Poststroke Care

Stroke outcomes can be optimized with an evidenced-based and systematic approach during all phases of recovery.

By Oluwole O. Awosika, MD; Bridget A. Rizik, MD; Holly K. Pajor, DO; Samir R. Belagaje, MD; Elisheva R. Coleman, MD; Daniel Woo, MD; and Brett M. Kissela, MD, MS
 

Acute Poststroke Care: Time is Still Brain During Recovery

Stroke is a leading cause of adult disability in the US. With the improvement and standardization of acute stroke therapeutics as discussed throughout this issue, there are increasing numbers of stroke survivors, with an estimated annual direct cost expected to reach $184 billion by 2030.1 The onus falls on acute care providers to be proactive in facilitating:

1) Early comprehensive and evidence- and expert consensus-based medical and rehabilitative care

2) Timely discharge to the most appropriate post-acute setting

3) Prevention of secondary complications of stroke across the continuum of recovery.

The critical time window for spontaneous neurobiologic recovery occurs in the first 3 months poststroke. According to the US Agency for Health Care Research and Quality, the average length of stay in an acute-care hospital after an acute stroke is 5.5 days, which translates to approximately 6% of the critical period for spontaneous neurobiologic recovery. Despite this urgency, observational studies in stroke recovery suggest that the majority of patients perform little to no physical activity in the acute hospital setting.2 There is some evidence to suggest that early mobilization in short durations is beneficial to recovery. Although long duration of exercise is currently not supported based on the primary outcome (negative result) of the AVERTa trial, subgroup analysis suggests that frequent but short periods (< 13.5 min) of mobilization may be of benefit as early as 24 hours after a stroke and was safe and associated with improved odds of a favorable outcome at 3 months.3 A recent study on early rehabilitation (within 48 hours) after intracerebral hemorrhage, reported improved survival and functional outcomes at 6 months.4

Additional approaches to enhancing a patient’s rehabilitation-potential and readiness include prevention and management of common medical and cognitive barriers to recovery. Barriers include inadequate sleep5 and nutrition.6 Early screening for disorders such as insomnia,7 obstructive sleep apnea (overnight pulse oximetry),8 delirium, depression, and impaired cognition may facilitate early interventions that can help to maximize recovery (Table 1).9

Although neuroplastic (eg, serotonergic and dopaminergic) drugs are safe and inexpensive, they are underused in the acute care setting. Although the exact mechanism underlying their neuroplastic effects are still under investigation, preclinical and neuroimaging studies suggest these agents may potentiate and accelerate the period of recovery.12 For, example, patients with and without depression who received fluoxetine, a commonly used selective serotonin reuptake inhibitor (SSRI) within days of stroke had improved functional motor outcomes (Fugl Myer) compared with those who received placebo.28 Subse-quent meta-analysis corroborated these findings and suggests that other SSRIs may have similar benefit.29

In addition to medical management and optimization, acute care providers should consult physical therapy (PT), occupational therapy (OT), speech therapy (SLP), and rehabilitation specialists (if available) early in the hospital course to assist with evaluation, management, and assistance with determining the appropriate disposition plan.30 Implementing a treatment plan during the earliest stages of stroke recovery may improve rehabilitation readiness, aid in determining post-acute hospital disposition, and best position a stroke survivor for recovery.

Figure 1. Algorithm for Post-Acute Care Rehabilitation Disposition

Choosing a Level of Postacute Care

The goal of a rehabilitation program is to optimize function, independence, and return to living in the community and prevent secondary complications (Table 2). Several options for disposition are available for stroke survivors and include inpatient rehabilitation (IRF), skilled nursing facility (ie, subacute rehabilitation), long term acute care facility (LTAC), and home (with home or outpatient physiotherapy) (Figure 1). Each level of postacute care varies in intensity and type of therapy provided and amount of physician and nursing involvement but all share a similar goal in maximizing function.

Inpatient Rehabilitation

The most comprehensive and intensive postacute option for qualifying stroke survivors, IRF is recommended in the current AHS/ASA guidelines for those with residual functional impairments who meet qualifying criteria (see below, Level IA Evidence) (Figure 2).31 Studies have shown that patients discharged to IRF setting have higher rates of discharge to community living and improved functional ability compared to those going to a skilled nursing facility.32,33 The IRF setting is ideal for motivated stroke survivors who can tolerate a minimum of 3 hours of intensive rehabilitation therapy per day, 5 days per week in at least 2 areas of functional impairment (physical and/or occupational therapy and speech); have active new (eg, bowel or bladder dysfunction or spasticity) or chronic medical issues that require daily evaluation and treatment by a rehabilitation physician (minimum of 3 days/week) and 24 hour nursing care, and have a high likelihood of being discharged into the community within 2-3 weeks.34 The IRF setting also offer services such as neuropsychologists and vocational and recreational rehabilitation and is ideal for individuals who may benefit from a multidisciplinary approach to their care.35 Given these opportunities, disposition to IRF is the current gold-standard in rehabilitation, with a few notable exceptions.

Figure 2. Inpatient Rehabilitation (IRF) Setting. Standard inpatient rehabilitation gym and available equipment (A); weekly multidisciplinary meeting (B ); independent activities of daily living stations are instrumental for assessing and preparing for transition to the home environment (C).

Long-Term Acute Care Facility

Discharge to an LTAC may be appropriate for individuals who are unable to tolerate 3 hours of intensive therapy per day but still have complicated medical and rehabilitative needs requiring long term care (> 3 weeks), such as those with ventilator dependence, functional-limiting cardiopulmonary disease, multisystem organ failure, polytrauma, or extensive burn injury.

Subacute Rehabilitation

As a third option, subacute rehabilitation is appropriate for individuals with limited medical needs at discharge who may not be physically able to participate in intensive physiotherapy, such as those who lack physical stamina, are unable to participate in the program due to limited carryover/mental alertness (ie, cannot follow commands), or have associated orthopedic injuries or weight bearing precautions. Subacute rehabilitation is usually reserved for patients who may not reach full or partial recovery. Rehabilitation and medical care are still dictated by a physician but there is not a Medicare requirement for daily physician visits.

In-Home or Outpatient Rehabilitation

Some patients may be suitable for discharge home with rehabilitation in an outpatient facility or through home health care. Home health care provides rehabilitation and nursing needs within an individual’s home. This is typically available to stroke survivors who are high functioning, do not need the intensity provided in an IRF setting, and are safe to be discharged home from the acute hospital. Advantages of home health therapy include evaluating the home environment for barriers to activities of daily living (ADLs) and providing the necessary equipment to complete ADLs as independently as possible within the context of their own living environment. Outpatient therapy is also an option for patients who qualify for discharge home. Also reserved for high functioning individuals, outpatient therapy requires transportation to and from a clinic but provides more resources and equipment in a gym environment—facilitating a smoother transition to independence within the community.

Timing of Decision Making

It is important to keep in mind that individuals who were not considered appropriate for IRF at acute hospital discharge and were subsequently discharged to a subacute rehabilitation or LTAC, are eligible for transfer to an IRF when they improve and are able to participate in intense rehabilitation. Therefore, determining postacute disposition should be based on the patient’s rehabilitation and medical needs at the time of assessment.

Preventing Secondary Complications

Survivors of stroke not only present with preexisting medical comorbidities, they also can develop a number of poststroke medical complications thereafter (Table 2). In the days to weeks following stroke, patients remain at highest risk of poststroke edema, hemorrhage, or seizures. Furthermore, acquired stroke impairments may also lead to complications, many of which are avoidable.30 For example, dysphagia may predispose patients to aspiration pneumonia, pneumonitis, or the progressive development of malnutrition. Neurogenic bladder and bowel put an individual at risk of retention or constipation respectively, with danger of infection, skin breakdown, and potentially end organ damage. The development of spasticity, a velocity dependent increase in tonic stretch reflexes, may result in joint dysfunction, contracture, dystonia, pain, and generalized functional impairment. Immobility also increases the risk of deep venous thrombosis and pulmonary embolism in the acute-subacute stages, and risk of osteoporosis and fractures chronically. Irrespective of the postacute care disposition, awareness of these potential secondary complications and early education of patients and caregivers may prevent their occurrence, or at the least reduce severity.

Conclusion

While promising new areas of research are underway to determine effective and reproducible approaches to enhance the rate and extent of recovery poststroke, this review provides practical approaches to optimizing and facilitating the delivery of comprehensive post stroke rehabilitation care. Taking advantage of the critical period of spontaneous neurobiological recovery through early mobilization, screening and treating of common medical and cognitive barriers and complications, triaging to the appropriate postacute care disposition, educating patients and caregivers, and preventing of secondary complications of stroke are steps in the right direction.

a. AVERT, A very early rehabilitation trial (NCT01846247)

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Oluwole O. Awosika, MD

Assistant Professor
Department of Neurology and Rehabilitation Medicine
University of Cincinnati
Cincinnati, OH

Bridget A. Rizik, MD

Resident Physician
Department of Neurology and Rehabilitation Medicine
University of Cincinnati
Cincinnati, OH

Holly K. Pajor, DO

Assistant Professor, Associate Residency Program Director
Department of Neurology and Rehabilitation Medicine
University of Cincinnati
Cincinnati, OH

Samir R. Belagaje, MD

Associate Professor
Department of Neurology and Rehabilitation Medicine
Emory University School of Medicine
Atlanta, GA

Elisheva R. Coleman, MD

Assistant Professor
Department of Neurology and Rehabilitation Medicine
University of Cincinnati
Cincinnati, OH

Daniel Woo, MD

Professor of Neurology and Vice-Chair of Research Department of Neurology and Rehabilitation Medicine
University of Cincinnati
Cincinnati OH

Brett M Kissela, MD, MS

Albert Barnes Voorheis Professor and Chair Department of Neurology and Rehabilitation Medicine
University of Cincinnati Gardner Neuroscience Institute
Senior Associate Dean for Clinical Research
University of Cincinnati College of Medicine
Chief of Research Services, UC Health
Cincinnati, OH

Disclosures

BMK and DW receive research grants from the National Institutes of Health (NIH). The other authors report no financial or other relationships relevant to this content.

 

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