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Stroke Rehabilitation

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Stroke Rehabilitation Robert Teasell MD FRCPC Professor and Chair-Chief Dept of Physical Medicine and Rehabilitation St. Joseph s Health Care London – PowerPoint PPT presentation

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Title: Stroke Rehabilitation


1
Stroke Rehabilitation
  • Robert Teasell MD FRCPC
  • Professor and Chair-Chief
  • Dept of Physical Medicine and Rehabilitation
  • St. Josephs Health Care London

2
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

3
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

4
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

5
  • 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

6
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

7
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

8
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)

9
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
10
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)

11
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
12
  • 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

13
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
14
  • 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

15
  • The Importance of Stroke Rehab Units

16
  • 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

17
  • 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

18
  • 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)

19
  • 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

20
At 6 weeks (Indredavik et al. 1990)
Significant benefit still seen at 10 years
21
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22
The Impact of Stroke Unit Care on Combined
Death/Dependency Post Stroke (Foley et al. 2007)
23
  • 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

24
Specialized Rehab Care
  • Specialized Stroke Rehabilitation is the gold
    standard of care

25
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

26
Nudo RJ 1997 Post-stroke lesion in squirrel
monkey, rehab results in expansion of hand
representation no rehab results in contraction
27
  • 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
28
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

29
  • The Earlier the Better

30
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

31
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

32
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

33
Therapy Intensity
34
  • 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

35
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38
  • Kalra et al. 1994

39
  • 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)
40
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

41
Greater Accountabilities
42
  • 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

43
Average daily direct therapy time
44
Time Spent in Therapeutic Activities
45
  • 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

46
  • 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

47
  • 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)

48
  • 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

49
  • 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

50
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

51
Where Did the Outpatients Go?
52
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

53
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

54
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

55
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

56
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
57
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