Stroke Rehab Case Study

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Stroke Rehab Case Study

• Robert Teasell MD FRCPC
• Professor and Chair-Chief
• Physical Medicine and Rehabilitation
• Schulich School of Medicine
• University of Western Ontario
• Lawson Health Research Institute
• St. Josephs Health Care
• London, Ontario

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Case Study

• 73 yo married male
• Rt MCA stroke, moderate size
• Seen by neurologist, imaged, Rx ASA
• Consult to Rehab seen 4 days later, put on wait
  list 4 days later admitted to a general rehab
  unit
• With assessments and weekend, patient initiates
  treatment 17 days post stroke onset

Is this good care? Could we do this better?
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Case Study

• Positives
• Good rehabilitation candidate (moderately severe
  stroke)
• Negatives
• Admitted to a general rehabilitation unit
• Delay in getting to rehabilitation and accessing
  therapy

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Specialized Rehab Care

• Specialized Interdisciplinary Stroke
  Rehabilitation is the gold standard of care

• 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

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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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Case Study

• Therapists on rehab unit assess the patient and
  set up a treatment schedule
• PT and OT schedule up to 1 hr of therapy each
• However, patient sometimes 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 lt30 minutes per day
  per discipline
• Is this a good model of care? Could we do this
  better with the resources we have? Is this the
  best it can be?

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Average daily direct therapy time
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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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Case Study Upper Extremity

• Patient at 4 weeks post-stroke has CMS of 2 in
  arm and 1 in hand
• The family dont believe enough is being done to
  improve function in the upper extremity
• How much U/E therapy should the patient be
  getting?

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Rehab of Hemiplegic U/E

• There is consensus opinion that in severely
  impaired upper extremities (less than CMS stage
  4) the focus of treatment should be on palliation
  and compensation
• For those upper extremities with signs of some
  recovery (stage 4 or better) there is consensus
  opinion that attempts to restore function through
  therapy should be made
• Barreca et al. 2001 Heart and Stroke Foundation
  Ontario Guidelines for Hemiplegic Upper Extremity

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Case Study

• Patient had significant Lt neglect to
  confrontational testing

Describe treatments available for the treatment
of left neglect
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Left Neglect Treatments

• Strong evidence enhanced visual scanning
  techniques improve visual neglect with
  improvement in function
• Strong evidence that limb activation therapies
  improve neglect

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Case Study

• For the same patient (moderate to good motor
  recovery, left sensory loss and nonfunctional
  upper extremity), his wife has read that if the
  patient rehearse movements of the involved
  extremity in their head that it may help
• Would mentally rehearsing movements be helpful?

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Mental Imagery

• There is strong evidence that mental practice may
  improve upper extremity motor and ADL performance
  following stroke

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Case Study

• Same patient with large right hemispheric stroke
  complains bitterly of left (hemiplegic) shoulder
  pain
• On examination he has a subluxed shoulder, marked
  pain on minimal external rotation and marked
  restriction of abduction and external rotation

What is the cause of the pain and how is it best
treated?
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Hemiplegic Shoulder Pain

• Etiology of pain is likely subscapularis/pectorali
  s muscle spasticity with a frozen shoulder
• Treatments of choice are very gentle range of
  motion exercises and later Bo-Tox injections into
  the spastic muscles

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Case Study

• At scheduled discharge there is concern that
  there is no outpatients so patient is kept an
  additional 2 weeks
• Even then patient must wait an additional 2 weeks
  to access outpatient therapy
• Is this good care? How could we do it better?

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Outpatient Therapy

• Outpatient therapy improves short-term functional
  outcomes
• 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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Case Study

• 73 y.o. male suffers a large Rt MCA infarct,
  undergoes rehab and is preparing for d/c
• Spouse reports feeling ill-prepared to manage him
  at home the social worker provides her with
  written material on home discharge and support
  systems
• Is this appropriate?

Doctor says you can come home when I am up to
it.
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Family Education

• Strong evidence of a positive effect, associated
  with the provision of information and education
  through a variety of intervention types
• One on one education sessions have a greater
  effect on outcome than the provision of
  information materials alone
• Strong evidence that skills training is
  associated with a reduction in depression
• Moderate evidence that training in basic nursing
  skills improves outcomes of depression, anxiety
  and quality of life for both the caregiver and
  the stroke patient