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Evaluation of and controversies in stroke rehabilitation
Evaluation of and Controversies in Stroke Rehabilitation Fletcher McDowell
The decline in stroke mortality, increased longevity, and modest increases in the incidence of stroke result in more individuals living with physical disability caused by cerebrovascular disease. This is creating an increasing burden on the facilities and expertise of individuals who are concerned with the rehabilitation of the patient after stroke. The costs of rehabilitation services are considerable, and there is concern about the cost-effectiveness of rehabilitative care for pat ients with stroke. Not every individual following a stroke is a candidate for rehabilitative therapy. A number of investigations have been conducted as to who is most likely to benefit from stroke rehabilitation. Third-party reimbursers in the United States have made determinations on this issue and have set guidehnes for admission criteria for inpatient rehabihtation. Admission criteria include that the patient must (a) be medically stable, (b) be responsive to verbal or visual stimuli, (c) have sufficient mental alertness to participate in a program, and (d) have a condition that indicates a potential for rehabilitation with a reasonable expectation of improvement. The patient must be able to enter a program that requires at least 3 h of active participation per day in physical therapy, occupational therapy, speech therapy, or rehabilitation nursing. A number of attempts have been made to determine from the large population of patients with stroke which ones might be the best candidates for rehabilitation. Assuming a population of 100 patients following an ischemic cerebral infarction 14 days after the ons et of stroke, approximately 14% of the patients will be dead, 13% will be normal, 20% will have hemiplegia, 49% will have hemiparesis, and 4% will have monoparesis. Thus, 73% of the total are potential candidates for inpatient rehabilitation. Analyzing this group of 73 patients, approximately 18-24 will be too well to need inpatient rehabilitation and 18-24 will be too neurologically impaired or medically unstable to
be able to enter a rehabilitation program, leaving approximately one-quarter to one-third of the total group as good candidates for rehabilitation. Similar findings have been reported from Great Britain in a study of 1,094 patients following stroke (1). Only 11% were considered suitable for rehabilitation. Eighteen percent of the group had a full recovery, 29% were dead within 2 months after admission, and 42% were unstable either because of the severity of the stroke or other medical illness. Thus, a relatively small percentage of the total population of patients with stroke are candidates for rehabilitation and can be expected to make enough improvement to justify the expense of further hospitalization. The average duration of hospitalization in rehabilitation centers for patients with stroke varies considerably across the United States and varies from 2 to 6 weeks. Criteria for admitting patients vary considerably dependmg on the view of the admitting physician and on the rehabilitation potential of the patient. The cost of rehabilitation care is considerable. At the Burke Rehabilitation Hospital, where the average patient with stroke has a length of stay of approximately 47 days, the cost of delivering inpatient care is approximately $23,000. The exact ingredients that make up a rehabilitation program for a patient with stroke are difficult to identify. Many patients with stroke have natural recovery of some neurological function in the 4-5 days after the onset of stroke, if any neurological recovery occurs at all. In the most common kind of stroke involving the right or left cerebral hemisphere, there usually is some sparing of trunk and leg function so that patients have some retention of voluntary leg movement and often are able to learn to ambulate. Arm function rarely returns to the point where it is useful (2). A number of things occur in a rehabilitation program that can be identified. First, those individuals that have right hemiparesis or hemiplegia learn by
J STROKE CEREBROVASCDIS, VOL
2, NO.1, 1992
61
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repeated instruction and experience to become largely left-handed and do those things with their uninvolved arm, which was not previously possible (3). Those patients with left hemiparesis learn how to manage daily activities using only one functional upper extremity. Patients in rehabilitation programs are taught how to dress and how to transfer from bed to chair and from chair to toilet using the arm and leg on the uninvolved side and the remaining function in the upper and lower extremity on the involved side. This is done by repeated encouragement and instruction from physical and occupational therapists. The example set by seeing what other patients with stroke can manage to do with disability is of great importance in stimulating the patient to improve function. There is no evidence that rehabilitation programs have any effect in restoring neurological function. However, it is possible for patients to learn how to become and remain highly functional in daily activities despite remaining and persistent neurological disability. Communication problems for patients with dysphasia are overcome by having the patient learn new strategies for using what communicative ability remains and for educating families and acquantances of the patient to help the patient in expressing his needs. Learning how to perform daily functional activities despite persistent neurological deficit requires an ability to learn and retain new information; this is difficult if there is considerable intellectual loss. Patients must be interested in improving function, despite the problem of significant loss of neurological function. Depression is an important factor in successful stroke rehabilitation. Numerous reports indicate that over 50% of patients with stroke are depressed at the time they enter rehabilitation programs (4-7). Controlled treatment trials using antidepressants have shown that, if the depression is treated, patients improve more rapidly and often have a better outcome than patients who are not so treated (8,9). Retained lower extremity function is extremely important because any restoration of the ability to use remaining function in a paretic leg usually means that the patient can ambulate. This is often assisted by proper bracing of the lower extremity correcting foot drop and ankle and knee instability, both of which are common consequences of hemispheric stroke and which rarely improve spontaneously. The outcome of programs of rehabilitation depends on the nature of the disability and also the amount and site of brain damage resulting from the stroke. Studies at the Burke Rehabilitation Hospital over the past 5 years have demonstrated that those
62
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patients who have primarily motor deficits have by far the best outcome (10). If in addition to the motor deficit there is a sensory impairment on the same side, the outcome expectations decline. If the patient has visual impairment in addition to the motor and sensory impairment, the outcome is questionable at best. It is necessary for rehabilitation programs to set realistic goals for patient function. These must be based on the degree of impairment the patient has and the structural problems of living at home. Those patients who have primarily motor involvement have an excellent chance of being able to walk 150 feet WIthout assistance, whereas those patients with motor, sensory, and visual impairments are unlikely to achieve this goal. Achieving independence in daily activities is much more likely to occur in a patient with only motor impairment and almost completely unhkely to occur in an individual who suffers from motor, sensory, and visual impairment on one side of the body. Follow-up studies of outcome over 2 years show that patients who have recovered enough function to go home following rehabilitation usually are able to remain at home. They retain improved function as long as intercurrent medical illness does not complicate the situation. The time course of improvement in function following stroke has been studied in a number of centers, both in the United States and in the United Kingdom (11,12). Neurological improvement occurs in the first few days after stroke, and functional improvement occurs within the first 3 months following stroke. This is reported to occur in the Framingham Study in those patients who were or were not involved in rehabilitation programs After approximately 3 months, there is little or no further improvement in such functions as language, performance of daily activities, mobihty, or intellect (12). Studies at the Burke Rehabilitation Hospital on the outcome for rehabilitation programs show plateaus of improved function at about 3-4 months following the onset of stroke for patients with all varieties of neurological impairment following stroke (10). A number of efforts have been made to identify those elements of a rehabilitation program that are most likely to contribute to improvement and their manipulation to hasten the recovery process or improve its outcome. Information from animal studies of stroke have shown that pharmacological agents, mainly amphetamine, may hasten recovery (13). In rat experiments in which the motor and sensory cortex has been removed, the administration of amphetamine causes
AIREN-NINDS1991 WORKSHOP
rapid improvement of motor 'function when compared to untreated animals. In these experiments, physical restraint retards improvement, and motor retraining augments the amphetamine effect. A number of agents including haloperidol, diazepam, Dilantin, c1onidine, and prazosin have been found to delay recovery in experimental stroke and in some instances to reinstate a physical deficit after recovery. Many of these agents are given to patients either prior to stroke or during their acute hospitalization. They are now being investigated in humans to see whether they impair the return of function or the rehabilitation process (14,15). The ability of amphetamine to alter the rehabilitation process has been studied in a small number of individuals with stroke with some suggestion that using this agent wiII improve outcome in rehabilitation programs (16). Rehabilitative programs for those patients with stroke who are suitable candidates are fairly effective in returning patients to some degree of functional independence and ability to hve at home. The number of patients who annually have a stroke and are suitable for rehabihtation programs remains small. The process of relearning and restoring normal function despite persistence of neurological deficit is difficult; in some cases, it is impossible, depending on the degree of neurological impairment Rehabilitation programs have enabled a large number of patients with stroke to remain at home, rather than become dependent on nursing home care and state support This justifies the rather sizable expense for carrying out those programs Application of rehabilitation programs similar to those found in affluent societies to other parts of the world is very problematical. WIth limited health care financing in most countries, it is likely that the cost-effectiveness of stroke rehabilitation does not match the need of health care funds for other conditions affecting large segments of the population that have the potential for a cure.
References 1. Smith DS, Goldenberg E, Ashburn A, et al. Remedial therapy after stroke-a randomized controlled trial. Br Med J 1981;282:517-20. 2 Stern PH, McDowell FH, MJiler ]M, Robinson M. Factors mfluencing stroke rehabilitation. Stroke 1971;2: 213-8. 3. Stern PH, McDowell FH, MJiler ]M, Robinson M. Effects of facilitation exercise techniques in stroke rehabihtation Arch Phys Med RehabII1970;51:526-31. 4. Folstein MF, Mailberger R, McHugh PRo Mood disorders as a specific complication of stroke. JNeutol Neurosurg Psyc1llatry 1977;40:1018-20. 5. Finklestein 5, Benowitz L, Baldessarinni R. Mood vegetative disturbances and dexamethasone suppression test after stroke. Ann NeuroI1982;12:463-8. 6 Robinson RG, Kubos KI, Starr LB, Rao K, Price TR The mood disorders in stroke patients importance of location of lesion Brain 1984;10781-93. 7. Reding M, Orto L, WJilensky P, et al The dexamethasone suppression test, an indicator of depression in stroke but not a predictor of rehabihtation outcome. Arch Neural 1985;42:209-12. 8 Reding M], Bush DB, Winter SW, McDowell FH The stability of functional improvement and in-home management post stroke (abstr). Stroke 1986,17:139. 9. Reding M], Orto LA, Winter SW, et al. Antidepressant therapy after stroke. A double-blind tnal Arch Neural 1986;43:763-5 10. Reding M], Potes E. Rehabihtation outcome following Initial unilateral hernisphenc stroke life table analysis approach Stroke 1988;19:1354-8. 11. Wade DT, Wood VA Recovery after stroke: the first three months J Neurol Neurosurg Psychiatry 1985;48:7-13 12. Kelly-Hayes M, Wolf PA, Kase CS, et al. TIme course of functional recovery after stroke. J Neuro Rehab 1989; 365-70. 13 Feeney DM, Sulton RL Pharmacotherapy of recovery of function after brain injury. CRC Cnt Rev Neurobiol 1987;3:135-97. 14 Goldstein LB,Davis]N Physician prescribing palterns after ischemic stroke. Neurology 1988,38:1806-9. 15. Goldstein LB,Matchar DB, Morgenlander ]C, Davis ]N. The influence of drugs on the recovery of sensorimotor function after stroke. J Neuro Rehab 1990;4:137-44 16. Crisotomo EA, Duncan PW, Propst MA, et al. Evidence that amphetamine WIth physical therapy promotes recovery of motor function in stroke patients Ann Neural 1988;23.94-7
J STROKE CEREBROVASC DIS , VOL 2, NO.1, 1992 63
The decline in stroke mortality, increased longevity, and modest increases in the incidence of stroke result in more individuals living with physical disability caused by cerebrovascular disease. This is creating an increasing burden on the facilities and expertise of individuals who are concerned with the rehabilitation of the patient after stroke. The costs of rehabilitation services are considerable, and there is concern about the cost-effectiveness of rehabilitative care for pat ients with stroke. Not every individual following a stroke is a candidate for rehabilitative therapy. A number of investigations have been conducted as to who is most likely to benefit from stroke rehabilitation. Third-party reimbursers in the United States have made determinations on this issue and have set guidehnes for admission criteria for inpatient rehabihtation. Admission criteria include that the patient must (a) be medically stable, (b) be responsive to verbal or visual stimuli, (c) have sufficient mental alertness to participate in a program, and (d) have a condition that indicates a potential for rehabilitation with a reasonable expectation of improvement. The patient must be able to enter a program that requires at least 3 h of active participation per day in physical therapy, occupational therapy, speech therapy, or rehabilitation nursing. A number of attempts have been made to determine from the large population of patients with stroke which ones might be the best candidates for rehabilitation. Assuming a population of 100 patients following an ischemic cerebral infarction 14 days after the ons et of stroke, approximately 14% of the patients will be dead, 13% will be normal, 20% will have hemiplegia, 49% will have hemiparesis, and 4% will have monoparesis. Thus, 73% of the total are potential candidates for inpatient rehabilitation. Analyzing this group of 73 patients, approximately 18-24 will be too well to need inpatient rehabilitation and 18-24 will be too neurologically impaired or medically unstable to
be able to enter a rehabilitation program, leaving approximately one-quarter to one-third of the total group as good candidates for rehabilitation. Similar findings have been reported from Great Britain in a study of 1,094 patients following stroke (1). Only 11% were considered suitable for rehabilitation. Eighteen percent of the group had a full recovery, 29% were dead within 2 months after admission, and 42% were unstable either because of the severity of the stroke or other medical illness. Thus, a relatively small percentage of the total population of patients with stroke are candidates for rehabilitation and can be expected to make enough improvement to justify the expense of further hospitalization. The average duration of hospitalization in rehabilitation centers for patients with stroke varies considerably across the United States and varies from 2 to 6 weeks. Criteria for admitting patients vary considerably dependmg on the view of the admitting physician and on the rehabilitation potential of the patient. The cost of rehabilitation care is considerable. At the Burke Rehabilitation Hospital, where the average patient with stroke has a length of stay of approximately 47 days, the cost of delivering inpatient care is approximately $23,000. The exact ingredients that make up a rehabilitation program for a patient with stroke are difficult to identify. Many patients with stroke have natural recovery of some neurological function in the 4-5 days after the onset of stroke, if any neurological recovery occurs at all. In the most common kind of stroke involving the right or left cerebral hemisphere, there usually is some sparing of trunk and leg function so that patients have some retention of voluntary leg movement and often are able to learn to ambulate. Arm function rarely returns to the point where it is useful (2). A number of things occur in a rehabilitation program that can be identified. First, those individuals that have right hemiparesis or hemiplegia learn by
J STROKE CEREBROVASCDIS, VOL
2, NO.1, 1992
61
AIREN-NINDS1991 WORKSHOP
repeated instruction and experience to become largely left-handed and do those things with their uninvolved arm, which was not previously possible (3). Those patients with left hemiparesis learn how to manage daily activities using only one functional upper extremity. Patients in rehabilitation programs are taught how to dress and how to transfer from bed to chair and from chair to toilet using the arm and leg on the uninvolved side and the remaining function in the upper and lower extremity on the involved side. This is done by repeated encouragement and instruction from physical and occupational therapists. The example set by seeing what other patients with stroke can manage to do with disability is of great importance in stimulating the patient to improve function. There is no evidence that rehabilitation programs have any effect in restoring neurological function. However, it is possible for patients to learn how to become and remain highly functional in daily activities despite remaining and persistent neurological disability. Communication problems for patients with dysphasia are overcome by having the patient learn new strategies for using what communicative ability remains and for educating families and acquantances of the patient to help the patient in expressing his needs. Learning how to perform daily functional activities despite persistent neurological deficit requires an ability to learn and retain new information; this is difficult if there is considerable intellectual loss. Patients must be interested in improving function, despite the problem of significant loss of neurological function. Depression is an important factor in successful stroke rehabilitation. Numerous reports indicate that over 50% of patients with stroke are depressed at the time they enter rehabilitation programs (4-7). Controlled treatment trials using antidepressants have shown that, if the depression is treated, patients improve more rapidly and often have a better outcome than patients who are not so treated (8,9). Retained lower extremity function is extremely important because any restoration of the ability to use remaining function in a paretic leg usually means that the patient can ambulate. This is often assisted by proper bracing of the lower extremity correcting foot drop and ankle and knee instability, both of which are common consequences of hemispheric stroke and which rarely improve spontaneously. The outcome of programs of rehabilitation depends on the nature of the disability and also the amount and site of brain damage resulting from the stroke. Studies at the Burke Rehabilitation Hospital over the past 5 years have demonstrated that those
62
/ STROKECEREBROVASCDIS, VOL 2, NO.1, 1992
patients who have primarily motor deficits have by far the best outcome (10). If in addition to the motor deficit there is a sensory impairment on the same side, the outcome expectations decline. If the patient has visual impairment in addition to the motor and sensory impairment, the outcome is questionable at best. It is necessary for rehabilitation programs to set realistic goals for patient function. These must be based on the degree of impairment the patient has and the structural problems of living at home. Those patients who have primarily motor involvement have an excellent chance of being able to walk 150 feet WIthout assistance, whereas those patients with motor, sensory, and visual impairments are unlikely to achieve this goal. Achieving independence in daily activities is much more likely to occur in a patient with only motor impairment and almost completely unhkely to occur in an individual who suffers from motor, sensory, and visual impairment on one side of the body. Follow-up studies of outcome over 2 years show that patients who have recovered enough function to go home following rehabilitation usually are able to remain at home. They retain improved function as long as intercurrent medical illness does not complicate the situation. The time course of improvement in function following stroke has been studied in a number of centers, both in the United States and in the United Kingdom (11,12). Neurological improvement occurs in the first few days after stroke, and functional improvement occurs within the first 3 months following stroke. This is reported to occur in the Framingham Study in those patients who were or were not involved in rehabilitation programs After approximately 3 months, there is little or no further improvement in such functions as language, performance of daily activities, mobihty, or intellect (12). Studies at the Burke Rehabilitation Hospital on the outcome for rehabilitation programs show plateaus of improved function at about 3-4 months following the onset of stroke for patients with all varieties of neurological impairment following stroke (10). A number of efforts have been made to identify those elements of a rehabilitation program that are most likely to contribute to improvement and their manipulation to hasten the recovery process or improve its outcome. Information from animal studies of stroke have shown that pharmacological agents, mainly amphetamine, may hasten recovery (13). In rat experiments in which the motor and sensory cortex has been removed, the administration of amphetamine causes
AIREN-NINDS1991 WORKSHOP
rapid improvement of motor 'function when compared to untreated animals. In these experiments, physical restraint retards improvement, and motor retraining augments the amphetamine effect. A number of agents including haloperidol, diazepam, Dilantin, c1onidine, and prazosin have been found to delay recovery in experimental stroke and in some instances to reinstate a physical deficit after recovery. Many of these agents are given to patients either prior to stroke or during their acute hospitalization. They are now being investigated in humans to see whether they impair the return of function or the rehabilitation process (14,15). The ability of amphetamine to alter the rehabilitation process has been studied in a small number of individuals with stroke with some suggestion that using this agent wiII improve outcome in rehabilitation programs (16). Rehabilitative programs for those patients with stroke who are suitable candidates are fairly effective in returning patients to some degree of functional independence and ability to hve at home. The number of patients who annually have a stroke and are suitable for rehabihtation programs remains small. The process of relearning and restoring normal function despite persistence of neurological deficit is difficult; in some cases, it is impossible, depending on the degree of neurological impairment Rehabilitation programs have enabled a large number of patients with stroke to remain at home, rather than become dependent on nursing home care and state support This justifies the rather sizable expense for carrying out those programs Application of rehabilitation programs similar to those found in affluent societies to other parts of the world is very problematical. WIth limited health care financing in most countries, it is likely that the cost-effectiveness of stroke rehabilitation does not match the need of health care funds for other conditions affecting large segments of the population that have the potential for a cure.
References 1. Smith DS, Goldenberg E, Ashburn A, et al. Remedial therapy after stroke-a randomized controlled trial. Br Med J 1981;282:517-20. 2 Stern PH, McDowell FH, MJiler ]M, Robinson M. Factors mfluencing stroke rehabilitation. Stroke 1971;2: 213-8. 3. Stern PH, McDowell FH, MJiler ]M, Robinson M. Effects of facilitation exercise techniques in stroke rehabihtation Arch Phys Med RehabII1970;51:526-31. 4. Folstein MF, Mailberger R, McHugh PRo Mood disorders as a specific complication of stroke. JNeutol Neurosurg Psyc1llatry 1977;40:1018-20. 5. Finklestein 5, Benowitz L, Baldessarinni R. Mood vegetative disturbances and dexamethasone suppression test after stroke. Ann NeuroI1982;12:463-8. 6 Robinson RG, Kubos KI, Starr LB, Rao K, Price TR The mood disorders in stroke patients importance of location of lesion Brain 1984;10781-93. 7. Reding M, Orto L, WJilensky P, et al The dexamethasone suppression test, an indicator of depression in stroke but not a predictor of rehabihtation outcome. Arch Neural 1985;42:209-12. 8 Reding M], Bush DB, Winter SW, McDowell FH The stability of functional improvement and in-home management post stroke (abstr). Stroke 1986,17:139. 9. Reding M], Orto LA, Winter SW, et al. Antidepressant therapy after stroke. A double-blind tnal Arch Neural 1986;43:763-5 10. Reding M], Potes E. Rehabihtation outcome following Initial unilateral hernisphenc stroke life table analysis approach Stroke 1988;19:1354-8. 11. Wade DT, Wood VA Recovery after stroke: the first three months J Neurol Neurosurg Psychiatry 1985;48:7-13 12. Kelly-Hayes M, Wolf PA, Kase CS, et al. TIme course of functional recovery after stroke. J Neuro Rehab 1989; 365-70. 13 Feeney DM, Sulton RL Pharmacotherapy of recovery of function after brain injury. CRC Cnt Rev Neurobiol 1987;3:135-97. 14 Goldstein LB,Davis]N Physician prescribing palterns after ischemic stroke. Neurology 1988,38:1806-9. 15. Goldstein LB,Matchar DB, Morgenlander ]C, Davis ]N. The influence of drugs on the recovery of sensorimotor function after stroke. J Neuro Rehab 1990;4:137-44 16. Crisotomo EA, Duncan PW, Propst MA, et al. Evidence that amphetamine WIth physical therapy promotes recovery of motor function in stroke patients Ann Neural 1988;23.94-7
J STROKE CEREBROVASC DIS , VOL 2, NO.1, 1992 63