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(Stroke. 1997;28:1522-1526.)
© 1997 American Heart Association, Inc.

Articles

Rehabilitation

Panel; Glen E. Gresham, MD, Chair; David Alexander, MD; Duane S. Bishop, MD; Carol Giuliani, PhD, PT; Gary Goldberg, MD; Audrey Holland, PhD; Margaret Kelly-Hayes, EdD, RN; Richard T. Linn, PhD; Elliott J. Roth, MD; William B. Stason, MD; Catherine A. Trombly, ScD

Key Words: AHA Medical/Scientific Statements • stroke • prevention

	Introduction

Top Introduction Scientific Basis for Stroke... Current Issues in Stroke... Rehabilitation Panel... References

 
Stroke is a condition with high incidence and mortality rates, leaving a large proportion of survivors with significant residual physical, cognitive, and psychological impairments.¹ The increasing number of older adults and the emergence of new therapies for acute stroke suggest there will be an increase in the number of stroke survivors living with disabilities. Furthermore, secular trends in stroke severity document a decrease in those most severely affected.² This shift to more moderately affected survivors places increased demands on rehabilitation efforts and services, making the issue of how to best limit stroke-related disability and health risks a major concern for healthcare providers in rehabilitation. At this time efforts to prevent stroke must be balanced with the pragmatic effort to prevent disability and maximize quality of life for those who have suffered the consequences of stroke.

The rehabilitation process involves six major areas of focus: (1) preventing, recognizing, and managing comorbid illness and medical complications; (2) training for maximum independence; (3) facilitating maximum psychosocial coping and adaptation by patient and family; (4) preventing secondary disability by promoting community reintegration, including resumption of home, family, recreational, and vocational activities; (5) enhancing quality of life in view of residual disability; and (6) preventing recurrent stroke and other vascular conditions such as myocardial infarction that occur with increased frequency in patients with stroke.³ To attain these goals, rehabilitation interventions should assist the patient in achieving and preserving maximum feasible functional independence.

Stroke rehabilitation is an active process beginning during acute hospitalization, progressing for those with residual impairments to a systematic program of rehabilitation services, and continuing after the individual returns to the community. It is an organized effort to help stroke patients maximize all opportunities for returning to an active and productive lifestyle. Because the clinical manifestations of stroke are multifaceted and complex, stroke rehabilitation is best implemented through the coordinated efforts of a team of rehabilitation professionals.

A well-conceived rehabilitation management plan is the basis for all rehabilitation. The first step is to match the patient with the appropriate rehabilitation services and setting (Figure). Reasonable medical stability, significant functional disability, and the ability to learn are the primary criteria for rehabilitation. Patients with severe cognitive deficits resulting in the inability to learn new strategies are unlikely to benefit from rehabilitation. A minimal level of physical endurance is also essential.

View larger version (41K): [in this window] [in a new window]   Figure 1. Framework for rehabilitation decisions after stroke. IADLs indicates instrumental activities of daily living.

The choice of rehabilitation setting for a patient meeting threshold criteria depends on the level of assistance needed to perform daily activities, the closeness of medical supervision required, and the ability to tolerate intense therapy. A patient requiring at least moderate assistance and who can tolerate activities requiring several hours of intense physical and mental effort each day has the potential to recover function more rapidly if referred to an intense (acute) rehabilitation program in a hospital or nursing facility. Patients unable to tolerate intense treatment, even if they need moderate to maximum assistance, will be better served in a lower level program in a nursing facility or at home.

Several measures are used to assess, construct, and evaluate the rehabilitation process over the recovery phases (Table 1). During the acute phase of stroke, baseline assessment should include a standardized level of consciousness, a neurological deficit scale, and a measure of global disability. In addition, the type and severity of stroke, presence of comorbid diseases, and functional health patterns should be documented.

View this table: [in this window] [in a new window]   Table 1. Assessment After Stroke

Because rehabilitation focuses on retraining in a number of domains, referred patients should have demonstrated minimum cognitive skills on screening. For documentation of severity of physical disability, the best validated assessment instruments are the Barthel Index⁴ and the Functional Independence Measure (FIM).⁵ These scales measure a range of activities essential to independence, including mobility, self-care, and continence. The FIM is a refinement of the Barthel Index and was developed to expand the number and sensitivity of domains measured. It has the added benefit of a comprehensive behavioral component.

Beyond these basic assessment domains, formal assessment and interventions are needed in a number of other areas of impairment. The choice of specific impairment measures depends on the patient's neurological impairments and most often includes assessment of motor skills, balance, mobility, affect/depression, communication disorders, dysphagia, functionally oriented cognition, functional health patterns, and continence. Measures of family functioning, instrumental activities of daily living (I-ADLs), and quality of life are helpful in documenting areas related to normal life patterns for those who return to the community. A complete listing of valid and reliable instruments can be found in the Agency for Health Care Policy and Research (AHCPR) Post-Stroke Rehabilitation Clinical Guideline.⁶

	Scientific Basis for Stroke Rehabilitation

Top Introduction Scientific Basis for Stroke... Current Issues in Stroke... Rehabilitation Panel... References

 
Rehabilitation is effective. At present, however, we cannot easily differentiate between the influence of specific interventions and the natural recovery process. The Copenhagen Study,⁷ a community-based population study of 1197 acute stroke cases examined weekly for neurological impairments and functional disability over a 6-month period, demonstrated that the best neurological outcome was reached within 11 weeks from stroke onset and best recovery of basic self-care and mobility skills within 12.5 weeks in 95% of the cohort. Ottenbacher and Jannell⁸ performed a meta-analysis of 3717 patients from 36 studies that examined the outcome of rehabilitation for poststroke patients. Each study compared two or more treatments designed to improve functional performance in subjects with hemiparesis. The authors found that those patients in a focused stroke rehabilitation program performed functional tasks better than approximately two thirds of patients in comparison groups. In a critical review of 165 studies by Wagenaar and Meijer,⁹ the authors concluded that stroke patients with hemiplegia benefit from expert care if it is offered early and intensively but cautioned that retraining because of deficits in activities of daily living may be more effective when it is task specific.

The state of the science in stroke rehabilitation was recently summarized in the 1995 AHCPR Post-Stroke Rehabilitation Practice Guideline.⁶ More than 1900 clinical research articles were reviewed, and nearly 500 were cited in the text of the guidelines. From this evidence base, recommendations were made according to the quality and level of research to support them. Four recommendations met the highest criteria, which were two or more randomized trials with good internal and external validity. The recommendations were:

• Whenever possible, patients with acute stroke should receive coordinated diagnostic, acute management, preventive, and rehabilitative services. Meta-analysis of the effects of stroke units found reduced mortality in patients treated in settings with comprehensive, coordinated rehabilitation services.¹⁰ A number of studies also indicated improved functional outcomes for those who were older and those with moderate levels of severity. Studies of stroke teams to supplement care on general medical services have yielded less convincing but positive results.
• Measures to prevent deep vein thrombosis should be implemented until the patient is no longer at high risk due to immobility. As many as 10% of deaths from stroke have been attributed to pulmonary embolism. The risk of deep vein thrombosis and thromboembolism is increased by paralysis of a limb and its resulting immobility.¹¹
• High priority should be given to prevention of stroke recurrence and stroke complications and to health promotion after the stroke survivor returns to the community. The risk of a recurrent stroke averages 7% to 10% per year, and the risk of complications remains high, especially in severely disabled people with limited mobility. Medical therapies and education are effective interventions.
• A high index of suspicion must be maintained and steps taken to determine the presence and cause of depression. Depression is estimated to occur in 11% to 68% of stroke patients, and major depression is estimated to occur in 10% to 27%.^{12 13 14} Its effects can produce cognitive problems, including deficits in orientation, language, visual construction, motor function, and frontal lobe tasks.¹⁵

The remaining AHCPR recommendations were supported by less rigorous evidence, but all were supported by either a single randomized clinical trial, nonrandomized trials, or quasi-experimental studies:

• A patient's ability to swallow should be assessed before oral intake of fluids or foods.
• If a urinary catheter was inserted during the acute phase of stroke, the catheter should be removed as soon as possible.
• Persistent urinary incontinence after a stroke should be evaluated to determine its cause, and specific treatment should be implemented.
• Patients should be mobilized as soon as medically possible after stroke.
• Patients who have some voluntary control over movements of the involved arm or leg should be encouraged to use the limb in functional tasks and offered exercise and functional training to improve strength and motor control, relearn sensorimotor relationships, and improve functional performance.
• Patients with aphasia should be offered treatment targeted at the identified language retrieval or comprehension deficits and aimed at improving functional communication.
• A patient's risk of falling should be assessed; methods developed to prevent falls should be based on the type and severity of neurological deficits.
• Measures to maintain skin integrity should be initiated during acute care and continued throughout rehabilitation.
• Patients who meet threshold criteria and need moderate to total assistance in mobility or performing basic activities of daily living are candidates for an intensive rehabilitation program if they can tolerate 3 or more hours of physical activity each day. If they cannot, they should be referred to less intensive programs.
• Bowel management programs should be implemented for patients with persistent constipation or incontinence.
• Prevention of shoulder injuries should emphasize proper positioning and support and avoidance of overly vigorous range-of-motion exercises.
• Choice of treatment for depression will depend on the cause and severity of symptoms.
• Family members and involved others should be given information about stroke and rehabilitation.
• Clinicians need to be sensitive to potential adverse effects of caregiving on the family and the health of the caregiver.
• Rehabilitation should follow well-supported principles of effective learning.
• Valued leisure activities should be identified, encouraged, and enabled.
• Assessment of ability to drive a car should be based on neurological examination, behavioral observation, and evaluation by the responsible state agency.

	Current Issues in Stroke Rehabilitation

Top Introduction Scientific Basis for Stroke... Current Issues in Stroke... Rehabilitation Panel... References

 
Research Priorities
Both basic and clinical research are critical to improving rehabilitation for stroke survivors. An increasing body of scientific evidence suggests that cortical functional reorganization occurs after central nervous system damage, and that this reorganization interacts with environmental influences that may facilitate functional recovery.^{16 17} Because rehabilitation seeks to enhance recovery after stroke, rehabilitation specialists are interested in investigating the neurological mechanisms of recovery and the mechanisms of skill reacquisition after stroke.

Major gaps in knowledge concerning the effectiveness of specific interventions to remediate communication disorders, sensorimotor, and cognitive perceptual impairments as well as those to restore functional independence exist. Relations between the site and extent of lesion, associated impairments, and the functional consequences need study to be adequately understood. Research is needed to establish the effects of a wide variety of rehabilitation therapies and interventions. Development of valid, standardized, reliable, and sensitive measures of rehabilitation provide the foundation for such endeavors.

Access to and Cost-Effectiveness of Rehabilitation
The effective delivery of poststroke rehabilitation requires development of an integrated care system that spans acute care, acute rehabilitation, subacute rehabilitation, outpatient services, home care, and community support services. Important developments for this are use of clinical pathways, effective information systems, and communication between levels and sites of care. Barriers that limit access to postacute stroke rehabilitation include uneven distribution of resources, inadequate insurance coverage, and lack of knowledge of the potential value of rehabilitation.

Important issues in cost-effectiveness in rehabilitation are selection of patients most likely to benefit, and selection of the most appropriate setting, timing, and duration and intensity of the process. Patient-valued outcomes such as functional ability, life satisfaction, quality of life, and minimal burden on family and society should also be considered.

The relevant cost of postacute care includes but is not limited to the direct cost of rehabilitation. Recurrence, complications of treatment, and long-term care costs are also important, as are the indirect cost of impact on caregivers and losses of economic productivity of the patient and caregiver. Recovery from stroke occurs over a prolonged period of time. Therefore, both the effectiveness of rehabilitation and the total cost must be measured over the entire episode of care.

	Rehabilitation Panel Recommendations

Top Introduction Scientific Basis for Stroke... Current Issues in Stroke... Rehabilitation Panel... References

 
The rehabilitation panel prepared the following recommendations for clinical practice, public policy, education, and research initiatives.

Clinical Practice Recommendations

• Implement interventions during the acute phase of stroke to promote recovery and prevent complications.
• Emphasize the importance of thorough and consistent assessment at each stage of the recovery process to guide treatment decisions and monitor progress.
• Prevent secondary disability by consistently promoting functional independence and opportunities to improve quality of life.
• Maintain a patient and family focus throughout rehabilitation.
• Support demonstration projects of late-stage rehabilitation and evaluate outcomes in terms of functional independence, communication, quality of life, and cost-effectiveness.

Public Policy Recommendations

• Advocate adoption of the AHCPR Guidelines for Post-Stroke Rehabilitation.
• Support provisions and implementation of the Americans With Disabilities Act.
• Develop a broad-based campaign for reintegrating persons with stroke disabilities into the community.
• Support the development and implementation of programs and legislation that address the physical, emotional, and economic burden of stroke.

Education Recommendations

• Promote continuing education for clinicians who need to change roles and responsibilities in stroke rehabilitation as healthcare delivery changes.
• Establish educational programs for professionals and the general public in collaboration with the AHA and others to address the efficacy of rehabilitation.
• Continue and extend networks such as the AHA Stroke Connection and other communications and support groups for stroke survivors in areas without representation.

Research Recommendations

• Expand knowledge of brain physiology and neurochemical mechanisms associated with recovery from stroke and the relationship between pathology, impairment, and disability.
• Develop and refine valid, reliable, and sensitive instruments to measure improvement after stroke.
• Design and implement large-scale randomized clinical trial initiatives to (1) identify the elements of care in specialized stroke units that contribute to improved survival and outcome; (2) test the effectiveness and efficacy of different types of rehabilitation interventions, including when, what, and where rehabilitation should take place; (3) examine the effectiveness of various intensities of treatment; and (4) delineate the characteristics associated with successful recovery of functional independence.
• Determine differences in outcomes and recovery trajectories for different stroke subtypes (including lesion location, etiology, and associated comorbidity).
• Explore the influence of neuroactive pharmacological agents on recovery of motor, language, and cognitive function.

	Footnotes

 
For reprint information, see page 1498.

	References

Top Introduction Scientific Basis for Stroke... Current Issues in Stroke... Rehabilitation Panel... References

 

1. Gresham GE. Past achievements and new directions in stroke outcome research. Stroke. 1990;21(suppl 2):II-1-II-2.
2. Wolf PA, D'Agostino RB, O'Neal MA, Sytkowski P, Kase CS, Belanger AJ, Kannel WB. Secular trends in stroke incidence and mortality: the Framingham Study. Stroke.. 1992;23:1551-1555.[Abstract/Free Full Text]
3. Roth EJ. Medical rehabilitation of the stroke patient. Be Stroke Smart: National Stroke Association Newsletter.. 1992;8:8.
4. Mahoney FI, Barthel D. Functional evaluation: the Barthel index. Md State Med J.. 1965;14:56-61.
5. Guide for the Uniform Data Set for Medical Rehabilitation (Adult FIM), Version 4.0. Buffalo, NY: State University of New York at Buffalo; 1993.
6. Post-Stroke Rehabilitation Guideline Panel. Post-Stroke Rehabilitation. Clinical practice guideline no. 16. Rockville, Md: US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research; 1995. AHCPR publication 95-0662.
7. Jorgensen HS, Nakayama H, Raaschou HO, Vive-Larsen J, Stoier M, Olsen TS. Outcome and time course of recovery in stroke, II: time course of recovery. The Copenhagen Stroke Study. Arch Phys Med Rehabil.. 1995;76:406-412.[Medline] [Order article via Infotrieve]
8. Ottenbacher KJ, Jannell S. The results of clinical trials in stroke rehabilitation research. Arch Neurol.. 1993;50:37-44.[Abstract]
9. Wagenaar RC, Meijer OG. Effects of stroke rehabilitation, I: a critical review of the literature. Journal of Rehabilitation Sciences.. 1991;4:61-73,97-109.
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11. Clagett GP, Anderson FA Jr, Levine MN, Salzman EW, Wheeler HB. Prevention of venous thromboembolism. Chest. 1992;102(suppl):391S-407S.
12. Eastwood MR, Rifat SL, Nobbs H, Ruderman J. Mood disorder following cerebrovascular accident. Br J Psychiatry. 1989;154:195-200.[Abstract/Free Full Text]
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15. Bolla-Wilson K, Robinson RG, Starkstein SE, Boston J, Price TR. Lateralization of dementia of depression in stroke patients. Am J Psychiatry.. 1989;146:627-634.[Abstract/Free Full Text]
16. Frackowiak K, Weiller C, Chollet F. The functional anatomy of recovery from brain injury. In: Chadwick DJ, Whelan J, eds. Exploring Brain Functional Anatomy With Positron Tomography. Ciba Foundation Symposium 163. New York, NY: John Wiley & Sons Inc; 1991.
17. Goldberg G. Rehabilitation research: toward a new approach to the study of human function and complex morbidity. Am J Phys Med Rehabil. 1991;70:107-108.

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