly. Therapies should be tailored to individual needs. Individuals at risk for falls should be provided with balance training and prescribed assistive devices if appropriate. Exercise programs designed to address deconditioning, increase cardiovascular fitness, and reduce the risk of another stroke is beneficial. When individuals are ready to be discharged from therapy, a home exercise program is indicated. Treatment for visual field, visuospatial, and eye movement deficits can be addressed in therapy.
As individuals continue to make progress in their therapies, returning to work and driving may be considered. Vocational rehabilitation is considered reasonable, and an on-the-road driving test is recommended. If an individual is not able to safely drive during the assessment, driver’s rehabilitation may be beneficial. Depression and anxiety are common after stroke with almost a third of individuals reporting depression after their injury.6 To address mood issues, education about stroke is recommended, and consultation with psychiatrists or psychologists can be useful. Anti-depressants have been found to be useful. Caregivers may also experience emotional distress as a result of the stroke. When they are supported, there is a positive benefit to the caregiver and individual who experienced the stoke. Community-based rehabilitation, such as quality outpatient therapy services, have been shown to reduce stress on caregivers as well as improve functional independence and participation in the community amongst stroke survivors.
WHAT IS GOOD DATA?
Practice guidelines are determined by research findings and consensus statements. Before a decision to recommend a new treatment or medication is made, the potential risks and benefits must be weighed via scientific research. The best data comes from studies that have a large and varied population (different genders, races, etc.) and utilize a randomized controlled trial design or metanalyses to draw conclusions. The more times a finding is replicated, the more likely the finding is not just chance. Unfortunately, science is expensive and time-consuming, and sometimes research cannot be conducted because refusing care or assigning deliberately poor care is unethical. In these cases, decisions may be made on just a few studies or research done in a less varied population. When that occurs, recommendations and guidelines may not be as strong as conclusions that can be drawn.
1. Benjamin EJ, Blaha MJ, Chiuve SE, et al. on behalf of the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics—2017 update: a report from the American Heart Association. Circulation. 2017;135:e229-e445.
2. 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 Feb 1;123(4):e18-e209. Epub 2010 Dec 15.
3. Brain Basics: Preventing Stroke. National Institute of Neurological Disorders and Stroke. https://www.ninds.nih.gov/Disorders/PatientCaregiver-Education/Preventing-Stroke. Updated on January 31, 2019. Accessed on June 4, 2019.
4. Winstein CJ, Stein J, Arena R. et al. Guidelines for adult stroke rehabilitation and recovery: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2016. 47(6), e98-e169.
5. Tatemichi TK, Desmond DW, Stern Y, Pai M, Sano M, Bagiella E. Cognitive impairment after stroke: frequency, patterns, and relationssip to functional abilities. Journal of Neurology, Neurosurgery, and Psychiatry. 1994; 57: 202-207.
6. Paolucci S. Epidemiology and treatment of post-stroke depression. Neuropsychiatr Dis Treat. 2008;4(1):145–154.
American Stroke Association https://www.strokeassociation.org/en
National Institute of Neurological Disorders and Stroke https://www.ninds. nih.gov/Disorders/All-Disorders/Stroke-Information-Page
The Internet Stroke Center http://www.strokecenter.org/patients/aboutstroke/what-is-a-stroke/
Center for Disease Control and Prevention https://www.cdc.gov/stroke/ index.htm