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.
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.
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.
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.
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)
1. Writing Group Members, Mozaffarian D, Benjamin EJ, et al. Heart disease and stroke statistics—2016 update. Circulation. 2016; 133(4):447-54.
2. Bernhardt J, Dewey H, Thrift A, Donnan G. Inactive and alone physical activity within the first 14 days of acute stroke unit care. Stroke. 2004;35(4):1005-1009.
3. Bernhardt J, Churilov L, Ellery F, et al. Prespecified dose-response analysis for a very early rehabilitation trial (AVERT). Neurology. 2016;86(23):2138-2145.
4. Liu N, Cadilhac DA, Andrew NE, et al. Randomized controlled trial of early rehabilitation after intracerebral hemorrhage stroke. Stroke. 2018;45(12):3502-3507.
5. Duss SB, Seiler A, Schmidt MH, et al. The role of sleep in recovery following ischemic stroke: a review of human and animal data. Neurobiol Sleep Circad Rhyth. 2017;2:94-105.
6. Bouziana SD, Tziomalos K. Malnutrition in patients with acute stroke. J Nutrit Metab. 2011;2011:167898.
7. Ramakrishnan K, Scheid DC. Treatment options for insomnia. Am Fam Phys. 2007;76(4):517-526.
8. Aaronson JA, van Bezeij T, van den Aardweg JG, van Bennekom C, Hofman WF. Diagnostic accuracy of nocturnal oximetry for setection of aleep apnea syndrome in stroke rehabilitation. Stroke. 2012;43(9):2491-2493.
9. Kotila M, Waltimo O, Niemi ML, Laaksonen R, Lempinen M. The profile of recovery from stroke and factors influencing outcome. Stroke. 2018;15(6):1039-1044.
10. Mead GE, Hsieh C-F, Lee R, et al. Selective serotonin reuptake inhibitors (SSRIs) for stroke recovery. Stroke. 2013 Mar;44(3):844-50.
11. Goldstein LB. Potential effects of common drugs on stroke recovery. Arch Neurology. 1998;55(4):454-456.
12. Cramer SC. Drugs to enhance motor recovery after stroke. Stroke. 2015;46(10):2998-3005.
13. Sabbouh T, Torbey MT. Malnutrition in stroke patients: risk factors, assessment, and management. Neurocrit Care. 2017:1-11.
14. Collaboration T. Effect of timing and method of enteral tube feeding for dysphagic stroke patients (FOOD): a multicentre randomised controlled trial. Lancet. 2005;365(9461):764-772.
15. Kennedy DO. B Vitamins and the brain: mechanisms, dose and efficacy-a review. Nutrients. 2016;8(2):68.
16. Aquilani R, Sessarego P, Iadarola P, Barbieri A, Boschi F. Nutrition for brain recovery after ischemic stroke. Nutrit Clin Pract. 2018;26(3):339-345.
17. Lehotský J, Tothová B, Kovalská M, et al. Role of Homocysteine in the ischemic stroke and development of ischemic tolerance. Front Neurosci. 2016;10:538.
18. Duss SB, Brill A-K, Bargiotas P, et al. Sleep-wake disorders in stroke—increased stroke risk and deteriorated recovery? An evaluation on the necessity for prevention and Treatment. Curr Neurol Neurosci Reps. 2018;18(10):72.
19. Topcuoglu MA, Saka E, Silverman SB, Schwamm LH, Singhal AB. Recrudescence of deficits after stroke: clinical and imaging phenotype, triggers, and risk factors. JAMA Neurol. 2017;74(9):1048-1055.
20. Black-Schaffer RM, Kirsteins AE, Harvey RL. 2. Co-morbidities and complications. Arch Phys Med and Rehabilita. 1999;80(5):S8-S16.
21. Carin-Levy G, Mead GE, Nicol K, Rush R, van Wijck F. Delirium in acute stroke: screening tools, incidence rates and predictors: a systematic review. J Neurol. 2012;259(8):1590-1599.
22. McManus J, Pathansali R, Stewart R, Macdonald A, Jackson S. Delirium post-stroke. Age Aging. 2007;36(6):613-618.
23. Narushima K, Robinson RG. Stroke-related depression. Curr Atheroscler Rep. 2002;4(4):296-303.
24. Kohno N, Abe S, Toyoda G, Oguro H, Bokura H, Yamaguchi S. Successful treatment of post-stroke apathy by the dopamine receptor agonist ropinirole. J ClinNeuroscience. 2010;17(6):804-806.
25. Villa R, Ferrari F, Moretti A. Post-stroke depression: mechanisms and pharmacological treatment. Pharmacol Therapeut. 2018;184.
26. Whyte EM, Lenze EJ, Butters M, et al. An open-label pilot study of acetylcholinesterase inhibitors to promote functional recovery in elderly cognitively impaired stroke patients. Cerebrovascr Dis. 2008;26(3):317-321.
27. Matsuzaki S, Hashimoto M, Yuki S, Koyama A, Hirata Y, Ikeda M. The relationship between post-stroke depression and physical recovery. J Affect Dis. 2015;176:56-60.
28. Chollet F, Tardy J, Albucher J-F, et al. Fluoxetine for motor recovery after acute ischaemic stroke (FLAME): a randomised placebo-controlled trial. Lancet Neurology. 2011;10(2):123-130.
29. Mead GE, Hsieh C-FF, Lee R, et al. Selective serotonin reuptake inhibitors (SSRIs) for stroke recovery. Cochrane Database Syst Rev. 2012; 11:CD009286.
30. Miller EL, Murray L, Richards L, et al. Comprehensive overview of nursing and interdisciplinary rehabilitation care of the stroke patient. Stroke. 2010;41(10):2402-2448.
31. Winstein CJ, Stein J, Arena R, et al. Guidelines for adult stroke rehabilitation and recovery: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2016; 47(6):e98-e169.
32. Chan L, Sandel EM, Jette AM, et al. Does postacute care site matter? A longitudinal study assessing functional recovery after a stroke. Arch Phys Med and Rehabilita. 2013;94(4):622-629.
33. Belagaje SR, Sun C-HJ, Nogueira RG, et al. Discharge disposition to skilled nursing facility after endovascular reperfusion therapy predicts a poor prognosis. J Neurointervent Surg. 2014;7(2).
34. for HHS. Medicare Program; inpatient rehabilitation facility prospective payment system for federal fiscal year 2018. Final rule. Federal register. 2017;82(148):36238-36305.
35. Gittler M, Davis AM. Guidelines for adult stroke rehabilitation and recovery. JAMA. 2018;319(8):820-821.
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.