Stroke Rehabilitation

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Stroke Rehabilitation

• Robert Teasell MD FRCPC
• Professor and Chair-Chief
• Dept of Physical Medicine and Rehabilitation
• St. Josephs Health Care London

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Objectives

1. Appreciate that standards of stroke rehab care
   in Canada are no longer ideal
2. Provide evidence for those elements of stroke
   rehab necessary to produce optimal outcomes
3. Understand the magnitude of the changes necessary
   to implement best practices

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The Importance of Stroke Rehab

• Strokes are Increasing
• t-PA treats anywhere from 5-10 of strokes and
  benefits about 1 in 7 (significant impact on 1
  of all strokes)
• Primary prevention is expensive and difficult
• First wave of baby boomers are now 60 years old
  and stroke is a disease of older people
• Demand for stroke rehabilitation services is
  going to dramatically increase

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The Need for Stroke Rehabilitation

• Once a stroke occurs specialized
  interdisciplinary rehab offers best opportunity
  for improving outcomes
• Animal and clinical evidence (gt800 RCTs) have
  demonstrated the benefit of stroke rehab and are
  unravelling the blackbox of stroke rehab
• Evidence-based stroke rehab saves money and
  improves lives
• Estimate at least 30 of stroke patients admitted
  to acute inpatient care should get stroke rehab

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• Stroke patients often have a complex array of
  deficits and potential complications
• Best addressed by an interdisciplinary team of
  physicians, therapists and nursing staff
• Moderately severe stroke patients appear to
  benefit the most
• Very severe stroke patients represent greatest
  challenge

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Case Study

• 73 yo married male
• Lt MCA stroke, moderate size, Oct 1 Mon
• Seen by neurologist, imaged, Rx ASA
• Oct 4 Thurs consult to Rehab seen Oct 8 Mon,
  put on wait list 4 days later Oct 12 Fri admit
  to rehab unit (50 of time a general rehab unit)
• Seen for assessment Oct 15 and 16 and therapy
  initiated Oct 17 Wed

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Case Study

• Therapists on rehab unit decide when and how much
  they see the patient
• PT and OT schedule up to 1 hr of therapy each but
  patient often arrives late, therapy is cancelled
  for therapist illness, inservices or charting,
  patient complains of fatigue or is off having a
  test, no therapy on weekends or holidays actual
  therapy time averages 20-25 minutes per day per
  discipline

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Case Study

• At scheduled discharge there is concern that
  there is no speech therapy in outpatients so
  patient is kept an additional 2 wks
• Patient is discharged Dec 3 but waits 4 wks
  before outpt therapy is initiated because of
  cutbacks and holidays
• LOS 51 days in rehab 14 days in acute care
  65 days (Cost gt 35,000 for inpatient care)

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Reality Check Trends in Ontario
Variable 2003/2004 2005/2006
Stroke rehab admissions 2,863 2,958
Mean LOS 38.7 days 33.5 days
Total rehab bed days 110,798 bed days 99,093 bed days
Days from stroke onset to rehab admission 21.1 days 18.3 days
Admission FIM 75.3 77.7
LTC Admissions 2,248 3,043
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Ontario Stroke Rehab 2005/2006

• 16,068 strokes hospitalized to acute care
  2005/2006
• 2,293 died and 13,775 alive at discharge from
  acute care
• 2,958 admitted to inpatient rehabilitation (21)
  of all strokes discharged from acute care
• Mean FIM admission 78 (median 80)
• Mean FIM discharge 102 (median 109)

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Item Canada (CIHI 2003, n1003)
Mean Age 70.8
Lived alone Pre-Stroke 24.5
Mean Admission FIM 75.2
Mean/Median Stroke Onset to Rehab Admit (days) 26/14
Mean Rehab LOS (days) 38
Mean Discharge FIM 96.3
Mean Increase in FIM 21.1
FIM Efficiency (FIM gains/day) 0.56
Number of Patients Home 67.3
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• Study of 7 stroke rehab centers (6 in United
  States, n1161 1 in New Zealand, n130)
• Comprehensive study of stroke rehabilitation
  examining the black box
• Compare with CIHI Data of Canadian Centers (2003)
• PROSP study, Archives of PMR Dec 2005 suppl

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Item US PSROP (n1161) Canada (CIHI 2003, n1003)
Mean Age 66.0 70.8
Lived alone Pre-Stroke 20.7 24.5
Mean Admission FIM 61.0 75.2
Median Stroke Onset to Rehab Admit (days) 7 14
Mean Rehab LOS (days) 18.6 38
Mean Discharge FIM 87.2 96.3
Mean Increase in FIM 26.2 21.1
FIM Efficiency (FIM gains/day) 1.4 0.6
Number of Patients Home 78.0 67.3
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• How do you get FIM efficiency of 1.4 (vs 0.6) or
  avg LOS of 25 days (vs. 52)?
• Apply Best Evidence and Do the Basics Well!
• Pts get admitted to specialized
  inter-disciplinary stroke rehab units
• Admitted earlier and more disabled
• More intensive therapy (standardization of
  therapies, greater accountability, weekend
  therapy)
• Move to high level tasks early
• Well developed outpatient services
• Apply best-evidence to save money! Significant
  incentives to be efficient and evidence-based

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• The Importance of Stroke Rehab Units

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• Randomized Controlled Trial
• n 251 stroke patients
• Acute stay 10 days randomized to treatment
  (inpatient rehab) or control (ad hoc community
  care)
• Rehab Unit LOS 27.8 days
• Community Care - 40 nursing home, 30 outpt
  therapy, 30 no formal rehab treatment

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• Results
• 7 month follow-up for all stroke patients
• Dependent (BI lt 75) or dead - 23 RU vs 38 CC
  (p.01)
• 39 reduction in worse outcomes with stroke rehab

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• Moderate to severe stroke (BIlt50) (n114)
• 62 CC vs 32 RU dead or dependent (p.002)
• 48 reduction in bad outcomes
• Barthel Index scores - 90 vs. 73 (p.005)

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• Randomized 220 acute strokes to Stroke Unit or
  General Medical Unit
• Maintained treatment for 6 weeks
• Outcomes home vs institution, mortality, Barthel
  index - at 6 and 52 weeks, 5 and 10 years
• Indredavik et al. 1990

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At 6 weeks (Indredavik et al. 1990)
Significant benefit still seen at 10 years
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The Impact of Stroke Unit Care on Combined
Death/Dependency Post Stroke (Foley et al. 2007)
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• Best Practice in Stroke Rehab involves
  specialized inter-disciplinary teams working in a
  highly coordinated manner to obtain best outcomes
• Stroke rehab is most effective for moderately
  severe stroke patients
• Rehabilitation therapies even account for benefit
  of acute stroke units

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Specialized Rehab Care

• Specialized Stroke Rehabilitation is the gold
  standard of care

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Brain Reorganization

• The brain has significant capacity to reorganize
  itself to recover from loss of function following
  a stroke
• Reorganization depends on training or
  rehabilitation and will not occur spontaneously

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Nudo RJ 1997 Post-stroke lesion in squirrel
monkey, rehab results in expansion of hand
representation no rehab results in contraction
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• Rehabilitation training (enriched environments
  with animals) increases brain reorganization with
  subsequent functional recovery

In animal studies key factors promoting recovery
include increased activity and a complex,
stimulating
environment
Lack of rehab causes decline in cortical
representation and delays recovery
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Brain Reorganization

• The brain has significant capacity to reorganize
  itself to recover from loss of function following
  a stroke
• Reorganization depends on training or
  rehabilitation and will not occur spontaneously
• Key elements of stroke rehab should be increased
  activity and a complex and stimulating environment

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• The Earlier the Better

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The Earlier the Better

• Brain is primed to recover early in
  post-stroke period
• Animal studies suggest there is a time window
  when brain is primed for maximal response to
  rehab therapies
• Delays are detrimental to recovery
• Clinical association between early admission to
  rehab and better outcomes

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Benefit of Early Therapy in Animals

• Methods
• Biernaskie et al. (2004) subjected rats to rehab
  x 5 weeks beginning at 5, 14 and 30 days post
  small strokes
• Control animals social housing

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Benefit of Early Therapy in Animals

• Results
• All received 5 weeks of enriched environment
• Day 5 admission marked improvement
• Day 14 moderate improvement
• Day 30 no improvement vs. controls
• Corresponding cortical reorganization in brain
  around stroke

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Therapy Intensity
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• RCT of 146 middle band strokes to stroke unit
  (SU) or gen med (GM) unit
• Median BI 4/20 initially in both
• Stroke Unit - BI 15 after 6 wks discharged at
  6 wks
• General Medical Unit - BI 12 after 12 wks
  discharged at 20 wks
• Kalra et al. 1994

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• Kalra et al. 1994

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• In a therapeutic day
• gt50 time in bed
• 28 sitting out of bed
• 13 in therapeutic activities
• Alone for 60 of the time
• Contrary to the evidence that increased activity
  and environmental stimulation is important to
  neurological recovery

(Inactive and alone, Bernhardt et al, Stroke 2004)
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Conclusions on Therapy Intensity

• More therapy results in improved outcomes
• Actual direct therapist-patient time and time
  spent in activation activities is important
• Rehab in Canada has traditionally struggled
  providing adequate therapy time

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Greater Accountabilities
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• Study compared motor and functional recovery
  after stroke between 4 European Rehab Centers
• Gross motor and functional recovery was better in
  Swiss and German than UK center with Belgian
  center in middle
• Time sampling study showed avg. daily direct
  therapy time of 60 min in UK, 120 min in Belgian,
  140 min in German and 166 min in Swiss centers
• Differences in therapy time not attributed to
  differences in patient/staff ratio (similar
  staffing)
• De Wit et al. Stroke 2007382101-2107

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Average daily direct therapy time
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Time Spent in Therapeutic Activities
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• In German and Swiss centers, the rehabilitation
  programs were strictly timed (therapists had less
  freedom), while in UK and Belgian centers they
  were organized on an ad hoc basis (therapists had
  more freedom to decide)!
• No differences were found in the content of
  physiotherapy and occupational therapy
• More formal management in the German center may
  have resulted in the most efficient use of human
  resources, which may have resulted in more
  therapy time for the patients
• De Wit et al. Stroke 2007382101-2107

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• U.S. Inpatient Stroke Rehabilitation is driven by
  Medicare which expects
• Participation (the 3 Hour Rule)
• Progress (FIM Gain of 1-1.5/day)
• Expedited Discharge Home or to SNF if progress is
  too slow or family unwilling/unable to take home

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• The 3 Hour Rule
• 3 hours/day of PT, OT SLP 5-6 days/wk
• Psychol, RN, VR, TR dont count (TROT sometimes)
• 55 min one-on-one therapy sessions with PT, OT,
  SLP daily and if pt cant handle 55 min then 2x30
  min is scheduled
• Patient therapist ratio is 71 each day,
  supplemented with rehab techs (aids)

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• In Addition
• 1-2 hrs daily of OT /or PT group sessions
• Weekly Speech/Cognitive group therapy sessions
• TR, VR, Psychology, RD, RN education
• Family are engaged very early in the process with
  caregiver training

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• Therapist must record face-to-face interactions
  with pt in 15 min increments
• Manager responsible at end of day to ensure
  patient received their full 3 hrs of therapy
• Any missed therapy must have a strong medical
  justification documented by MD and therapist
• Failure to deliver enough time means loss of
  payment

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Reality Check Therapy is Cheap LOS is Not

• Therapists are not replaced when sick or absent
• Laissez-faire attitude towards rehab therapies
  even though it is what we are supposed to be
  doing
• At least 60 of stroke rehab budget costs are
  nursing (versus lt20 of core therapies) which
  have better developed accountabilities
• Stroke rehab patient gets an average of a little
  over one hour of therapy per day

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Where Did the Outpatients Go?
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Outpatient Therapy

• Outpatient therapy improves short-term functional
  outcomes
• Hospital same as home-based
• Outpatient therapy is relatively inexpensive (1
  PT/1 OT/0.5 SLP/0.5 SW cost of 1 rehab inpt
  bed)
• Reduces rehospitalization and allows earlier
  discharge home
• Estimated savings is 2 for every 1 spent on
  outpatient therapies
• First thing cut with budget pressures

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Cochrane Review of OutPt Rehab

• 14 RCTs of 1,617 patients (Outpatient Trialists
  2003) involved in home based, day hospital and
  outpatient clinic
• Therapy reduced the odds of a poor outcome
  (death, deterioration or dependency) (OR 0.72
  95 CI 0.57-0.92 p0.009)
• Number needed to treat in order to spare one
  person from experiencing a poor outcome was 14
• U.S. colleagues put a lot of emphasis on
  Outpatient Programs

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Stroke Rehab Structural Issues

• Only 21 of admitted stroke patients are admitted
  to rehabilitation in Ontario
• At least 50 of stroke rehabilitation patients
  are admitted to general rehabilitation units
• Decline in outpatient resources across Ontario
  due to budget cutbacks
• Health care authorities need to ensure
  appropriate structures in place only partially
  successful and seems to be declining, albeit
  slowly

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Stroke Rehab Process Issues

• Patients are still often admitted to
  rehabilitation after excessive delays
• The intensity of rehab therapies and the rehab
  experience remains deficient on most rehab units
• Accountabilities remain poor and administrative
  creep is a problem
• Maintenance care is declining or nonexistent
• Our processes remain provider-driven

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Stroke Rehab in Canada
Canadian Stroke Rehab Proposed Goals
Admission to Rehab 10-17 days post-stroke onset 5-7 days post-stroke onset
Intensity of Therapy PT , OT or SLP average 20-25 minutes per day 3 hours of therapy per day extending to weekends
Weekend Therapy and Statutory Holidays No therapy (sometimes weekend LOAs) Active therapy every day
Therapy Time Regulation Little or no regulation therapists set their own times accountabilities are often lax Carefully regulated therapists time carefully accounted for therapists replaced when off
Rehab Length of Stay 35-45 days 25 days
Rehab FIM Efficiency 0.6-0.8 gt 1.0
Outpatient Therapy Often wait list or not available Well developed and readily available
System Designed for Who? Provider-driven care Patient-driven care
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