Rehabilitation and Recovery of the Patient With Stroke

Key Points

Neurologic rehabilitation is primarily concerned with lessening physical and cognitive impairments and functional disabilities, as well as returning patients to more normal participation in daily life.
Rehabilitative strategies draw upon basic mechanisms of post-injury neural adaptations and learning and memory.
The reacquisition of skills depends on experience- and training-induced synaptic reorganization, as well as behavioral compensation.
Many preventable and reversible medical complications that may impede progress should be anticipated and managed.
Focused, progressively challenging, task-related, intensive practice clearly improves outcomes for cognitive, language, and motor skills.
Whereas most of the major improvements in the motor control related to walking and self-care occur within the first 2–3 months after stroke, further gains in speed, endurance, accuracy, and strength can be accomplished with additional practice of desired motor skills and exercise at any time after stroke.
Training may be augmented by mental practice, robotic-assists, noninvasive brain stimulation, virtual reality environments, and, potentially, by drugs that act on molecular mechanisms of learning or dendritic and axonal growth, as well as by cellular interventions that aim to reconnect a circuit or modulate circuit activation.

Mechanisms for Gains

A decrease in impairments and disabilities over the first 1–3 months after a stroke is often called spontaneous recovery . Resolution of edema, heme, ion fluxes, cell and axon physiologic dysfunction, and diaschisis from transsynaptic and neurotransmitter dysfunction, along with immune cascades and regeneration-associated gene expression and neurogenesis, may contribute to restitutive biologic activity that augments gains for up to a few months, but especially within the first 3–4 weeks after onset. Rehabilitation interventions can provide extrinsic drives that manipulate intrinsic biologic activity. For example, practice and skills learning induce activity-dependent plasticity, which include a variety of biological adaptations demonstrated in molecular, electrophysiologic, and morphologic studies in recovering animals, as well as from functional neuroimaging studies in humans. ^, Patients make gains by experience-driven or training-induced changes within partially spared pathways, across the synaptic connections of flexible neuronal assemblies that represent movements, sensation, and cognition, within connected oscillating networks, and within multiple representational maps in parallel, distributed networks. In recent years, new modalities to directly facilitate or modulate these pathways in combination with skills practice have come into clinical trials, including repetitive transcranial magnetic stimulation (TMS) or transcranial direct cortical stimulation (tDCS), drugs that may act on targets for learning and memory, and drugs, vectors, and cellular interventions for neuromodulation and tissue repair.

Rehabilitation approaches also emphasize compensatory strategies for more severe impairments and disabilities that persist. Patients are trained to substitute a latent skill, learn a new way to accomplish a goal (e.g., bend forward to enable reaching to a cup or reduce duration of weight bearing in single-limb stance on the paretic leg during stepping), alter the environment to make a task easier, or change their expectations about performing a particular task. Most compensatory approaches require learning, so gains may be reflected in experience-dependent plasticity.

The optimal duration and intensity of training are uncertain for human rehabilitation strategies. More intensive, task-oriented practice seems to enhance learning and performance for those tasks, although there are limits to the benefits of repetitive practice in the face of a degraded motor system. Most patients receive no more than a few months of formal inpatient and outpatient retraining. Intensive rehabilitation often amounts to less than 20 hours of engagement in physical, occupational, or speech therapy across many tasks. This modest amount of practice may be far less than what is required to regain the ability to walk at a speed that permits community activities or to improve word-finding skills.

Based on these potential mechanisms for lessening impairment and increasing daily functioning after stroke, approximately 300 randomized clinical trials (RCTs) of rehabilitation interventions have been published yearly for the past 5 years (retrieved from PubMed in January 2019). In addition, consensus guidelines for stroke rehabilitation, which drew upon past trials, have been published by groups in 10 countries.

Assessing Impairment, Disability, Activity, and Quality of Life

Outcome measurements that are unique to stroke rehabilitation emphasize ordinal scales that reflect changes in self-care and community-related activities. The Barthel Index (BI) and the Functional Independence Measure (FIM) are commonly used for the semi-quantification of the level of independence in activities of daily living (ADLs), which reflects the burden of caregiving. On admission to inpatient rehabilitation, the majority of patients have a moderate level of disability, with a BI of 40–60 or a total FIM score of 40–80 with a mean of 60 ( Table 60.1 ). These scales do not reflect fine motor function, the quality and time of execution of a skill, or whether an affected upper extremity is used to carry it out. Patients who score 100 on the BI or more than 60 on the motor subscore of the FIM are usually continent and can feed, bathe, and dress themselves; get up out of bed and chairs; ambulate household distances; and ascend and descend stairs. A maximum score does not imply that they can cook, keep house, live alone, and meet the public, but they usually get along without attendant care. A BI of less than 60 at hospital discharge predicts a level of dependence that makes discharge to home less likely.

Table 60.1

Metrics for First Admission for Inpatient Stroke Rehabilitation Based on National Results (419,823 Patients) Reported by the Uniform Data System for Medical Rehabilitation (2013).

Functional Independence Measure Subscores (0–7 per Item)	At Admission	At Discharge
Self-care (6 items; max 42)	20.0	30.4
Sphincter (2 items)	7.7	10.2
Mobility (3 items)	8.3	13.8
Locomotion (2 items)	3.7	8.1
Communication (2 items)	8.9	10.9
Social cognition (3 items)	12.0	15.3
Total	60.6	88.7
Patient Characteristics
Age (years)	70
Onset (days)	12
Stay (days)		13.5
Living Site (%)
Community		78
Long-term care		7.1
Acute care		9.6

FIM scale: 1 = total assistance, 4 = minimal contact help, 7 = completely independent.

A general relationship exists between motor impairment and disability scores. The Fugl-Meyer Motor Assessment is an ordinal scale with ceiling effects that reflects selective versus synergistic movements against gravity. It is often used in trials of rehabilitation interventions. Recent studies suggest that the initial Fugl-Meyer motor score obtained within 2 weeks after onset of hemiparesis for the arm or leg can be used to predict the score 3–6 months post-stroke in many patients. Most patients will regain approximately 70% of their initial selective motor control by this scale. The NIHSS score also describes the severity of impairment observed during inpatient stroke rehabilitation, but it is less sensitive to changes beyond 3 months in relationship to gains in ADLs.

Aspects of functional recovery in an affected arm are reflected in clinical trials by the Wolf Motor Function Test and the Action Research Arm Test, among others. They employ standardized arm/hand/finger tasks that are timed or rated for degree of completion. Efforts to measure the kinematics of the arm during tasks or legs during walking have required expensive motion capture systems and great expertise, but wearable sensors such as accelerometers and devices like the Kinect (Microsoft) with infrared camera and projector are increasingly finding quantitative uses. In addition, a recent 2-camera system that can be simply set up provides 3D kinematic analysis of head, trunk, arm, hand, and finger segments that are automatically identified; deep learning-based methods using convolutional neural network architectures automatically analyze the imaged data to quantify multi-joint movements during seated tasks.

Step counters are often used in trials to compare baseline and final amount of walking activity after a mobility intervention. They are most accurate for capturing the slow walking speeds at less than 0.8 m/s of hemiparetic persons when worn on the lower leg, rather than waist or wrist. Wearable sensors with an accelerometer, gyroscope, Bluetooth, and other features have begun to offer continuous scale measures of walking speed, distance, step count, and spatiotemporal features such as stance and swing-time symmetry for every bout of walking. Most were designed for a laboratory, but they should become more available for community monitoring of gait and arm use, as well as provide repeated remotely obtained outcome measurements. By using the data for behavioral reinforcement, sensors can serve as a tool for tele-rehabilitation, self-management, and treatment compliance.

Health-related QOL, which includes a patient’s perception of physical functioning as well as mental, psychosocial, and emotional state, has been measured most often by the Stroke Impact Scale (SIS). This self-report tool with 64 items (a short form includes 16) assesses eight domains and covers strength, hand function, ADLs, instrumental ADLs, mobility, communication, memory, emotion, thinking, and participation. Self-reports may over- and understate the ground truth about exercise and activity.

Organization of Services

Patients who are at a supervised or minimally assisted level of self-care are usually discharged from the acute hospital setting to the home with either home health or outpatient therapy. By the end of the first 2 weeks after a stroke, and usually by 5 days after onset, up to 20% of patients in the United States are referred for inpatient rehabilitation. These patients must need ongoing supervision by physicians and nurses, have enough stamina to participate in rehabilitation therapies for at least 3 hours a day, and have adequate psychosocial supports, so the rehabilitation team can anticipate discharge to the home or to a board-and-care facility. Further criteria include adequate motivation and cognition for learning. Patients who do not meet these criteria may receive therapies in a skilled nursing facility. In the United States, the average acute rehabilitation unit stay has fallen to approximately 14 days compared to 20 days early in this century and 4–6 weeks in the 1980s. This shortened period of insurance-covered hospital care in the United States may have resulted in greater selectivity for rehabilitation admissions, and more moderately impaired and fewer severely impaired patients. Facilities in Japan and Switzerland, among other countries, are allowed acute rehabilitation unit stays for approximately 60 days.

The earlier the initiation of an inpatient rehabilitation program (within 20 days of onset of stroke compared to 20–60 days in subjects with similar levels of disability), the better the outcomes. Recent trials have not revealed any advantage of initiating mobility-related therapy within 24 hours of onset. Length of stay during inpatient rehabilitation is discussed during weekly conferences in which the team reassesses the patient’s progress toward reasonable functional goals, which most often include the ability to walk 150 feet, transfer to the toilet, and take nutrition safely with no more than minimal caregiver assistance. Patients often need medical equipment for discharge, such as a lightweight wheelchair, a cane, an ankle-foot-orthosis (AFO), and a tub bench, along with follow-up medical and disability-oriented community care.

The milieu of a dedicated rehabilitation unit improves outcomes, partly from the focus on prevention of medical complications related to immobility, on retraining functional activities, on family training, on the intensity of retraining skills, on early recognition of mood disorders, and on organizing outpatient follow-up.

Community mobility, cooking and cleaning skills, leisure activities, social isolation, and support for caregivers often continue to be problematic for 2-year survivors of a stroke. The clinician should ask about instrumental ADLs and mobility during chronic care. A brief, intermittent pulse of outpatient therapy, focused on the maintenance or better recovery of specifically trained skills, is now covered under Medicare in the United States on a yearly basis. The gains noted in most RCTs of interventions carried out beyond 1 year after stroke support this potential for better functioning.

Rehabilitation-Related Medical Complications

During inpatient rehabilitation, approximately one-third of patients have a urinary tract infection, urinary retention, musculoskeletal pain, or depression. Up to 20% fall, experience a rash, or need continuous management of blood pressure, hydration, nutrition, or glucose levels. Approximately 10% have a transient toxic-metabolic encephalopathy, pneumonia, cardiac arrhythmias, pressure sores, or thrombophlebitis. Up to 5% have a pulmonary embolus, seizures, gastrointestinal bleeding, heart failure, or other medical complications. Beyond inpatient care, bowel and bladder dysfunction, pain-induced spasticity, and other complications require ongoing vigilance. Levels of evidence for treatments of common complications were reviewed in a consensus statement.

Bladder Dysfunction

Urinary incontinence occurs in up to 60% of patients in the first week after a stroke, but the rate tends to decline to less than 25% at hospital discharge without a specific medical treatment. Across studies, approximately 18% of those who were incontinent at 6 weeks after stroke are still so at 1 year. Urinary tract infections develop in approximately 40% of patients during acute stroke and rehabilitation care. Persistent lack of bladder control is often secondary to an unstable detrusor muscle or to detrusor-sphincter dyssynergia.

In patients with retention of urine volumes greater than 250 mL, intermittent bladder catheterization with a clean technique probably lessens the risk of an infection, although there is little evidence for this claim. Perineal cleanliness should lessen the risk of infection by fecal contamination. Most patients with incontinence after a hemispheric stroke have either a small bladder and are unable to suppress the micturition reflex or become aware of filling too late to void in a urinal, commode, or toilet. Scheduled voiding is one good approach. Urodynamic testing, usually not performed as an inpatient, may point to an abnormality of urine filling and storage, bladder emptying, or a combination of both, making the choice of medication more rational. Use of an anticholinergic agent such as 5 mg of oxybutynin before sleep may allow greater filling and less urgency or incontinence overnight. Medications may reduce outlet obstruction in men, but prostate surgery may be indicated for a stable outpatient.

Musculoskeletal and Central Pain

Pain is common after a stroke and can limit participation in therapy. Central pain may become a major source of disability, especially after a thalamic-parietal stroke, but affects fewer than 5%. Some patients only need assurance that the pain or dysesthesia does not represent a serious complication or a warning signal of another stroke.

Shoulder pain in the hemiparetic arm develops in 5%–50% of patients in different studies. Pain exacerbates hypertonicity and may trigger flexor and extensor spasms and dystonic postures. Physical modalities, analgesics, anti-inflammatory agents, and an occasional local anesthetic or steroid injection reduce most sources of musculo-ligamentous pain. A sling for the shoulder or an orthotic to hold the wrist and fingers in extension may also prevent further complications.

Burning or hypersensitivity from central pain may respond to gabapentin, carbamazepine, lamotrigine, tricyclic antidepressants, pregabalin, baclofen, and other medications, based on small RCTs.

Depression

Depression was diagnosed in the community-based Framingham Study in 47% of 6-month stroke survivors, but was simultaneously diagnosed in 25% of age- and sex-matched controls. In a population-based cohort of Swedish patients with stroke whose mean age was 73 years, the prevalence of major depression was 25% at hospital discharge, 30% at 3 months after stroke, 16% at 1 year, 19% at 2 years, and 29% at 3 years. By 3 months after stroke, greater dependence in ADLs and social isolation have been associated with depression. Premorbid depression was a strong risk factor for major depression after stroke. The symptoms that lead to a treatment trial during rehabilitation tend to be lack of motivation and carryover of therapies from day to day, feelings of fatigue and lack of energy, hopelessness, and poor sleep with recurrent negative thoughts, which seem to limit progress.

Counseling during rehabilitation may lessen the risk for depression, especially when directed toward concerns that patients have about becoming a burden on others. A meta-analysis of 52 rather small trials of one of several selective serotonin reuptake inhibitors (fluoxetine, sertraline, citalopram and others) suggested a modest benefit, compared to no treatment, on dependence, disability, impairment, anxiety, and depression at any time after stroke. Side effects were not significant. The results were quite heterogeneous, however. Tricyclic antidepressants at 10–25 mg in the evening may lessen insomnia and depression, but their anticholinergic effects may have a negative impact. Methylphenidate at a dose of 5–10 mg bid during daytime sometimes has a rapid onset of effect on mood and attention, especially in the elderly. Exercise in subacute and chronic stroke seems to lessen depression at an intensity of at least 30 minutes 3–5 days a week.

Fatigue

The symptom of fatigue after hemiparetic stroke is described by 20%–40% of community dwellers. Although a bit vague in meaning, fatigue includes sluggishness, easy tiring, low energy, lack of motivation, impaired endurance, and sleepiness. The source may be a mood disorder or psychological and physical manifestations of disability, medications, cardiovascular fitness, and disease. Symptoms may also arise from fatigability, meaning diminishing strength that follows repetitive movements, leading to greater weakness superimposed on underlying paresis, as well as from deconditioning. Interventions that have had modest success include selective serotonin reuptake inhibitor (SSRI) antidepressants or stimulants such as methylphenidate and modafinil, ruling out a sleep disorder, conditioning and strengthening exercises, and scheduled rest periods after scheduled physical activity.

Dysphagia

Swallowing disorders may cause malnutrition, dehydration, and aspiration pneumonia. The stroke and any associated toxic-metabolic encephalopathy may combine to cause lethargy, inattention, poor judgment, and impaired control or sensitivity of the tongue and cheek. These problems often impair the oral stage of swallowing. Patients cannot form a bolus; food is pocketed in the cheek; the swallowing reflex may be delayed; and the bolus slides over the base of the tongue and collects in the valleculae and hypopharynx. In addition, patients may take too much food or liquid in a bolus, which then enters the airway before triggering a swallow reflex. Slow oral intake, a cough or wet voice after swallowing, and a rising blood urea nitrogen level point to the potential for clinical complications of dysphagia. Risk factors and predictors of the need for a feeding tube include older age, stroke severity on admission, lesion location (frontal operculum), initial risk of aspiration, and initial impairment of oral intake. Fiberoptic endoscopic evaluation of swallowing (FEES) can identify pharyngeal dysphagia. A videofluoroscopic modified barium swallow (MBS) study provides the best information about the safety and efficacy of the stages of swallowing. An MBS study performed with less than a teaspoonful of thin barium, the same of thickened barium, and a test of swallowing with a barium-coated piece of cookie help document problems at the oral, pharyngeal, and esophageal stages. The therapist can simultaneously assess the effect of changes in head and neck position on deglutition. During inpatient rehabilitation, an abnormal MBS study result reveals the greater risk for pneumonia in aspirators compared to non-aspirators. Nasogastric feeding tubes and gastrostomies do not appreciably lessen the risk of aspiration, probably because of gastric reflux, aspiration of oral secretions, and errors in tube placement.

Therapies include compensatory head repositioning such as flexing or turning to one side, tongue and sucking exercises, double swallowing, and supraglottic and dry coughing. Limited trials suggest the potential value of TMS and neuromuscular electrical stimulation of pharyngeal muscles. Few high-level evidence trials are available to support any one therapy. If dysphagia persists near the time of discharge from inpatient rehabilitation, a gastrostomy or gastrojejunostomy tube is a comfortable portal for nutrition.

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