Rehabilitation in Younger Strokes

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Rehabilitation in Younger Strokes

• Robert Teasell MD FRCPC
• Professor and Chair-Chief
• Department of Phys Med Rehab
• Schulich School of Medicine
• University of Western Ontario
• Lawson Health Research Institute
• St. Josephs Health Care London
• London, Ontario, Canada

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Objectives

• Understand rehabilitation of young stroke
  patients has unique features
• Appreciate role of social factors in the
  rehabilitation of younger stroke patients
• Understand role of age in rehabilitation of more
  severe stroke patients

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Case Study 1

• 26 y.o. separated woman
• 3.5 wks ago sustained ruptured Rt MCA aneurysm 2
  days post-partum
• Rt frontotemporal craniotomy and evacuation of
  hematoma
• Dense Lt hemiplegia, dysphagia, hypophonic voice,
  urinary retention, decreased sensation and
  neuropathic pain on Lt side, Lt homonymous
  hemianopsia and Tersons syndrome

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Case Study 1 (cont)

• Transferred to Stroke Rehab Unit 3.5 weeks post
  stroke and discharged almost 4 months later

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Case Study 1 (cont)

• Sensation on Lt side severely impaired
• Able to transfer w/c to bed independently /-
  hand support, using a standing pivot transfer
• Ambulating 60 meters with single cane and
  supervision
• Propel wheelchair up to 50 meters
• Manage full flight of stairs with handrail and
  supervision
• Left neglect and vision interfered with higher
  level IADLs

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Case Study 1 (cont)

• Went to live with her parents
• Stroke Rehab Pilot OP Program for 11 months
• Cerebral angiogram showed a small AVM during that
  time and underwent resection of AVM
• Began teaching piano, got a part-time retail job
  and moved into her own home less than 2 years
  post event with her young son

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Stroke in Young Patients

• Stroke is generally considered to be a condition
  that occurs in elderly individuals
• For every 4 individuals experiencing a stroke, 1
  is under the age of 65 and 3-4 of all strokes
  are under the age of 45
• Disproportionate number of younger strokes
  admitted for rehabilitation

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Young Stroke Patients Have Unique Issues

• Employment is important
• More likely to be responsible for childcare
• Family stress and psychosocial consequences
• Rehab strategies for elderly patients is not
  always applicable for younger stroke patients
• Given they live a long time disproportionate
  amount of costs of stroke
• Few studies have assessed the specific needs of
  young stroke patients

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Stroke Etiology in Young Patients

• Stroke patients in younger populations, have a
  wider variety of etiologies than older stroke
  cohorts
• In approximately one-third or more of young
  stroke patients a diagnosis is not made
• Hemorrhagic strokes together constitute 30-35 of
  all strokes under the age of 50 15-20 of all
  strokes over the age of 50

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Recovery and Prognosis

• Young stroke patients demonstrate greater
  neurological and functional recovery and hence
  have a better prognosis
• Older patients limitations include less
  physiological reserve for recovery (frailty),
  lesser opportunity for neurological
  reorganization and higher prevalence of co-morbid
  conditions, particularly cognitive impairment

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Case Study 2

• 16 year old with Moya Moya disease undergoes a
  revascularization procedure
• Infarction of Rt MCA, ACA and PCA total loss of
  hemisphere (underwent 3 lobectomies)
• Rehabilitation went on for 5 months
• Berg balance score went from 0 to 41/56
• Wheelchair dependent on admission but on
  discharge able to walk with minimal assistance

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Prognosis

• Young stroke patients are more likely to return
  home after stroke, and recovery was most dramatic
  with moderately severe strokes
• Younger patients had relatively high scores for
  functional ability as measured by ADLs and
  independent ambulation

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Rehab of Younger Stroke Patients

• Rehabilitation of young stroke patients is the
  same process as that of older stroke patients
• Make greater and more rapid neurological recovery
  and can tolerate more intense therapy

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Rehab of Younger Stroke Patients

• Rehab of younger stroke patients has associated
  social issues
• Family supports
• Presence of young dependents
• Marital stress
• Return to work
• Less willigness to participate in adaptive
  behaviours
• Need to live longer to live with a possible
  disability

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Rehab Priorities of Young Stroke Patients

• Hartke and Brashler (1994) reported on 100 young
  stroke survivors who responded to a questionnaire
  about rehabilitation
• Patients and physicians were asked what programs
  they felt what would be most helpful during
  inpatient rehabilitation

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Rating of Program Importance in Young Stroke
Rehabilitation
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Rehab Priorities of Young Stroke Patients

• Only high-functioning stroke survivors chose
  vocational counselling frequently
• Low-functioning survivors ranked family
  counseling higher and may have been expressing
  greater concern over family strain due to their
  dependence
• Interventions concerning sexual functioning,
  parenting, and dating/interpersonal relationships
  were chosen relatively less frequently, although
  they might be developmentally salient at a
  younger age (Hartke and Brashler 1994)

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Family Stress

• Stroke tends to affect all family members who
  themselves often have to make significant
  adjustments to deal with disability
• Correlations found between amount of strain and
  level of depression in spouses of younger stroke
  patients
• Initial assessment of spousal depression and
  quality of life 1 year post-stroke predicted by
  initial levels of stress
• Partner distress was often due to emotional
  distress in children having difficulty coping

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Case 3

• 31 y.o. female decreased LOC, left hemiplegia,
  vomiting
• MRI revealed infarcts Lt cerebellum, Rt thalamus,
  Rt hemi-pons due to mid-basilar artery thrombosis
• Intubation with subsequent tracheostomy, ICU stay
  and a feeding tube

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Case 3 (cont)

• Initial problems included a spastic Lt
  hemiparesis, Lt ataxia, dysarthria, dyphagia,
  diplopia and emotional lability
• Acute care x 6 wks and rehab x 18 wks

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Case Study 3 (cont)

• At discharge able to ambulate with rollator
  walker and one-person assist and ADL-independent
• Combination of ataxia and hemiparesis presented
  special challenges
• By one year continuing to improve ambulating
  with Rollator walker or cane falling every day
• Able to exercise for 2 hrs per day on elliptical
  treadmill
• Back to work 3.5 years later part-time

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Case Study 3 (cont)

• Lived with her husband highly athletic and
  independent individuals
• Husband initially very stressed and required
  extensive counselling worried about coping at
  home, finances
• Initially he claimed the stroke was a good thing
  because it brought them closer together
• Sexual activity problematic because he felt more
  like a caregiver
• Split up 3 years after the stroke

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Family Stress

• Caregivers at highest risk of depression are
  reportedly the spouses of younger, more severely
  impaired patients with lower household incomes,
  smaller social networks with whom they visit
  frequently, and lower levels of future optimism
  and expectation (Tompkins et al. 1988)

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Family Stress

• Teasell et al. (2000) found 38 of young stroke
  patients experienced conflict with their spouse
  while on rehab unit sufficient that inpatient
  rehabilitation staff charted it
• One in seven couples separated within 3 months of
  the stroke
• 22 of young stroke patients appeared to
  experience conflict with children during
  inpatient rehabilitation

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Family Stress

• Visser-Meily et al. (2005) noted that the
  severity of stroke had an impact on the amount of
  support a family received from hospital
  rehabilitation staff
• Longer hospitalization correlated with the amount
  of attention rehab staff gave children of young
  stroke patients
• Inpatient rehab staff did not pay more attention
  to children with adjustment problems

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Role Change

• With more typical older stroke patients, families
  often experience role reversal children may
  become parents to their husband wife may need to
  assume husbands roles around the home, etc.
• Less of an issue with young stroke patients
  whereby old roles may need to be resumed parents
  may need to reparent a previously independent
  child

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Case Study 4 (cont)

• 15 y.o. female admitted with large Lt subcortical
  stroke etiology unknown ? PFO Rx t-PA
• Very active in athletics, oldest of 3 siblings,
  honor student, part-time babysitter, normal kid
  beginning to develop her own independence
• 10 days later admitted with Rt hemiparesis 7
  week stay in rehab CMS 6/7 except for foot 4/7
• Returned to part-time school after 6 months and
  resumed soccer

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Case Study 4

• Able to run but could not stand on one foot
• Neuropsychs later showed mild impairments with
  executive skills, mild word-finding difficulties,
  working memory, behavioural inhibitions, visual
  spational abilities and attention
• Remained honor student but could no longer do
  mathematics no science career
• Had to deal with mom making all her decisions for
  her

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Institutionalization

• Black-Schaffer and Winston (2004) found young
  severe stroke patients often had longer
  hospitalizations than older stroke patients
  cohorts
• Older patients are recognized as having less
  chance of functional recovery and are more
  promptly discharged to nursing homes or
  institutional care longer rehab visits for
  younger stroke patients result in greater rehab
  gains and greater likelihood of going home

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Institutionalization

• Teasell et al. (2000) reported institutionalizatio
  n in only 4 of 83 stroke patients lt 50 years of
  age admitted to stroke rehab units
• The common feature to each of these 4 strokes
  was a severe disabling stroke(s) occurring in
  association with poor social support

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Institutionalization

• Black-Schaffer and Winston (2004) and Adunsky et
  al. (1992) both noted that institutionalization
  of these patients was rare, that young patients
  tended to be in rehab longer and reached much
  higher levels of functioning than elderly stroke
  patients
• Attributed in part to lack of coexisting medical
  problems and lack of organic intellectual
  impairment

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Return to Work

• Vocational issues are unique to younger stroke
  patients
• Monga (1997) noted, The rehabilitation community
  has devoted only limited effort to the task of
  defining what is meant by the phrase return to
  work, to develop measures of vocational function,
  to applying these measures to patient
  populations, and to tracking return to work as a
  measure of rehabilitation outcome.

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Return to Work

• Studies show few young stroke patients are able
  to return to previous or any full-time employment
  one-year post-stroke even if physical deficits
  are minimal (Glozier et al. 2008)
• Consistently, young stroke patients reduced the
  number and/or complexity of tasks performed
  (Black-Schaffer and Osber 1990)

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Case Study 5

• 35 y.o. married salesman with a Lt cerebellar and
  pontine infarct
• 2 days later life-threatening cerebellar bleed
  and underwent Lt cerebellar resection
• Etiology of stroke never established
• Clinically Rt hemisensory loss, severe Lt ataxia,
  dysarthria, diplopia, urinary retention, extreme
  paresis, fatigue and some memory loss
• Admitted to inpatient rehab for 4 mos and made
  slow steady improvements

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Case Study 5 (cont)

• Mobility hindered by severe Lt ataxia, and Rt
  hemisensory loss severe dysarthria
• Experienced mood swings with frustration which
  improved as disability declined
• At discharge 3 months later he was able to
  ambulate slowly with a cane and was independent
  in ADLs
• Still experiencing diminished balance, decreased
  coordination Lt side, Rt sensory deficits and
  numbness, fatigue and weight gain
• 1.5 yrs post-stroke able to return gradually to
  his previous work but never as good as before

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Factors Predicting Return to Work

• White collar work and education (sedentary, work
  autonomy, coworker coverage)
• Full-time paid employment pre-stroke
• Lack of psychiatric illness
• Limited residual muscle weakness
• Lack of apraxia
• Lack of aphasia
• Lack of cognitive difficulties

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Cognitive Deficits and RTW

• Cognitive deficits following stroke increasingly
  recognized as important factor in RTW
• Many of the cognitive deficits are subtle
• Neuropsychological testing may be required to
  accurately delineate the extent of cognitive
  problems and determine how they might impact
  patients eventual return to work post-stroke
• Mercier et al. (1991) found neuropsychological
  testing to be predictive of better return to work
  outcomes

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Fatigue in Young Stroke Patients

• 51.3 of young stroke patient experience chronic
  fatigue which can negatively affect scholastic,
  vocational and social pursuits
• Independently associated with unfavourable
  functional outcomes and unemployment at mean 6
  months follow-up
• Post-stroke depression is present in one-quarter
  of young strokes

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Support Organizations

• Post rehabilitation, young stroke patients want
  to connect with others who share similar
  experiences
• Patients need time to come to terms with changed
  physical abilities, work, family and social life

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Rehabilitation of Severe Strokes

• Cortical reorganization is dependent on adjacent
  or connected cortical areas taking over lost
  function
• Given extent of brain damage in severe strokes,
  pts typically severely compromised for cortical
  reorganization and neurological recovery

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Probability of Walking gt 150 ft Without
Assistance
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Rehab of Severe Strokes

• Several RCTs comparing specialized stroke rehab
  to generalized stroke rehab for severe stroke
  subsets more likely
• Be discharged home
• Shorter length of hospital stay
• Reduced mortality
• Minimal functional gains
• Concept of slow-stream stroke rehab remains
  unproven

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Case Study 6

• 46 y.o. married female
• Hemorrhage involving Rt pons, midbrain and basal
  ganglia
• Resulting bilateral hemiparesis, Rt ataxia,
  dysphagia, dysarthria, bowel and bladder
  incontinence
• Admitted to Parkwood Stroke Rehab Unit 55 days
  post-stroke
• Kept in rehabilitation 5.5 mos

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Case Study 6 (cont)
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Case Study 6 (cont)
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Case Study 6 (cont)

• At discharge pt. required moderate to maximum
  assistance with all ADLs due to ataxia,
  hemiparesis and limited shoulder movement
• Dysphagia with G-J tube eventually removed at
  time of discharge and on minced diet
• Required one to two person transfer
• Ambulating 10 meters with moderate assistance and
  cueing
• Discharged home with strong family, private
  insurance and Home Care support

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Case Study 6 (cont)

• Pilot Interdisciplinary outpatient therapy
  Program 3 mos
• COVS 34 to 46 Berg 5 to 7
• After 3 week break, Comprehensive Outpatient
  Rehab Program (CORP) x 5 months
• 3.5 years after last therapy at home

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Case Study 6 (cont)

• CORP readmit Nov 15, 2005 Jan 27, 2006
• Berg Balance 12/56 COVS 48/91
• Feb 6, 2006 to March 14, 2006 admitted to
  hospital for AVM removal
• Rehab March 14 April 12, 2006 for
  deconditioning

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Rehab of Young Severe Strokes

• Young stroke patients appear to do better than
  older stroke patients
• Important consideration when deciding on whether
  younger stroke patients would benefit from stroke
  rehabilitation
• Severe stroke patients are inevitably admitted if
  young not necessarily the case with similar
  older stroke patients

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Summary

• Young stroke patients have many unique
  rehabilitation issues
• They make a more rapid and complete
  neuro-recovery
• They have a number of unique social issues
• More likely to benefit from stroke rehabilitation
  if they suffer a severe stroke

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The End