Evidence Based Stroke Rehabilitation

1. Evidence Based Stroke Rehabilitation Scott Hardin MD Medical Director of Rehabilitation Services, Aurora St. Luke’s Clinical Safety Officer, Aurora St Luke’s Vice Chief of Staff, Aurora St Luke’s

2. Evidence Based Stroke Rehabilitation Disclosures None

3. 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

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

5. Evidence Based Stroke Rehabilitation History 600 BC Hippocrates – 4 humours 160 AD Galen – advanced the humour theory 1599 “the stroke of God’s hand” 1732 Robinson described the typical apoplectic patient

6. Evidence Based Stroke Rehabilitation History Mid 1600s Jacob Wepfer cerebral hemorrhage blocked cerebral arteries 1920s cerebral angiography 1935 blood letting debunked

7. Evidence Based Stroke Rehabilitation History 1950s first carotid endarterectomy 1960s Doppler ultrasound 1960s hypertension a modifiable risk 1970s aspirin CT scanning PET scanning

8. 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

9. Evidence Based Stroke Rehabilitation History 1990s tPA approved combined dipyridimole and aspirin 2000s acute cerebral artery thrombectomy carotid artery stenting

10. 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

11. 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

12. Evidence Based Stroke Rehabilitation Why does rehab work? Neural Plasticity – the ability of the brain to reorganize and learn new functions

13. 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 won’t fly

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. Evidence Based Stroke Rehabilitation Evidence based/Outcomes based data EBRSR reviews stroke literature relative to: techniques therapies devices procedures medications

21. 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

22. 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)

23. 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

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

25. 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

26. Evidence Based Stroke Rehabilitation Evidence based/Outcomes based data EBRSR Stroke Rehab Elements care pathways don’t 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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

39. 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

40. Evidence Based Stroke Rehabilitation Evidence based/Outcomes based data EBRSR Dysphagia a variety of treatments can be used to improve swallowing function post stroke

41. 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

42. 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 don’t help reduce DVT

43. 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

44. 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

45. 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

46. 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

47. Evidence Based Stroke Rehabilitation Evidence based/Outcomes based data EBRSR Depression exercise training does not help

48. Evidence Based Stroke Rehabilitation Evidence based/Outcomes based data EBRSR Miscellaneous unclear if acupuncture helps Reikki does not help HBO does not help

49. 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