Donate Help Contact The AHA Sign In Home
American Heart Association
Stroke
Search: search_blue_button Advanced Search
Stroke. 1997;28:1522-1526

Free Article
This Article
Free upon publication Free Article
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow Request Permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Gresham, G. E.
Right arrow Articles by Trombly, C. A.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Gresham, G. E.
Right arrow Articles by Trombly, C. A.

(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
up arrowTop
*Introduction
down arrowScientific Basis for Stroke...
down arrowCurrent Issues in Stroke...
down arrowRehabilitation Panel...
down arrowReferences
 
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 (FigureDown). 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 1Down). 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
up arrowTop
up arrowIntroduction
*Scientific Basis for Stroke...
down arrowCurrent Issues in Stroke...
down arrowRehabilitation Panel...
down arrowReferences
 
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:

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:


*    Current Issues in Stroke Rehabilitation
up arrowTop
up arrowIntroduction
up arrowScientific Basis for Stroke...
*Current Issues in Stroke...
down arrowRehabilitation Panel...
down arrowReferences
 
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
up arrowTop
up arrowIntroduction
up arrowScientific Basis for Stroke...
up arrowCurrent Issues in Stroke...
*Rehabilitation Panel...
down arrowReferences
 
The rehabilitation panel prepared the following recommendations for clinical practice, public policy, education, and research initiatives.

Clinical Practice Recommendations

Public Policy Recommendations

Education Recommendations

Research Recommendations


*    Footnotes
 
For reprint information, see page 1498.


*    References
up arrowTop
up arrowIntroduction
up arrowScientific Basis for Stroke...
up arrowCurrent Issues in Stroke...
up arrowRehabilitation 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.
  10. Langhorne P, Williams BO, Gilchrist W, Howie K. Do stroke units save lives? Lancet.. 1993;342:395-398.[Medline] [Order article via Infotrieve]
  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]
  13. Morris PLP, Robinson RG, Raphael B. Prevalence and course of depressive disorders in hospitalized stroke patients. Int J Psychiatry Med. 1990;20:349-364.[Medline] [Order article via Infotrieve]
  14. Robinson RG, Szetela B. Mood change following left hemispheric brain injury. Ann Neurol.. 1981;9:447-453.[Medline] [Order article via Infotrieve]
  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.



This article has been cited by other articles:


Home page
The International Journal of Robotics ResearchHome page
A. Gupta, M. K. O'Malley, V. Patoglu, and C. Burgar
Design, Control and Performance of RiceWrist: A Force Feedback Wrist Exoskeleton for Rehabilitation and Training
The International Journal of Robotics Research, February 1, 2008; 27(2): 233 - 251.
[Abstract] [PDF]


Home page
StrokeHome page
M. J. Alberts, R. E. Latchaw, W. R. Selman, T. Shephard, M. N. Hadley, L. M. Brass, W. Koroshetz, J. R. Marler, J. Booss, R. D. Zorowitz, et al.
Recommendations for Comprehensive Stroke Centers: A Consensus Statement From the Brain Attack Coalition
Stroke, July 1, 2005; 36(7): 1597 - 1616.
[Abstract] [Full Text] [PDF]


Home page
StrokeHome page
D. Sulch, A. Melbourn, I. Perez, and L. Kalra
Integrated Care Pathways and Quality of Life on a Stroke Rehabilitation Unit
Stroke, June 1, 2002; 33(6): 1600 - 1604.
[Abstract] [Full Text] [PDF]


Home page
NEJMHome page
T. Brott and J. Bogousslavsky
Treatment of Acute Ischemic Stroke
N. Engl. J. Med., September 7, 2000; 343(10): 710 - 722.
[Full Text] [PDF]


Home page
StrokeHome page
Measuring and Improving Quality of Care : A Report From the American Heart Association/American College of Cardiology First Scientific Forum on Assessment of Healthcare Quality in Cardiovascular Disease and Stroke
Stroke, April 1, 2000; 31(4): 1002 - 1012.
[Full Text] [PDF]


Home page
CirculationHome page
Measuring and Improving Quality of Care : A Report From the American Heart Association/American College of Cardiology First Scientific Forum on Assessment of Healthcare Quality in Cardiovascular Disease and Stroke
Circulation, March 28, 2000; 101(12): 1483 - 1493.
[Full Text] [PDF]


This Article
Free upon publication Free Article
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow Request Permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Gresham, G. E.
Right arrow Articles by Trombly, C. A.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Gresham, G. E.
Right arrow Articles by Trombly, C. A.