Evidence Based Stroke Rehabilitation

Scott Hardin MD
Medical Director of Rehabilitation Services, Aurora St. Lukes Clinical Safety Officer, Aurora St Lukes Vice Chief of Staff, Aurora St Lukes

Evidence Based Stroke Rehabilitation

Disclosures None

Evidence Based Stroke Rehabilitation

Goals Briefly review the history of stroke Learn the pertinent epidemiological facts of stroke now and into the future Gain an appreciation that, despite there being almost 1000 RCT regarding stroke outcomes, we are still in the infancy of understanding why we do what we do

Evidence Based Stroke Rehabilitation

Goals Review data from the excellent resource Evidence Based Review of Stroke Rehabilitation (EBRSR)

Evidence Based Stroke Rehabilitation

History 600 BC Hippocrates 4 humours 160 AD Galen advanced the humour theory 1599 the stroke of Gods hand 1732 Robinson described the typical apoplectic patient

Evidence Based Stroke Rehabilitation

History Mid 1600s Jacob Wepfer cerebral hemorrhage blocked cerebral arteries 1920s cerebral angiography 1935 blood letting debunked

Evidence Based Stroke Rehabilitation

History 1950s first carotid endarterectomy 1960s Doppler ultrasound 1960s hypertension a modifiable risk 1970s aspirin CT scanning PET scanning

Evidence Based Stroke Rehabilitation

History 1980s
stroke prevention/risk modification smoking identified as risk

1990s
endarterectomy proven to be effective anticoagulants and a fib blood pressure and cholesterol

Evidence Based Stroke Rehabilitation

History 1990s
tPA approved combined dipyridimole and aspirin

2000s
acute cerebral artery thrombectomy

carotid artery stenting

Evidence Based Stroke Rehabilitation

Epidemiology >700,000 total strokes per year in the US Mortality is still about 50% However, stroke mortality fell 12% between 1990 and 2000 Men 1.25 x risk of women Blacks have 2x risk of stroke vs white; Hispanic is in between

Evidence Based Stroke Rehabilitation

Epidemiology There are an estimated 5 million stroke survivors in the US More than 1.1 million with some form of chronic disability Baby boomers Disability

Evidence Based Stroke Rehabilitation

Why does rehab work? Neural Plasticity the ability of the brain to reorganize and learn new functions

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data In its toddlerhood Will be important to show we matter Soon, doing things because we think it works wont fly

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data Indredavik et al 1990 randomized 220 strokes to the IRF* unit or general medical unit outcomes were home or not, mortality, BI at 6 and 52 weeks, 5 years and 10 years
*IRF = Inpatient Rehabilitation Facility

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data Indredavik et al 1990 Across all time frames statistically significant: lower mortality in the IRF group lower institutionalization in the IRF group higher home living in the IRF group higher BI scores in the IRF group

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data Ronning and Guldvog 1998
randomized controlled trial 251 strokes compared community care (no IRF) to IRF outcome was dependence (BI<75) or death

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data Ronning and Guldvog 1998
7 month follow up 23% IRF patients dead or dependent vs 38% community care (p=.01) 39% reduction in worse outcomes with IRF care

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data Foley, et al 2007 Meta analysis of IRF stroke unit trials
world wide consistent statistical benefit of IRP units over other types of post stroke care in reductions in mortality and less dependency

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data EBRSR Evidence Based Review of Stroke Rehabilitation
2001 systematically reviews all outcomes based stroke literature, summarizes and grades it www.ebrsr.com

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data EBRSR reviews stroke literature relative to:
techniques therapies devices procedures medications

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data EBRSR
extensive and comprehensive database search strategies 3407 studies reviewed 2000 in depth studies reviewed 956 RCT Methodological quality assessed using the PEDro scale

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data EBRSR
grading scale (based on the AHCPR) Level 1a (strong) Level 1b (moderate) Level 2 (limited) Level 3 (consensus) Level 4 (conflicting)

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data EBRSR
only the data from the 956 RCTs are used for determination of evidenced based recommendations

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data EBRSR
Recommendations are broken into:
Efficacy of Stroke Rehab Outpatient Stroke Rehab Mobility/Lower extremity Painful hemiplegic shoulder Perceptual disorders Dysphagia/Aspiration Medical complications Community reintegration Young stroke Outcome measures Elements of Stroke Rehab Secondary Prevention Upper extremity Cognitive/Apraxic disorders Aphasia Nutritional interventions Depression Miscellaneous Severe Stroke Stroke Triage

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data EBRSR
Stroke Triage early screening early admission, but patients with severe stroke better managed in a less acute setting younger (<55) patients with moderate to severe strokes should always be admitted to IRFs

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data EBRSR
Stroke Rehab Elements care pathways dont improve outcomes or reduce costs greater intensities of PT and OT improve functional outcomes unclear intensive language therapy the greater functional improvements from IRF care are maintained long term

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data EBRSR
Lower extremity and mobility

Bobath is as good but slower

focused balance training is beneficial rhythmic auditory sensory stim helps PBWS on treadmill questionable strength training is beneficial

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data EBRSR
Lower extremity and mobility

cardiovascular training is good

WC self propel does not help using canes enhances mobility e stim with gait training improves gait EMG/biofeedback improves gait training

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data EBRSR Lower extremity and mobility
tilt table or night splinting prevent contracture AFOs help e stim and U/S reduce spasticity

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data EBRSR
Upper extremity initial degree of motor impairment is the best predictor of motor recovery NDT is not superior effects of enhanced therapy, task specific training, sensorimotor training and mental practice unclear

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data EBRSR
Upper extremity

hand splinting does not help

robots help a little CIT helps virtual reality helps Botox helps tone/spasticity but maybe not function

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data EBRSR
Upper extremity PT may not reduce spasticity IPC does not help edema FES does improve function

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data EBRSR
Cognition

1/3 of stroke patients develop dementia Stroke patients have 10x risk of developing dementia Depression contributes to cognitive impairment in stroke

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data EBRSR
Cognition

treating hypertension in stroke patients reduces their dementia risk gesture training is effective for treating ideomotor apraxia

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data EBRSR
Language therapy

is efficacious in aphasia when provided intensely for the first three months group therapy may improve communicative and linguistic abilities

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data EBRSR
Language therapy

CPU-based aphasia therapy helps

forced use aphasia therapy helps repetitive transcranial magnetic stimulation and polarity specific transcranial direct stimulation may help

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data EBRSR
Language therapy

piracetam, levodopa, memantidine, dextroamphetamine and donezepil may improve language function bromocriptine, cholinergics, dextran and moclobemide do not help

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data EBRSR
Dysphagia

VBMS is the only sure way to diagnose dysphagia and aspiration

Aspiration rates are high risk of developing pneumonia is related to aspiration severity

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data EBRSR
Dysphagia

all stroke survivors should be npo until assessed SLPs should see all patients who failed the swallow screen dysphagic individuals should feed themselves

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data EBRSR
Dysphagia

a variety of treatments can be used to improve swallowing function post stroke

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data EBRSR
Medical complications

indwelling catheters should only be used in specific instances timed voiding, biofeedback pelvic training, behavioral therapy and weekly in home visits reduce incontinence

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data EBRSR
Medical complications

incidence of DVT is less than 10%

anticoagulation reduces DVT LMW heparin is more effective than unfractionated heparin compression devices dont help reduce DVT

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data EBRSR
Medical complications 10% of post stroke patients have seizures osteoporosis is common after stroke and can be reduced with ipiflavone, vit D + Ca, vit B12 + folate, sunlight, and bisphosphonates

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data EBRSR
Depression

1/3 develop depression

influence of stroke location and propensity to develop depression not understood depression negatively impacts recovery

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data EBRSR
Depression depression is associated with cognitive impairment early initiation of post stroke antidepressants is effective in preventing depression various medication classes are effective in depression

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data EBRSR
Depression

pharmacologic treatment improves functional recovery treatment with antidepressants improves long term survival ECT and TCMS are effective music therapy helps

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data EBRSR
Depression

exercise training does not help

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data EBRSR
Miscellaneous

unclear if acupuncture helps

Reikki does not help HBO does not help

Evidence Based Stroke Rehabilitation

Evidence based/Outcomes based data Summary
many of the treatments we provide stroke patients are proven to help them many of the treatments we may be providing stroke patients have been shown not to help (and yet we do them anyway!) the EBRSR is an excellent resource to obtain data regarding the latest RCT evidence based outcomes information