New Guidelines for Stroke Rehabilitation

By Jamie Santa Cruz

New guidelines on stroke that were released in May are the first to focus specifically on rehabilitation and recovery.

Each year nearly 800,000 individuals are affected by stroke in the United States.1 The relative rate of death from stroke has dropped substantially in recent years, but stroke patients often face substantial difficulties regaining normal daily function. The need to reverse stroke damage and restore function to the extent possible has prompted the release of new guidelines from the American Heart Association (AHA) and the American Stroke Association (ASA) on adult stroke rehabilitation.2

"While there have been a lot of advances in acute stroke management, we still have a long way to go in terms of preventing and reversing the damage that occurs at the time of stroke," says Joel Stein, MD, a professor and chair of the department of rehabilitation and regenerative medicine at Columbia University College of Physicians and Surgeons and vice-chair of the writing committee for the new guidelines. "As a result, there are many people who survive a stroke who are left with significant disability and who require rehabilitation services to regain as much of their function as they can."

Focus on the Long Term
The new guidelines are the eighth set on stroke to be jointly released by the AHA and the ASA. Previous guidelines, however, have focused on acute management of stroke. The new guidelines, released in May 2016, are the first to focus specifically on rehabilitation and recovery.

Much of the need for rehabilitation guidance stems from across-the-board increases in life expectancy in stroke patients as well as in the general population, says Carolee Winstein, PhD, a professor of biokinesiology and physical therapy at the University of Southern California and the chair of the writing committee for the guidelines. Longer lifespans have created a paradox in the sense that people live more years, but those extra years of life are not necessarily high quality. "Advances in earlier times were to increase longevity, but disability has become now our biggest challenge," Winstein says.

In keeping with the theme of increasing longevity, an overarching goal of the guidelines is to reframe stroke and encourage providers to view it less as an acute event and more as a chronic disease. In most cases, Winstein says, stroke is the result of cardiovascular pathology, and many stroke patients will live 10, 20, or 30 years with chronic disease even after the acute stroke event. Shifting the paradigm from an acute event to a chronic disease changes what is important in care. "Because these people are surviving, in large part because of better acute management, the issue of rehabilitation and recovery and living a longer life of higher quality becomes more paramount," Winstein says.

Inpatient Rehabilitation Facilities Preferred for Qualified Patients
The new guidelines recommend that qualified stroke patients go to an inpatient rehabilitation facility rather than a skilled nursing facility for rehabilitation when such a facility is available. Multiple studies show that patients referred to inpatient rehabilitation achieve greater functional recovery and are more likely to return to community living than those referred to a skilled nursing facility.3-6 According to Stein, it's not clear what aspect of inpatient rehabilitation facilities is associated with improved outcomes, as there are several differences in the type of care characteristic in each setting. The differences include availability of various therapy services (eg, physical therapy, occupational therapy, and speech therapy), frequency of physician involvement, and the specialization of physicians and nurses. "It's a little hard to tease apart which is the primary contributor to the better outcomes," Stein says.

In a general sense, however, the advantage of inpatient rehabilitation facilities is that there tends to be more coordinated, multidisciplinary care, according to Winstein. "Stroke is a very complex issue. It doesn't just affect one system; it affects multiple systems. So you have to have an interdisciplinary team, a multidisciplinary team working around the patient," she says. Although she acknowledges that there are some skilled nursing facilities that focus on rehabilitation and provide the type of coordinated care recommended in the guidelines, coordinated care is less common in this setting.

Currently inpatient rehabilitation facilities are underutilized in many geographic areas, Stein says. Sometimes this is due to lack of availability, but even when inpatient rehabilitation facilities areavailable, there is considerable practice variation, even within a given region, in terms of whether physicians refer patients to an inpatient rehabilitation facility vs a skilled nursing facility. The causes of the variation are not fully understood, but the variation in practice appears to be based more on local referral relationships than on patient need. "If there is a skilled nursing facility across the street from the hospital, maybe the physicians at the hospital follow their patients there," Stein says. "There may be preference for that facility as opposed to the rehabilitation hospital across town. The converse is true as well."

While the guidelines encourage inpatient rehabilitation centers where possible, Stein emphasizes that patients need to be qualified in order to enter inpatient rehabilitation. The guidelines themselves do not provide specific qualifying criteria, due partly to the fact that the question of qualifying criteria hasn't been adequately studied. But generally speaking, Stein says, patients who have significant impairments following a stroke but who had had good functional status prior to the stroke are typically good candidates for inpatient rehabilitation, whereas those with poor functional status prior to a stroke are usually better suited to a skilled nursing facility.

At the least, Winstein says, candidates for inpatient rehabilitation facilities need to be in stable condition, have enough endurance to withstand a minimum of three hours of therapy per day, and be free of any other serious medical issues requiring treatment. For those who do not meet these criteria, a skilled nursing facility is the preferable choice.

Fall Prevention Programs Recommended for All Patients
A second key highlight of the guidelines is the recommendation that all stroke patients participate in a formal fall prevention program prior to being discharged from the hospital. "There is a very high number of patients who fall after they go home after a stroke, and these falls are usually preventable," Winstein says. A basic fall prevention program should teach patients about medications following stroke that may cause dizziness; it should also educate patients on the importance of removing from the home obstacles such as throw rugs, how to lock the wheelchair prior to standing up, and how to use a cane safely. "These fall prevention programs are very successful, and they are more successful if the families are also involved so they can monitor the situation and monitor the environment if necessary," Winstein says.

Need to Evaluate for Depressive Symptoms
Depression is extraordinarily common after stroke, affecting up to 33% of stroke survivors.7 Although poststroke depression typically responds well to standard pharmacological treatments (ie, selective serotonin reuptake inhibitors), it often goes untreated, according to Stein. Thus the new guidelines encourage health care providers to evaluate patients for depression in poststroke follow-up visits. "The issue is that many people attribute some of the depressed mood that they see in stroke survivors to a natural response to bad circumstances," Stein says. "Family members, patients themselves, and physicians who are not attuned to this may say things like, 'What do you expect? They had a stroke.' That's doing patients a big disservice. It's a treatable condition, and failure to treat can result in a less optimal functional outcome."

Further Highlights
Additional recommendations from the new guidelines include the following:

1. Individuals who have had a stroke and reside in long term care facilities should be evaluated for calcium and vitamin D supplementation.

2. Stroke patients should be provided with enriched environments to increase cognitive engagement. "Don't treat the person like they can't engage anymore in the world," Winstein says. "Music, computers, anything that will stimulate engagement and challenge the brain in a constructive way should be incorporated."

3. Individuals with balance concerns or who are at risk for falls should be provided with a balance training program. According to Winstein, such a program can be provided on an outpatient basis or in a community center.

4. Intensive, repetitive mobility-task training, covering topics such as how to get up from a chair, how to go down stairs, and how to step up and down a curb, should be provided to all stroke patients who have gait limitations.

5. Stroke patients who successfully pass screening should receive an individually tailored exercise program. According to Winstein, it is not entirely clear at present that participating in an exercise program will reduce the risk of a secondary stroke, but survivors will certainly receive benefits to cardio respiratory fitness. "Since stroke is primarily a cardiovascular disease, it makes perfect sense that addressing that head on is extremely beneficial," she says. Patients often assume that their limitations following a stroke mean that they can no longer be active, she adds, but exercise has multiple benefits in terms of cognition and mood, and providers should educate patients on which forms of activity are available to them.

6. Patients with stroke who are being assessed for activities of daily living, instrumental activities of daily living, and mobility should be considered candidates for community- or home-based rehabilitation when feasible.

Finally, Winstein says, as a general principle, providers should take care to view stroke patients as more than simply the sum of their limitations. "Recovery after stroke is not totally dictated by the physiology," she says. "There is also mindset and how people are treated. Their fundamental psychological needs, if considered, can have a huge impact on their recovery."

— Jamie Santa Cruz is a freelance writer based in Englewood, Colorado.

References
1. Mozzafarian D, Benjamin EJ, Go AS, et al. Heart disease and stroke statistics — 2015 update: a report from the American Heart Association. Circulation. 2015;131(4):e29-e322.

2. 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.

3. Deutsch A, Granger CV, Heinemann AW, et al. Poststroke rehabilitation: outcomes and reimbursement of inpatient rehabilitation facilities and subacute rehabilitation programs. Stroke. 2006;37(6):1477-1482.

4. Kramer AM, Steiner JF, Schlenker RE, et al. Outcomes and costs after hip fracture and stroke: a comparison of rehabilitation settings. JAMA. 1997;277(5):396-404.

5. Kane RL, Chen Q, Finch M, Blewett L, Burns R, Moskowitz M. Functional outcomes of posthospital care for stroke and hip fracture patients under Medicare. J Am Geriatr Soc. 1998;46(12):1525-1533.

6. Keith RA, Wilson DB, Gutierrez P. Acute and subacute rehabilitation for stroke: a comparison. Arch Phys Med Rehabil. 1995;76(6):495-500.

7. Paolucci S, Gandolfo C, Provinciali L, Torta R, Toso V, DESTRO Study Group. The Italian multicenter observational study on post-stroke depression (DESTRO). J Neurol. 2006;253(5):556-562.