Stroke Rehab Case Study

1. 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. Joseph’s Health Care London, Ontario

2. 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?

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

4. 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

5. 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

6. 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 <30 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?

7. Average daily direct therapy time

8. 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 2007:38:2101-2107

9. Case Study: Upper Extremity • Patient at 4 weeks post-stroke has CMS of 2 in arm and 1 in hand • The family don’t believe enough is being done to improve function in the upper extremity How much U/E therapy should the patient be getting?

10. 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

11. Case Study Patient had significant Lt neglect to confrontational testing Describe treatments available for the treatment of left neglect

12. Left Neglect Treatments • Strong evidence enhanced visual scanning techniques improve visual neglect with improvement in function • Strong evidence that limb activation therapies improve neglect

13. 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?

14. Mental Imagery There is strong evidence that mental practice may improve upper extremity motor and ADL performance following stroke

15. 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?

16. Hemiplegic Shoulder Pain • Etiology of pain is likely subscapularis/pectoralis 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

17. 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?

18. 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

19. 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.”

20. 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