Abstract
Stroke rehabilitation begins during the acute hospitalization once the patient is medically and neurologically stable. Rehabilitation, with involvement of a multidisciplinary rehabilitation team early during the care of the stroke patient, is one of the critical components of stroke unit care that results in improved outcome and shortened length of stay. While practices vary between countries and among hospitals, at our centers and in most US stroke centers the major focus of rehabilitative efforts occurs after discharge from the acute stroke unit, and is beyond the scope of this book (e.g. the EXCITE trial of constraint-induced movement therapy).
Stroke rehabilitation begins during the acute hospitalization once the patient is medically and neurologically stable. Rehabilitation, with involvement of a multidisciplinary rehabilitation team early during the care of the stroke patient, is one of the critical components of stroke unit care that results in improved outcome and shortened length of stay. While practices vary between countries and among hospitals, at our centers and in most US stroke centers the major focus of rehabilitative efforts occurs after discharge from the acute stroke unit, and is beyond the scope of this book (e.g. the EXCITE trial of constraint-induced movement therapy1). We will focus on those aspects of rehabilitation care that are relevant to acute stroke management.
The primary goals of acute stroke rehabilitation are to prevent medical complications, minimize impairments, and maximize function while preventing recurrent strokes. The principles of rehabilitation are the same in patients with ischemic stroke and in those with intracerebral hemorrhage.
Early involvement of speech, occupational, and physical therapists in the care of patients on stroke units is associated with a decreased risk of medical complications associated with immobility including aspiration pneumonia, urinary tract infections, falls, and pressure ulcers.2
Early Acute Stroke Rehabilitation Trials
The body of research to support stroke rehabilitation is growing. There are a number of trials of early acute stroke rehabilitation that are relevant to the acute hospital setting.
AVERT 2 (phase II) and AVERT (phase III): A Very Early Rehabilitation Trial for stroke. In the acute stroke setting, very early mobilization (VEM) focused on assisting patients to be upright and out of bed within 24 hours of stroke was shown to be safe in the phase II AVERT trial.3 However, in the phase III AVERT trial stroke patients who had VEM were less likely to be functionally independent (mRS 0–2) at 3 months as compared to usual care.4,5 There was no difference in mortality or adverse events between the VEM and usual-care rehabilitation groups.
FLAME: Fluoxetine for Motor Recovery after Acute Ischemic Stroke. In the FLAME trial, patients who received fluoxetine 20 mg within 5–10 days of moderate to severe AIS onset had significantly better motor performance than those who received placebo at 90 days even after controlling for post-stroke depression.6 Fluoxetine was demonstrated to be safe, and the only notable side effect was gastrointestinal upset.
FOCUS: Effects of fluoxetine on functional outcomes after acute stroke: a pragmatic, double-blind, randomized, controlled trial. In the FOCUS trial, AIS patients who received fluoxetine 20 mg within 2–15 days of a moderate-severity stroke had no difference in functional independence as measured by mRS score at 6 months as compared to placebo.7 The fluoxetine-treated group were significantly less likely to develop depression, but more likely to suffer bone fractures than the placebo-treated group during the first 6 months post stroke. Motor performance score was not measured.
Take-Home Messages
Rehabilitation priorities on the stroke unit:
Prevention of medical complications.
Early assessment of rehabilitation needs, utilizing a multidisciplinary rehabilitation team.
Early initiation of rehabilitation therapies within 24 hours of stroke may be safe, but has not been shown to improve 3-month outcomes. Increase intensity of therapy, as tolerated by the patient.
Use of fluoxetine should be individualized in those with depressive symptoms post stroke, and not used routinely for all patients with motor impairments.
Multidisciplinary Rehabilitation Team
The main components of the rehabilitation team are speech therapy, physical therapy, occupational therapy, and psychosocial therapy.
Speech Therapy
Speech therapy (ST) in the stroke unit has two main components: assessment of swallowing and assessment of language function. Both are assessed by a speech and language pathologist (SLP).
Swallowing
The need for swallowing assessment has already been addressed in describing the routine care of the patient with infarct and hemorrhage (Chapter 3). Dysphagia (difficulty with swallowing) is common, occurring in 30–65% of post-stroke patients.8
Dysphagia may cause malnutrition, dehydration, and aspiration pneumonia. A bedside swallowing screen should be carried out in all patients before allowing them to eat. If patients are unable to swallow effectively within 12–24 hours, a nasogastric tube (NGT) or Dobhoff tube (DHT) should be placed for enteral feeding. In fully conscious patients with hemispheric stroke, generally, this can be removed and the patient fed by mouth within several days. If there is any question, a modified barium swallow (MBS) or a fiberoptic endoscopic evaluation of swallowing (FEES) should be completed to assess for aspiration and the patient’s ability to safely swallow food and liquids of varying consistencies.
However, many stroke patients have prolonged dysphagia. Most often this occurs in patients with brainstem strokes or with hemispheric stroke associated with depressed level of consciousness, dementia, or confusion. In these cases, a percutaneous endoscopic gastrostomy (PEG) tube may need to be placed. Generally, we wait 3–5 days or so after the stroke before deciding to place a PEG, though in patients who will obviously need one, there is no reason to wait. Begin the process of planning for a PEG early, since it takes several days to arrange. Antiplatelet or anticoagulation therapy will raise concerns of bleeding risk and should be addressed as early as possible so as not to delay PEG placement. In our hospitals, the procedure can be done by gastroenterologists, general surgeons, or interventional radiologists.
Language
A description of the different aphasic syndromes is beyond the scope of this book. Most stroke patients have non-fluent-type aphasias, where their speech output is reduced or absent, with comprehension being variably affected. It is less common to see pure fluent aphasias affecting only comprehension, though this certainly can occur. Aphasia, especially impaired comprehension, can seriously impede other aspects of rehabilitation since the patient often cannot understand the instructions given by the therapist. As with other aspects of stroke recovery, practice and time with ST will result in at least some improvement in language function, with comprehension usually improving first. Pharmacotherapy with amphetamines or cholinergic and dopaminergic agents may provide benefit for particular aphasic syndromes but is unproven.
The patient’s and the family’s frustration with impaired ability to communicate should be dealt with in a supportive manner until improvement begins to occur.
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