Rehabilitation for Disabling Stroke

Rehabilitation after stroke concentrates on reducing physical and cognitive impairments and the disabilities they induce so as to return patients to more independently managed self-care, mobility, communication, and daily activities. Care goals include prevention of the complications of immobility, dysphagia, pain, bowel and bladder dysfunction, sleep and mood disorders, as well as treatment of risk factors for cardiovascular disease and stroke.

Optimal management to provide retraining strategies, assistive devices, and caregiver support requires an interactive team of therapists, nurses and aides, and physicians with neurological rehabilitation, primary care, and other expertise within a model of chronic care. Only 20% of patients who suffer a stroke are admitted for inpatient rehabilitation. They usually have a hemiparesis that prevents walking without human assistance on admission, as well as degraded independence for self-care. Fig. 168.1 is a typical decision tree for placement planning during the acute stroke hospitalization. Only 31% of stroke survivors receive any outpatient rehabilitation , significantly lower than expected if clinical guidelines were followed. One may assume that most of the 69% who had no formal rehabilitation received little or no education or support for activities of daily living (ADLs), mobility practice, and fitness exercise.

Scientific Bases

Studies of the scientific bases for neurological rehabilitation after stroke have led to a general consensus: Progressive practice of task-related skills assisted by a therapist in an adequate dose leads to improvement of motor, cognitive, or behavioral skills mostly restricted to what was trained, via mechanisms of activity-dependent molecular, cellular, synaptic, and structural and physiological plasticity within spared neural ensembles and networks. This underlying adaptability or neuroplasticity, which is most highly manifest in animal models in the first month after onset and for 3 months in patients (see Chapter 35 , Carmichael), enables reorganization and rewiring within residual perilesional, ipsilesional, and contralesional cortical and subcortical circuits, as well as the neural ensembles that represent, for example, a skilled movement . Synaptic mechanisms of learning and memory also contribute to compensatory, adaptive strategies.

Rehabilitation Outcome Measures

The intention to address impairment, functional disability, activity, and participation requires a range of outcome measurement tools for clinical trials. There are many examples of each. This chapter includes studies with primary outcomes drawn from some of the most commonly used upper and lower extremity function tools that have high reliability . Based on these measures, ADLs tend to reach a plateau of improvement by 12 weeks after onset of stroke. About 70% of gains above the baseline Fugl–Meyer Motor Assessment (FM, see later) score also evolve by three months after onset of mild–moderate hemiparesis . Some patients with severe hemiparesis or hemiplegia in the first week (FM score <20) may improve their motor control if enough corticospinal tract fibers are spared. If no wrist or finger extension is present 2 weeks after an ischemic stroke, functional use of the hand is very unlikely. As many trials have shown, however, less robust but valued goal-specific improvements, such as faster walking speed or improved grasp and pinch with greater daily incorporation of the affected hand, can be made at any time after stroke, as long as enough motor control is latently available to enable progressive practice.

The FM of impairment has been used in the majority of upper extremity trials in hemiparetic persons. It grades increasingly complex multijoint movement tasks of the arms (top score 66) and legs (best score 34) from 0 to 3 (cannot perform and partially or fully performed motion), reflecting simple movements within a synergistic pattern to more selective motion. Maximal strength required, however, is only against gravity.

Casual or fastest walking speed over a 10- or 15-m flat surface and distance walked in 3 or 6 min are the most frequently employed ratio scale measures for changes in gait and mobility. Speed reflects many of the sensorimotor, balance, and cognitive components that go into safe walking. These tasks in a clinic setting may not reflect walking pace and endurance in the home or community. A commercial device with an accelerometer is often used for a few days during a clinical trial to reveal the number of steps taken daily outside of the clinic, but the accuracy for hemiplegic gait drops sharply as walking speed falls below 0.6 m/s.

Functional use of the affected upper extremity has been measured by ordinal scales, such as the Arm Research Action Test (ARAT), and timed tasks, such as the Wolf Motor Function Test (WMFT). The modified ARAT consists of four subtests including grasp, grip, pinch, and gross movement. All tasks are scored on a four-point scale from 0 to 3 where 0 reflects poor hand function and 3 reflects good hand function for a total possible score of 57. The WMFT uses 15 timed reach and grasp or pinch movements and two strength tasks. An unimpaired hand average score is about 5 s, but patients often average 15–45 s or get a 120 s score if unable to perform. The quality of the movement can also be scored on a 6-point ordinal scale.

The Functional Independence Measure (FIM, Table 168.1 ) is perhaps the most commonly employed American inpatient tool for assessing ADLs. The 0–7 scale reflects the burden of care on others to aid the disabled person. As a functional measurement, the person need not be able to use the affected arm at all to score as fully independent and only has to walk 150 feet at a speed as slow as 0.4 m/s to be graded independent. Scoring is much less sensitive to change three months after onset. The Stroke Impact Scale is a self-reported measure of domains relevant to activity and participation and it too may be less sensitive to change in patients with chronic stroke.

Table 168.1

Functional Independence Measure (FIM) Scores for Stroke Admissions and Discharges (National Uniform Data System for Medical Rehabilitation ^a Data for 101,885 Entries in 2014)

Items	Entry	Discharge
Self-care	18.9	29.0
Eating
Grooming
Bathing
Dressing upper body
Dressing lower body
Toileting
Sphincter control	7.4	9.9
Bladder management
Bowel management
Mobility and transfers	7.8	13.2
Bed-to-chair and wheelchair-to-chair transfer
Toilet transfer
Tub and shower transfer
Locomotion	3.5	7.8
Walking or wheelchair use
Climbing stairs
Communication	8.0	10.2
Comprehension
Expression
Social cognition	11.1	14.5
Social interaction
Problem solving
Memory
Total FIM rating (maximum score 126)	56.6	84.7

Burden of care rating for each sub item.

7 = Complete independence (timely, safely).

6 = Modified independence (device).

5 = Supervision.

4 = Minimal assistance (subject contributes 75% or more).

3 = Moderate assistance (subject contributes at least 50%).

2 = Maximal assistance (subject contributes at least 25%).

1 = Total assistance (subject contributes 0% up to 25%).

a UDSMR is a division of University of Buffalo Foundation Activities, Inc. Report generated 11/17/15.

Stages of Rehabilitation

Acute Stroke Admission

Rehabilitation assessment and treatment can begin by two days after onset in medically stable patients (e.g., alert and interactive, afebrile, no orthostatic hypotension, and no side effects of new medications) who are not hemodynamically at risk for further hypoperfusion.

The large multicenter, A Very Early Rehabilitation Trial (AVERT), compared mobilization within 24 h after stroke onset to usual care to determine whether this inexpensive strategy could lead to better functional outcomes. The early group, however, was mobilized at a mean of 18 h and only one-third by 12 h, compared to 22 h for the usual care group, which seems rather soon compared to most American stroke units. Patients with severe stroke and serious complications were excluded. The earlier group had somewhat worse outcomes on the modified Rankin Scale, but the findings do not support delaying mobilization unless medical contraindications require this.

Fig. 168.1 shows a typical decision tree for discharge placement after acute stroke. To admit a patient for subacute inpatient rehabilitation, the major decision-making components include the ability to learn, adequate motivation, adequate social support to avoid eventual placement in a skilled nursing facility, and capacity to participate in at least 3 h of daily therapies.

Inpatient Subacute Rehabilitation

The primary goal is to enable patients to become independent enough to be manageable at home, with help by a trained caregiver or support services as needed. To best achieve this, transfers, walking, and toileting usually have to approach a minimally assisted level by FIM criteria. Although inpatient rehabilitation is called intensive, the reality across units internationally is for actual practice of walking to average about 17 min a day . By providing medical care and insight into the neural bases of manifest and subtle impairments and disabilities, the physician can lead the rehabilitation team toward problem-solving solutions. Much medical care usually accompanies inpatient rehabilitation, mostly related to premorbid diseases, further management of the etiology of the new stroke, adjustments of medications, bladder infections, pain, and mood and sleep disorders.

Tables 168.1 and 168.2 describe average admission and discharge data for a first stroke rehabilitation admission. In general, FIM scores <60 at discharge make it less likely that patients can return home without fulltime physical assistance. The rehabilitation team aims for the safest discharge setting and concentrates on the skills, assistive equipment, and home modifications necessary to return to the community. With lengths of stay averaging only 15 days, home health rehabilitation services are usually needed to transfer what was learned as an inpatient to the home setting.

Table 168.2

Characteristics of Patients in UDSMR for Stroke in Table 168.1 .

Age >64 years	66%
Gender: male	50.7%
Married	47%
Medicare payer	70%
Onset to rehabilitation transfer (days)	9.1
Length of stay (days)	14.7
Living Site Prehospital
Alone	26%
Family/relatives	68%
Friends	2%
Attendant	0.5%
Living Site at Discharge
Home/community	74%
Long-term care	17%
Acute care	9%

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