REHABILITATION OF THE STROKE PATIENT
• Stroke rehabilitation improves functional outcomes.
• A comprehensive rehabilitation team composed of physicians, nurses, therapists, and community reintegration professionals can achieve the best outcomes.
• Early evaluation of family support and the home environment is critical to prevent unnecessary institutionalization.
• Evaluation and management of modifiable stroke risk factors, such as smoking, hypertension, and diabetes, are imperative during stroke rehabilitation to prevent stroke recurrence.
• Rehabilitation of the stroke patient can be hindered by conditions such as pneumonia (usually caused by aspiration), deep venous thrombosis, urinary tract infections, shoulder pain, depression, and spasticity. Early identification and treatment of these conditions are necessary to maximize functional outcomes.
According to the National Center for Health Statistics, 5.6 million Americans live with the disability caused by a previous stroke. Stroke is the leading cause of permanent disability in adults. Conservative estimates suggest that about 45% of stroke patients have moderate to severe disabilities requiring rehabilitation.
The goals of stroke rehabilitation are to maintain and optimize medical management, to maximize functional recovery, to minimize disability, and to improve quality of life and participation in society. The rehabilitative approach endeavors to provide patient-centered care that is organized, comprehensive, and specific to the needs of the stroke patient. The concerted efforts of the patient, family, and rehabilitation team are essential for achieving these goals. Recovery after stroke can be a long and challenging process for the patient and the family. Although functional gains occur most rapidly in the first year after a stroke, additional motor recovery is possible beyond 1 year when patients are involved in targeted rehabilitation programs.
The rehabilitation team is composed of rehabilitation physicians (physiatrists), other physicians such as neurologists and neurosurgeons, rehabilitation nurses, occupational therapists, physical therapists, speech and language pathologists, rehabilitation neuropsychologists, social workers, case managers, nutritionists, vocational counselors, and pharmacists. A goal of the acute inpatient rehabilitation team is discharging the patient to the least restrictive environment, ideally home. To accomplish this goal, it is critical to evaluate family support and the home environment.
Rehabilitation should start as part of the acute stroke inpatient stay.
The decision-making process to determine the appropriate rehabilitation setting after discharge is described in Figure 1. Speech- language pathologists, physical therapists, and occupational therapists evaluate deficits in cognition, communication, deglutition, mobility, and activities of daily living. The severity of deficits in these major areas and the ability of the patient to tolerate therapy determine the appropriate rehabilitation setting.
FIGURE 1 Determination of rehabilitation needs of patients being discharged after an acute stroke.
Stroke patients with mild deficits are able to return home with home or outpatient therapy services. Patients with moderate to severe strokes benefit from more intensive therapy in an institutional setting. Comprehensive inpatient rehabilitation is suitable for patients with moderate to severe deficits who can tolerate intensive rehabilitation (3 h/day for 5 days each week or 15 hours of therapy over a 7 day period). If the severity of deficits or medical comorbidities limits the ability of the patient to participate in intensive therapy, alternate settings can be considered.
During the inpatient rehabilitation stage, medical management focuses on secondary stroke prevention: diet; exercise; smoking cessation; and reducing complications, including optimizing blood pressure control while maintaining cerebral perfusion, preventing and treating lipid disorders, and managing post-stroke pain, depression, and abnormal muscle tone. During this stage, much of the rehabilitation effort is directed toward educating stroke survivors about complications and the importance of adherence to medical recommendations.
Medical complications, such as deep venous thrombosis and related thromboembolism, pneumonia (usually related to aspiration), skin breakdown, and urinary infections, can hinder a patient’s recovery.
Early identification of these complications is necessary to maintain progress in the rehabilitation effort. Other complications, such as seizures and cardiac decompensation, are possible and should be monitored.
Stroke often causes significant impairment and activity limitations.
Deficits in strength, swallowing, vision, balance, muscle tone, communication, comprehension, cognition, attention, sensory perception, and bladder function are common and can cause difficulty completing activities of daily living, walking, transferring to and from different surfaces, and getting in and out of the bed. Post-stroke depression, fatigue, and pain are common and should be addressed to maximize participation in rehabilitative efforts.
Transition to the chronic phase begins after the patient is medically stable and inpatient therapy goals are met. Outpatient therapy services are initiated in conjunction with physiatric, primary care, and neurologic follow-up.
Hemiparesis, or one-sided weakness, is one of the most frequent complications after stroke. Recovery of motor function varies. Often, it is limited by muscle atrophy, co-contraction of agonists and antagonists, and abnormal tone. Usually, motor recovery is preceded by the development of patterned muscle movements, or synergies.
Synergies occur when select muscles contract in a predictable manner. In the paretic upper extremity, a flexion synergy pattern (i.e., humeral adduction, internal rotation, elbow flexion, forearm pronation, and wrist and finger flexion) is common. In the lower extremity, extension synergies (i.e., hip internal rotation, adduction, extension, knee extension, and ankle extension and inversion) predominate. These patterns can be regarded as functional and nonfunctional. For instance, extension synergy patterns of the lower limb can augment rehabilitation because this position fosters early ambulatory therapy. Conversely, flexion synergy patterns in the upper extremity can significantly impair arm function.
Rehabilitation of the patient with hemiparesis should concentrate on maintaining range of motion and improving strength and posturing. Exercise programs should incorporate functional use of the hemiparetic limb and weight bearing to promote limb recognition, better alignment, muscle elongation, and muscle tone reduction.
Hemiparesis can lead to contracture, particularly when profound weakness is present, and contracture occurs most commonly in the wrist and ankle. Resting hand splints and solid ankle-foot orthoses can be used to maintain the limb in a neutral position. These devices can be used to prevent loss of motion, control muscle tone, and aid in positioning, particularly when wheelchairs are necessary.
Functional electrical stimulation (FES) has gained increasing interest as a means of enhancing functional movement and strength. Muscle contraction is induced with electrical stimulation. Many products on the market incorporate FES technology for the treatment of footdrop and hand weakness.
Preservation of scapulohumeral positioning is a critical component of rehabilitation. With shoulder weakness, the scapula becomes downwardly rotated, causing the glenoid fossa to move vertically and resulting in humeral subluxation. Traditionally, shoulder slings have been prescribed for the hemiplegic shoulder, but their effectiveness in preventing subluxation is questionable.
FES has been used to augment motor return in the hemiplegic shoulder and prevent subluxation. Despite advances in the treatment of the hemiplegic shoulder, it is still unclear which therapeutic interventions should constitute the standard of care.
Constraint-induced therapy (CIT), a therapeutic approach in which the nonparetic limb is restrained, can improve functional movement of the paretic upper extremity in patients with residual hand and wrist movement, even in patients more than 1 year after a stroke.
More recently, CIT concepts have been applied to the treatment of aphasia. By limiting the use of nonverbal communication and stimulating verbal output, participants were able to improve language performance and communication.
Weight-supported treadmill training has been proposed to enhance gait training after a stroke. Although a recent clinical trial showed no clear benefit from weight-supported treadmill training on improving gait speed, walking ability, or balance, some advocate for continued research on the effects of this training on overall health, including maintaining bone mass and decreasing insulin resistance.
Dysphagia after stroke occurs acutely in approximately 50% of stroke patients. Identifying dysphagia in this population is essential for preventing associated morbidity and mortality. Stroke patients with dysphagia are at risk for dehydration, malnutrition, and aspiration pneumonia. As allowed by their overall clinical status and consciousness level, stroke patients should be evaluated as early as possible during their acute hospital stay. Trained clinicians (most commonly speech-language pathologists) should evaluate the patient to make recommendations regarding further dysphagia evaluation or testing and the need for diet modifications or dysphagia rehabilitation.
Hemiplegic Shoulder Pain
Stroke survivors with residual hemiparesis or weakness are at risk for pain syndromes (particularly in the upper extremity), which can significantly limit rehabilitation efforts. These pain syndromes are usually multifactorial. In the rehabilitation setting, prevention of shoulder pain is key, and interventions should focus on proper positioning, handling, and transfer techniques.
In severe cases, shoulder pain can be accompanied by hand swelling, tenderness, skin changes, erythema, hyperhidrosis, and allodynia. When this occurs, it is referred to as shoulder-hand syndrome, a subtype of complex regional pain syndrome (CRPS). Although the mechanism and cause are unclear, it has been suggested that this process is the result of an overreaction to a neurologic insult and may be inflammatory in nature. In some cases, the pain is severe, resulting in decreased and guarded movements of the limb that limit functional use. Shoulder pathology such as rotator cuff strains or tears, bicipital tendonitis, subacromial and subdeltoid bursitis, and glenohumeral subluxation or dislocation contribute to post-stroke shoulder pain and should be treated.
Nonpharmacologic treatment focuses on desensitization techniques, gentle range-of-motion exercises, and physical modalities (e.g., heat, cold, transcutaneous electrical nerve stimulation [TENS], FES).
Pharmacologic management includes medications typically used for neuropathic pain syndromes, such as anticonvulsants, tricyclic antidepressants (TCAs), nonsteroidal anti-inflammatory drugs, topical agents (e.g., lidocaine [Xylocaine],1 clonidine [Catapres-TTS],1 capsaicin [Zostrix]1), and injections of steroid or local anesthetics.
Antispasmodic medications have been used. When pain relief is not achieved with conservative treatment, sympathetic blocks can be considered. Sympathectomies and spinal cord stimulators can be considered as last resorts.
Spasticity after stroke can significantly impact rehabilitation. The classic upper extremity flexor synergy pattern (i.e., adducted shoulder with flexed elbow, wrist, and fingers) can markedly interfere with the function of the affected arm. Conversely, the classic lower extremity extensor synergy pattern (i.e., extended hip and knee and ankle plantar flexion) can be advantageous for ambulation if plantar flexion can be controlled by physical or pharmacologic agents. If untreated, these patterns can lead to abnormal positioning and contracture.
Treatment of spasticity after stroke should address positioning and exacerbating factors. Splinting or bracing, appropriate wheelchair sitting position, and physical therapy techniques are important to prevent contracture and promote motor recovery. Painful or noxious stimuli can exacerbate spasticity. Shoulder pain, pressure sores, deep venous thrombosis, bladder distention, and constipation are examples of stimuli that can exacerbate spasticity. Pharmacologic treatment should take into account the presence of these triggers because spasticity is likely to improve after the stimuli are resolved or relieved.
Pharmacologic treatment of post-stroke spasticity presents some challenges. Effective antispasticity agents such as baclofen (Lioresal) or tizanidine (Zanaflex) can cause somnolence or weaken unaffected muscles, which can significantly affect rehabilitation. Localized treatments such as botulinum toxins (Botox, Dysport, Myobloc, Xeomin)1 injections or phenol blocks1 can be useful, because treatment can be directed toward muscles that are affecting functional use of the limbs. Surgical interventions can be used for patients with severe spasticity limiting functional positioning or for those with the potential for functional grip if tendon lengthening or transfer can be considered.
Stroke patients can experience many cognitive deficits, including visuospatial neglect, cognitive-linguistic deficits, apraxia, memory loss, and attention deficits. Cognitive rehabilitation should concentrate on treatment of the specific deficits of the patient.
Visuospatial rehabilitation (including scanning training) is recommended for deficits associated with visual neglect after right stroke. Cognitive-linguistic therapies are recommended for left hemispheric stroke patients with language deficits. Treatment of apraxia should include specific gestural and strategy training.
The use of medications that may impair cognitive function should be limited. Medications that are commonly considered during a stay in a rehabilitative facility that may have a significant impact on cognition and rehabilitation are highlighted in Table 1.
Neuropharmacologic Agents Commonly Used During Stroke Rehabilitation
1 Not FDA approved for this indication.
Depression and Neuropharmacology
Depression can be seen in up to one half of all stroke patients. It has been associated with poor functional outcomes and more severe impairments. Vegetative symptoms can have a significant impact on rehabilitative efforts because participation in therapy is critical.
Psychoactive drugs can be beneficial and should be considered.
Selective serotonin reuptake inhibitors (SSRIs) are recommended in this population because of a better side effect profile and because of the undesirable anticholinergic side effects of TCAs. In cases unresponsive to treatment with SSRIs, nortriptyline (Pamelor) may be helpful. In the rehabilitation setting when rapid short-term improvement in symptoms is necessary to increase participation in therapy, the use of psychostimulants (e.g., methylphenidate [Ritalin]1) may be indicated. Table 1 shows the neuropharmacologic agents commonly used during stoke rehabilitation. Psychotherapy has been associated with modest improvement in post-stroke depression and is considered to be part of a multidisciplinary approach. Research has demonstrated the benefit of the antidepressant fluoxetine (Prozac)1 on motor recovery; administration of the drug for 3 months as an adjunct to physical therapy improved motor functioning in post-stroke patients.
Bladder dysfunction after stroke depends on the stroke’s location. During the rehabilitation phase, the most common problem is urinary incontinence and urgency associated with uninhibited bladder contraction. Ultrasound bladder scans (usually every 4 h and after voiding) should be ordered to detect bladder distention and urinary retention. It is standard practice to intervene when bladder volumes are greater than 500 mL. If volumes exceed this cutoff point, intermittent catheterization should be started. Intermittent catheterization is preferable to indwelling catheters because the risk of urinary tract infection is higher with the latter. Bladder scans are usually discontinued when post-voiding residual volumes at 3- to 4- hour intervals are low (< 150 mL) for a period of 24 to 48 hours.
Mobility and Use of Adaptive Equipment
Activity limitations vary among stroke survivors and can include difficulties with bed mobility, wheelchair propulsion, transfers, gait, stairs, and the basic activities of daily living. The goal of physical therapy and occupational therapy is to maximize functional independence. Addressing mobility limitations is fundamental in stroke rehabilitation because it is related to long-term care needs and independence.
Transfer training comprises learning how to maneuver from one surface or height to another. Ideally, patients should learn to roll and transfer toward the involved and uninvolved sides; however, early mobility efforts are directed to the uninvolved side to minimize the risk of injury.
Gait deviations are common after stroke and interfere with safety and efficiency of locomotion. If an assistive device is needed, the goal of physical therapy is to progress to the least restrictive device possible. Hemiwalkers and wide-based quad canes provide the most stability. An ankle-foot orthosis may be indicated for patients with decreased ankle control and footdrop. Instruction in ascending or descending stairs depends on assistive device requirements. With weakness, stairs are ascended by initiating movement with the uninvolved or stronger lower extremity. This process is reversed when descending.
For some stroke survivors, functional ambulation is not a realistic goal. In these cases, the wheelchair becomes the primary means of locomotion. Wheelchair prescription requires considerable skill and training and must take into account posturing, body habitus, cognition, physical fitness level, and the home environment. An appropriate wheelchair prescription is required to maximize mobility and prevent complications such as shoulder pain. Physical and occupational therapists should evaluate the patient before providing wheelchair recommendations to vendors. Hemi wheelchairs (i.e., wheelchairs situated closer to the ground) and one-arm drive wheelchairs allow hemiplegic patients to use the uninvolved side for wheelchair propulsion. Lap boards with arm supports can be added to improve hemiparetic arm posturing and sitting symmetry.
For some stroke survivors, the ability to return to driving is considered one of the most important long-term rehabilitation goals. Formal driving rehabilitation programs are available to evaluate and improve driver safety. Driver rehabilitation specialists perform vision, cognitive, and perceptual examinations. Perception tests assess reaction times to visual and auditory stimuli. Values for vision and reaction times are standardized and state-dependent. Specialists should also perform a behind-the-wheel assessment, beginning in a parking lot and progressing to the negotiation of more complex traffic situations. Many modifications can increase independence and assist with a return to driving, including a spinner knob, which can be attached to the steering wheel to allow one-arm control; hand controls for acceleration and braking; left foot pedals to compensate for right foot impairment; and wheelchair lifts.
Adaptive equipment, including bracing, shoe modification, and other tools, increases independence through completion of activities of daily living (e.g., long-handled sponge, reacher, shoe horn, mirror, sock aids) and is extremely beneficial for those with moderate to severe strokes, particularly if hemiparesis is dense (Figure 2).
Silverware, pens, and other utensils can be modified for easier maneuverability. Multipodus boots can be used to prevent plantar flexion contracture development in the hemiparetic limb.
FIGURE 2 Adaptive equipment commonly used during stroke rehabilitation. The tapered front scoop dish (A) has nonskid feet to keep the plate from sliding. The curved edge simplifies scooping food. The dish is especially suited for individuals who have limited flexibility, have decreased motor coordination, or feed using one hand, such as a hemiparetic stroke patient. The reacher (B) is used to get items from the floor. The long-handled dressing aid (C) is used to reach clothes on the floor or to bring clothes up the paretic side. The long-handled shoe horn (D) aids with slipping into shoes. The long-handle sponge (E) is used for reaching the involved side while bathing or when the shoulder range of motion does not allow reaching. The leg lifter (F) and the sound upper limb can be used to assist in moving the paretic lower limb. Adapted feeding utensils (G) are used for patients with grip weakness or difficulties with upper limb range of motion; left to right: bent-handle spoon, no-grip fork, rocker bottom knife, and thick-handle spoon. No-tie laces (H) are elastic shoelaces that do not require tying. When using the sock-donning aid (I), the sock slides onto the plastic portion of the device, and the strap is used to pull the sock with the device on the foot.
Falls are common after moderate to severe strokes. In rehabilitation settings, fall prevention usually requires a multimodal approach.
Strategies include use of bed-chair alarms, placing those at risk close to the nursing station, wearing skid socks, limiting or refraining from polypharmacy, eliminating slick or irregular floors, and in some cases, providing a sitter for closer monitoring. Physical and occupational therapists must include general safety and fall recovery as part of the treatment plan.
Depending on the location of the stroke, the visual system may be involved. One of the most debilitating visual impairments is visuospatial neglect, a complication of right hemisphere strokes. Left- sided stimuli are not attended to or recognized, and affected individuals must learn to deal with this deficit. Other complications include gaze weakness or paralysis, diplopia, visual field loss, ptosis, tracking disorders, decreased visual acuity, and cortical blindness.
Screening for primary visual skills, including visual acuity, visual fields, and visual tracking, should be done by physiatrists, neurologists, and occupational therapists. If problems are identified, patients should be referred to neuro-ophthalmologists and low-vision rehabilitation programs. Visual acuity problems often can be addressed by incorporating the use of glasses into the therapy session or by changing the prescription. Eye movement disorders and visual field deficits usually lessen as time elapses and may respond to treatment with prisms, head positioning, and unilateral eye occlusion with tape or a patch technique. Prism therapy has also shown promise in treating hemispatial neglect. Those with continued visual field impairment should be taught eye movement techniques to expand the visual area.
Brain-Based Therapies: Noninvasive Brain Stimulation
Repetitive transcranial magnetic stimulation (rTMS) applies a brief magnetic field to the scalp with enough intensity to penetrate the skull and induce neuronal activation. Some promising results have been seen when rTMS is used after stroke. A second modality, transcranial direct current stimulation (tDCS), applies low-voltage electrical current to stimulate or modify neuronal activity in the brain cortex.
The stimulation is applied to discrete areas of the head to target affected areas. Although the side-effect profile of these techniques is positive, more research is necessary to determine best candidates for treatment and optimal treatment protocols.
The aim of robotic technology is to use an adjustable, programmable device to augment mobility in a task-specific manner. Robots can serve in an assistive (perform desired function) or therapeutic capacity (enhance gait or upper extremity function) and are suitable for this purpose as they not only enable more intensive therapy than conventional modes but also incorporate a greater degree of activity repetition. Present recommendations are for use as an adjunct to traditional rehabilitation interventions.
Stroke rehabilitation requires the concerted efforts of the patient, family, and medical professionals. A multidisciplinary team with training to address the particular impairments and functional limitations of the stroke patient is critical. The physician’s efforts should focus on preventing complications and treating stroke sequelae with the primary goal of improving overall function and participation in society.
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1 Not FDA approved for this indication.