Chapter  16:  Post-Stroke Rehabilitation: Clinical Guideline Number 16

Basic Principles of Rehabilitation

Rehabilitation During the Acute Hospitalization

Stroke rehabilitation should begin as soon as the diagnosis of stroke is established and life-threatening problems are under control. Highest priorities are to prevent complications from the present stroke, prevent recurrent stroke, and mobilize the patient and encourage resumption of self-care activities as soon as medically feasible.

A considerable body of evidence, mainly from countries in Western Europe, indicates that better clinical outcomes are achieved when patients with acute stroke are treated in a setting that provides coordinated, multidisciplinary stroke-related evaluation and services. Skilled staff, better organization of services, and earlier implementation of rehabilitation interventions appear to be important components.

The value of early mobilization has been amply demonstrated. Measures should begin with range-of-motion exercises and physiologically sound changes of position in bed on the day of admission, and should be followed by progressively increased levels of activity as soon as medically tolerated. Early mobilization also includes encouragement to resume self-care activities and socialization.

Etiologic-specific measures to prevent recurrent stroke should be implemented in all patients. Evidence of effectiveness is especially strong for carotid endarterectomy in patients with 70 to 99 percent obstruction of the carotid artery, use of anticoagulants in patients with nonvalvular atrial fibrillation or other cause of cardiac embolic stroke, and use of antiplatelet agents in patients who have had a transient ischemic attack (TIA).

The value of low-molecular-weight (LMW) heparin or low-dose heparin (LDH) to prevent deep vein thrombosis in immobilized patients with stroke is well supported. Warfarin, intermittent pneumatic compression, and elastic stockings are also effective. Appropriate measures should be implemented in all immobilized patients.

Swallowing problems (dysphagia) are common after stroke and may cause aspiration. The patient's ability to swallow should be assessed before oral intake is begun, and techniques to facilitate swallowing should be implemented in affected patients. A feeding gastrostomy or nasogastric tube may be required if the patient does not regain the ability to swallow safely.

Patients who have had seizures after stroke should be given anticonvulsant medication to prevent recurrent seizures. Maintenance of skin integrity, fall prevention, and management of bowel and bladder function are important. Indwelling urinary catheters should be used only with patients who cannot be otherwise managed and should be removed as soon as possible to avoid urinary tract infections or other complications.

Patient and family support and education are intrinsic components of acute care for stroke. Adequate understanding of the cause and manifestations of the stroke, its treatment, and the prognosis are particularly important, as is counseling to help the patient and family deal with their concerns. Discharge planning extends support and education, identifies a postdischarge setting, and seeks to ensure continuity of care.

Screening for Rehabilitation and Choice of a Setting

All stroke survivors need caring, support, and education, but only some need formal rehabilitation. People who recover completely from their strokes will not need rehabilitation, and others will be too incapacitated to benefit from rehabilitation. Between these extremes are people with varying degrees of disability. For these individuals, the goal should be to identify the best possible match between their needs and the capabilities of available rehabilitation facilities.

A screening examination for rehabilitation should be performed as soon as the patient's medical and neurological condition permit by a person who is experienced in rehabilitation and has no direct financial interest in the referral decision. The screening examination uses information recorded in the medical record, but also needs to include direct examination of the patient and use of a well-standardized disability (e. g., activities of daily living) instrument and mental status screening test.

Threshold criteria for admission to a comprehensive rehabilitation program are medical stability, the presence of a functional deficit, the ability to learn, and enough physical endurance to sit supported for at least 1 hour and to participate actively in rehabilitation to at least some extent. Admission to an interdisciplinary program should be limited to patients who have more than one type of disability and who therefore need the services of two or more rehabilitation disciplines; patients with a single disability can benefit from individual services, but do not need an interdisciplinary program.

Stroke rehabilitation can be conducted in inpatient rehabilitation hospitals or rehabilitation units in acute care hospitals, in nursing facilities with rehabilitation programs, in outpatient facilities, or in the home. Hospital programs are usually the most comprehensive and intense and have the best medical coverage. A few nursing facility programs are similar to hospital programs, but many are less comprehensive. The wide variability in the capabilities of nursing facility programs makes it incumbent on the referring physician or hospital to evaluate the capabilities of the program with specific reference to each patient's needs. Outpatient and home rehabilitation programs also vary widely in their comprehensiveness and intensity.

Patients who are medically unstable are not suitable for any rehabilitation program. Those who have complex medical problems that require frequent attention are usually better treated in facilities that have round-the-clock coverage not only by rehabilitation nurses and physicians, but also immediately available consultant services by other medical specialists. Patients with moderate or severe disabilities and sufficient physical endurance to tolerate intense rehabilitation (at least 3 hours of physically demanding exercises per day) are candidates for intense hospital or nursing facility programs. Patients with milder degrees of disability and those who have poor physical endurance or limited attention spans are usually better served by lower intensity programs in nursing facilities, at home, or in outpatient facilities. The characteristics of the home environment and availability of social support may affect the feasibility of home or outpatient rehabilitation; for the latter, availability of transportation can also be a constraint. In some instances, a further period of recuperation in a nursing facility or at home will allow enough recovery for a patient to enter a comprehensive rehabilitation program at a later time. Providers need to remain alert to these opportunities, and patients and families should be made aware that reassessment could occur in the future, leading to a change in treatment.

Managing Rehabilitation

Transition to the Community

Return to a community residence after an acute hospitalization for stroke, or after an inpatient rehabilitation program, can be difficult for the stroke survivor and family alike. At this time, the person has to assume increased responsibility for independent functioning in the absence of the supportive environment of the inpatient setting, with the family or other caregivers providing needed support. Continuity of services is important during this period, and patient and family counseling may be needed to facilitate family functioning and improve outcomes.

The patient's continuing needs for medical care and rehabilitation should be coordinated by a single clinician in collaboration with the individual and family. An initial visit with this care coordinator should be scheduled no later than 1 month after discharge. Close communication among providers, the patient, and the family is critical to developing a coherent care plan and avoiding gaps or inconsistencies in care.

After the return to a community residence, progress needs to be evaluated at regular intervals to document whether the person is maintaining gains made during rehabilitation, progressing toward more independent function, and successfully reintegrating with the family and community.

Rehabilitation services generally should be phased out slowly after completion of hospital or nursing facility rehabilitation programs or during home or outpatient programs to avoid the feeling of abandonment and provide opportunities for "tuneups." Continued rehabilitation services should be justified, however, by documented evidence of progress.

Community supports are important for many stroke survivors. Acute care hospitals and rehabilitation facilities should maintain up-to-date information on community resources and offer assistance to patients and their families in obtaining needed services. Individual health care providers should be familiar with available services and sources of information.

Issues that arise after return to a community residence include safety and fall prevention, health promotion, sexuality, resumption of leisure and community activities, driving, and return to work. Each of these areas needs to be carefully addressed.

Conceptual Model

The goals of rehabilitation can be visualized according to the conceptual framework of disablement developed in the World Health Organization's (WHO) International Classification of Impairments, Disabilities, and Handicaps (ICIDH) (World Health Organization, 1980) and Nagi's functional limitation" model (Nagi, 1965). The former classifies disablement in terms of "disease," "impairment," "disability," and "handicap," in which disease is the underlying diagnosis and pathologic process, impairment is the loss or abnormality of physical or psychological capacities, disability is a restriction or lack of ability of a person to perform an activity in daily life, and handicap is a disadvantage resulting from an impairment or disability that limits or prevents fulfillment of a role that is normal for that person.

Nagi, on the other hand, emphasizes "pathology," "impairment," "functional limitation," and "disability," where pathology is the "interruption or interference of normal bodily processes or structures"; impairment is "loss or abnormality of mental, emotional, physiological, or anatomical structure or function"; functional limitation is "restriction or lack of ability to perform an action or activity in the manner or within the range considered normal"; and disability is the "inability or limitation in performing socially defined activities and roles expected of individuals within a social or physical environment." The disability model envisioned by Nagi has the advantages of emphasizing the causative role of risk factors and the importance of the quality of life. "Disability" in Nagi's framework is equivalent to "handicap" in WHO's framework and avoids the negative implications attached to this term.

Relationship of functional assessment and interventions (more...)

   Relationship of functional assessment and interventions to the World Health Organization's impairment, disability, and handicap model

Figure 1

Outcome Measures

Potential measures of the success of stroke rehabilitation include:

• Survival.

• Normalized health patterns (such as nutrition, continence, and sleep).

• Freedom from physical pain and emotional distress.

• Cognitive and communicative abilities.

• Freedom from impairments affecting motor control, mobility of joints, sensation, speech and language, and other areas.

• Independence in mobility and the basic activities of daily living.

• Independence in complex daily functions and social roles.

• Successful family function and adaptation.

• Quality of life.

Actual performance of a function is a better measure of success than the capacity to perform the function in the supportive environment of a rehabilitation program. Motivation, confidence, stimulation, and environmental factors can all strongly affect actual performance.

The ability of a person with a stroke to return home after treatment is usually regarded as a desirable outcome. This may not be the case, however, if the person's needs for physical care and support impose intolerable burdens on caregivers.

Scope of the Guideline

This guideline is intended for use by all of the professionals who participate in post-stroke rehabilitation. It is specifically directed at the patient with a first stroke who has residual hemiparesis with or without other neurological impairments. Most recommendations will also apply to the person with a recurrent stroke or with stroke-related neurological impairments in the absence of hemiparesis.

Clinical flow diagram for stroke rehabilitation

   Clinical flow diagram for stroke rehabilitation

Figure 2

Between these extremes are patients with persistent functional deficits who are potential candidates for individual rehabilitation services or an interdisciplinary program. The choice of rehabilitation setting will depend on careful evaluation of clinical findings and the capabilities of rehabilitation facilities in a given community. The fundamental components of any program are baseline assessment, development of rehabilitation goals and a plan for achieving them, implementation of interventions, and monitoring of progress.

When goals have been achieved or a plateau in progress has been reached, the patient is discharged from rehabilitation or transferred to another type of setting (e.g., to an outpatient or home program from an inpatient setting). Transition to a community residence or the cessation of rehabilitation services often raises difficult issues of adaptation and continuity of care that need to be addressed.

Nomenclature in Stroke Rehabilitation

This guideline employs a standard terminology to describe rehabilitation settings, programs, interventions, and participants. Following are definitions of some of the more important terms used. See the Glossary for other definitions.

Panel Selection and Guideline Development

Format and Classification of Recommendations

Each guideline recommendation is justified in terms of the level of research evidence supporting it and the degree of consensus on it among panel members. The distinction between support derived from scientific studies and that derived from expert opinion is important. Well-performed and relevant scientific studies provide a higher standard of evidence when they are available, but many aspects of stroke rehabilitation have not been addressed by such studies. Expert judgments supplement research evidence by factoring in clinical experience and human values that are not easily captured in scientific studies, and by extrapolating from scientific findings that were obtained with specific populations under specific conditions to a broad clinical context.

Support for recommendations is characterized as follows

• Research Evidence:

• A.

• Supported by the results of two or more randomized controlled trials (RCTs) that have good internal validity, and also specifically address the question of interest in a group of patients comparable to the one to which the recommendation applies (external validity).

• B.

• Supported by a single RCT meeting the criteria given above for "A"-level evidence, by RCTs that only indirectly address the questions of interest, or by two or more nonrandomized clinical trials (case control or cohort studies) in which the experimental and control groups are demonstrably similar or multivariate analyses have effectively controlled for group differences.

• C.

• Supported by a single non-RCT meeting the criteria given above for "B"-level evidence, by studies using historical controls, or by studies using quasi-experimental designs such as pre- and post-treatment comparisons.

• NA (not available).

• Recommendation is not addressed by experimental studies.

• Expert Opinion:

• Strong consensus.

• Agreement among 90 percent or more of panel members and expert reviewers.

• Consensus.

• Agreement among 75 to 89 percent of panel members and expert reviewers.

Incidence and Prevalence

Stroke incidence, defined as the number of acute strokes per year, depends primarily on the age, sex, and race mix of the population, whether only first strokes or all strokes are counted, whether transient ischemic attacks (TIAs) are included as well as completed strokes, and the diagnostic criteria used.

The average age-adjusted incidence rate of first strokes has been reported to be 114 per 100,000 but ranges from 81 to 150 per 100,000 in different studies (Terent, 1993). Men have 30 to 80 percent higher rates than women (Broderick, Phillips, Whisnant, et al., 1989; Harmsen, Tsipogianni, and Wilhelmsen, 1992; Wolf, D'Agostino, O'Neal, et al., 1992). The incidence of stroke doubles with every decade after 55 years of age (Dyken, Wolf, Barnett, et al., 1984). In Rochester, Minnesota (1980 to 1984), incidence increased nearly ninefold between ages 55 to 64 and 85 years or over (Broderick, Phillips, Whisnant, et al., 1989). Stroke rates are 50 percent higher in African-American men than in white men, and 130 percent higher in African-American women than in white women (Gillum, 1988).

First-ever strokes account for about 75 percent of acute events and recurrent strokes for about 25 percent (Terent, 1993). The recurrence rate is 7 to 10 percent per year and is highest in the first year after a first stroke. In the Framingham Study, recurrence was found to be particularly common for thrombotic stroke and more frequent in men (Sacco, Wolf, Kannel, et al., 1982).

Stroke prevalence--the number of living persons at any given time who have had a stroke--depends on the interaction of incidence and survival. Studies in Rochester, Minnesota, have found stroke prevalence to be 500 to 800 cases per 100,000 population (Matsumoto, Whisnant, Kurland, et al., 1973; Whisnant, Fitzgibbons, Kurland, et al. , 1971). These figures are similar to those of other countries (Terent, 1993).

Mortality

The average 30-day case fatality rate from stroke in the 1970s and 1980s was 21 percent, with a range from 17 percent (Broderick, Phillips, Whisnant, et al., 1989) to 34 percent (Bonita, Beaglehole, and North, 1984); 1-year mortality ranged from 25 to 40 percent; and 3-year mortality from 32 to 60 percent. Ten-year survival in the Framingham Study is 35 percent (Wolf, D'Agostino, O'Neal, et al., 1992). Hence, about half of the people with first strokes live for 3 or more years and more than one-third live for 10 years. Mortality rates for intracerebral hemorrhages are much higher than those for infarction. In Rochester (1984), the 30-day case fatality rate was 48 percent for intracerebral hemorrhage compared with 17 percent for all strokes (Broderick, Phillips, Whisnant, et al., 1989).

Stroke mortality rates have been declining steadily since the early 1950s in the United States (Broderick, Phillips, Whisnant, et al., 1989; Cooper, Sempos, Hsieh, et al., 1990) and most Western European countries (Bonita, Steward, and Beaglehole, 1990). The decline probably reflects the combined effects of better control of modifiable risk factors such as hypertension, earlier diagnosis, and better acute management of the patient (Broderick, Phillips, Whisnant, et al., 1989; Garraway, Whisnant, and Drury, 1983; McGovern, Burke, Sprafka, et al., 1992; Wolf, D'Agostino, O'Neal, et al., 1992).

Etiology

Stroke etiologies can be classified broadly into atherothrombotic brain infarction, hemorrhage, or other. A classification scheme for brain infarction (ischemic strokes) developed in the multicenter TOAST trial in the United States has the advantages of clinical relevance and reliability (Adams, Bendixen, Kappelle, et al., 1993). This system divides infarctions into large artery atherosclerosis, cardioembolism, small vessel occlusions, or infarcts of undetermined cause. Hemorrhages may be intracerebral or subarachnoid. Accurate diagnoses are difficult to achieve based on clinical impressions alone and require information from laboratory studies including computed tomography (CT) scanning, magnetic resonance imaging (MRI), and angiography. Even with laboratory studies, however, the diagnosis represents a "best clinical guess" in a substantial number of patients. Definitions differ among studies and need to be taken into account when interpreting the results.

Risk Factors for Stroke

Risk factors for stroke can be divided into those that are potentially modifiable and those that are not (Dyken, Wolf, Barnett, et al., 1984). Most important among modifiable risk factors are TIAs, hypertension, diabetes mellitus, atrial fibrillation, left ventricular hypertrophy, and cigarette smoking. Prior stroke, age, sex, race, and family history are important nonmodifiable factors.

The paramount modifiable risk factor for stroke is hypertension. The relationship is with both diastolic and systolic blood pressure and is especially strong for levels above 160/95 mm Hg.

The presence of cardiac abnormalities such as atrial fibrillation, left ventricular hypertrophy, coronary heart disease, and congestive heart failure increases the risk of stroke at each blood pressure level. Acute myocardial infarction and atrial fibrillation predispose to embolism from cardiac thrombi, and nearly 15 percent of strokes in the Framingham Study have been attributed to atrial fibrillation (Wolf, Abbott, and Kannel, 1987). The risk of cerebral infarction is five times higher in individuals with electrocardiographic evidence of left ventricular hypertrophy even after other risk factors are taken into account. The relationship between blood lipids and stroke is not clear even though increased lipid levels have been related to carotid artery disease. Low serum cholesterol has been found in Hawaiian, Japanese, and other populations despite an increased incidence of cerebral hemorrhage (Yano, Reed, and MacLean, 1989).

The association of cigarette smoking with stroke holds for thrombotic strokes as well as intracerebral and subarachnoid hemorrhages. A recent meta-analysis of 32 studies found that smoking increased the risk of stroke by about 50 percent in both sexes and all age groups, and that risk was directly related to the number of cigarettes smoked per day (Shinton and Beevers, 1989).

Heavy consumption of alcohol, cocaine use, and obesity have also been linked to an increased incidence of stroke.

Among fixed risk factors, increasing age is by far the strongest. Seventy-two percent of strokes occur in people 65 years of age or over. Males have a higher risk of stroke than females in all but the oldest age groups, and African Americans have a twofold higher risk. In African Americans, about one-third of the increased risk is attributable to cardiovascular risk factors, another third to factors related to family income, and one-third is unexplained (Gillum, 1988).

Neurological Deficits

Table 2. Neurological deficits following stroke

Table 2. Neurological deficits following stroke

Neurological deficit	Acute		Chronic
	Stroke Data Bank[a] (infractions only)	Finland[b]	Finland[b] (12 months)	Framingham[c] (6 or more months)
	Percent
Right hemiparesis	44	NR	NR	22
Left hemiparesis	37	NR	NR	23
Bilateral hemiparesis	7	NR	NR	3
Total with hemiparesis	88	73	37	48
Ataxia	20	NR	NR	NR
Motor coordination	NR	86	61	NR
Hemianopsia	26	NR	NR	13
Visual-perceptual deficits	32	NR	41	NR
Aphasia	30	36	30	18
Dysarthria	48	57	21	16
Sensory deficits	53	NR	NR	24
Cognitive deficits (memory)	36	NR	(31)	NR
Depression	NR	NR	29	NR
Bladder control	29	29	9	NR
Dysphagia	12	13	4	NR

Note: NR = not reported.

Comorbidities in Stroke Patients

Many patients have comorbid conditions that increase the risk of recurrent stroke and compromise the patient's ability to participate in active rehabilitation. The Framingham Study examined the frequency of comorbidities in stroke survivors and matched controls and found that the stroke survivors had significantly more hypertension (67 vs. 45 percent), hypertensive heart disease (53 vs. 31 percent), coronary heart disease (32 vs. 20 percent), obesity (22 vs. 12 percent), diabetes mellitus (22 vs. 10 percent), arthritis (22 vs. 12 percent), left ventricular hypertrophy (21 vs. 6 percent), and congestive heart failure (18 vs. 5 percent) (Gresham, Phillips, Wolf, et al., 1979).

Time Course of Recovery From Stroke

Neurological and functional recovery occurs most rapidly in the first 1 to 3 months after a stroke (Kelly-Hayes, Wolf, Kase, et al., 1989; Skilbeck, Wade, Hewer, et al., 1983), but some patients continue to progress after that time, especially with respect to language and visuospatial functions (Andrews, Brocklehurst, Richards, et al., 1981; Hier, Mondlock, and Caplan, 1983; Meerwaldt, 1983; Skilbeck, Wade, Hewer, et al., 1983). In Rochester, Minnesota, the proportion of patients with strokes who were "moderately severely" or "severely" disabled (Rankin grades IV or V) decreased from 58 percent at the time of stroke onset to 26 percent at discharge, and 17 percent among survivors after 6 months but remained relatively constant thereafter (Dombovy, Basford, Whisnant, et al., 1987). In Framingham, improvement in motor strength and performance of self-care functions slowed 3 months after stroke, but continued at a reduced pace throughout the first year, especially in patients with cerebral infarctions (Kelly-Hayes, Wolf, Kase, et al., 1989). Cognitive function improved only during the first 3 months. The Durham County Study (Duncan, 1992) found dramatic recovery of motor function during the first 30 days and slower but continued improvement thereafter in more severely impaired individuals. Arguments that neural and functional recovery can continue beyond 3 to 6 months are supported by a recent study in which patients with motor deficits were followed for 6 months after discharge from a rehabilitation unit (Ferruci, Bandinelli, Guralnik, et al., 1993). Though time since the onset of stroke was not reported, it is reasonable to assume that most patients were at least 2 months "poststroke" at the time of discharge. Neuromuscular function, mobility, and activities of daily living continued to improve during followup, especially in more severely impaired patients.

Disability After Stroke

Activities of Daily Living

Table 3. Disabilities after stroke in the Frenchay (more...)

Table 3. Disabilities after stroke in the Frenchay Health District, United Kingdom, during 1981-1983

Type of disability	Acute[a]	6 months
	Percent
Not oriented	55	27
Marked communication problem	52	15
Motor loss (partial or complete)	80	53
Bowel incontinence	31	7
Urinary incontinence	44	11
Needs help with grooming	56	13
Needs help with toileting	68	20
Needs help with feeding	68	33
Needs help with dressing	79	31
Needs help with bathing	86	49
Needs help with transfers from bed to chair	70	19
Unable to walk independently	73	15
Very severely dependent	38	4
Severely dependent	20	5
Moderately dependent	15	12
Mildly dependent	12	32
Physically independent	12	47

[a] Acute figures are minimal estimates for acute stroke, since many patients were not assessed during the first week after onset.

Source: Adapted with permission from Wade, 1994.

"Basic" activities of daily living (ADL) include mobility and self-care functions such as dressing, bathing, feeding, toileting, grooming, and transfers (e.g., chair to bed, in and out of bath) that a person must be able to perform to be independent. "Instrumental" activities of daily living (IADL) are more complex functions such as use of a telephone, meal preparation, money management, use of public transportation, home and child-care tasks, and recreational and work activities. Basic ADL is usually measured on disability scales such as those recommended in Chapter 3. Findings from population-based studies (Dombovy, 1993) indicate that independence in self-care ADL improves with time. Partial or total dependence in self-care ADL was reported in 67 to 88 percent of patients within 3 weeks of onset of stroke (Dombovy, Basford, Whisnant, et al., 1987; Kojima, Omura, Wakamatsu, et al., 1990; Kotila, Waltimo, Niemi, et al., 1984; Wade and Hewer, 1987a), but in only 24 to 53 percent of survivors 6 months to 5 years after their strokes (Ahlsio, Britton, Murray, et al., 1984; Dombovy, Basford, Whisnant, et al., 1987; Gresham, Phillips, Wolf, et al., 1979; Kojima, Omura, Wakamatsu, et al., 1990; Kotila, Waltimo, Niemi, et al., 1984; Wade and Hewer, 1987a). The exclusion of fatalities needs to be considered in interpreting long-term results since these individuals usually have had more severe strokes. Frequencies and recovery patterns for different types of ADL in a community study in the United Kingdom are shown in Table 3.

Quality of Life After Stroke

Most stroke survivors experience a decrease in levels of activity and overall quality of life. In the Framingham Study, they were found to socialize less, have fewer interests and hobbies, be less able to use public transportation or perform household tasks, and be less likely to engage in vocational pursuits than a stroke-free control group (Gresham, Phillips, Wolf, et al., 1979). In another study, they consistently reported that their quality of life was worse than before the stroke and had not improved over the 2 intervening years (Ahlsio, Britton, Murray, et al., 1984). In this study, deterioration was at least as strongly related to psychological problems such as depression and anxiety as to physical dependency measured by ADL. Depression, dependence on others, and inability to return to work all contribute to diminished quality of life (Niemi, Laaksonen, Kotila, et al., 1988; Viitanen, Fugl-Meyer, Bernspang, et al., 1988).

The ability to return home is also an important dimension of the quality of life, though the resulting burden on caregivers may offset the benefits. Rates of institutionalization after stroke range from 10 to 29 percent (Dombovy, Basford, Whisnant, et al., 1987; Gresham, Phillips, Wolf, et al., 1979; Kelly-Hayes, Wolf, Kannel, et al., 1988; Kotila, Waltimo, Niemi, et al., 1984; Lehmann, DeLateur, Fowler, et al., 1975; Silliman, Wagner, and Fletcher, 1987).

Gender Differences

Age-adjusted disability levels after stroke are similar in men and women (Wade, Hewer, David, et al., 1986). However, women report more disability and unmet social needs (Branch and Jette, 1981; Jette and Branch, 1981). Greater differences have been found in women between actual lifestyles and observed capacity to function (Kelly-Hayes, Jette, Wolf, et al., 1992). In Framingham, women are institutionalized twice as often as men (Kelly-Hayes, Wolf, Kannel, et al., 1988). Marital status is a more important predictor of the patient's ability to live independently in men than in women, due at least partly to the greater support provided by female caregivers (DeJong and Branch, 1982).

Criteria for Evaluating Assessment Instruments

The essential characteristics on which clinical assessment instruments are evaluated are sensibility, validity, reliability, and sensitivity to change.

• Sensibility

• refers to the instrument's overall reasonableness, importance, and ease of use. Feinstein (1987) suggests that sensibility is the major factor determining the success or failure of a clinical measure.

• Validity

• is the ability of an instrument to measure what it is intended and presumed to measure. An instrument's criterion validity is determined by comparing its results to an agreed-on gold standard. Its predictive validity is its ability to predict future outcomes.

• Reliability

• has two dimensions. Interobserver reliability refers to the ability of two different individuals who administer the instrument to a particular patient to achieve similar results. Test-retest reliability refers to whether repeated use of the measure yields consistent results in the absence of a change in the patient.

• Sensitivity to change

• is the ability of the measure to detect clinically important changes. Instruments used to monitor the patient's progress during rehabilitation must accommodate the full range of performance levels, must have scales with sufficiently fine gradations that small changes can be detected, and must permit evaluation of specific types of impairments or disabilities rather than relying solely on summary scores.

The instruments recommended in this guideline are in wide use and have been evaluated with respect to most or all of the above criteria. They are practical and feasible to administer, and they yield meaningful results that can easily be communicated to the patient and family.

Level of Consciousness

Disturbances in consciousness are a strong predictor of adverse outcomes after stroke. They are more likely when brain damage is extensive, especially if the brain stem is involved or when cerebral edema or increased intracranial pressure is present. A prolonged deep coma after a stroke is rare and is more likely to complicate intracranial hemorrhage than infarction.

Evaluation of the level of consciousness involves observation of the patient's spontaneous behavior, responses to external stimuli (verbal or painful), and interactions with others. It is usually described in terms of the patient's best performance as being alert, drowsy, stuporous, or comatose. Repeated observations are needed because findings often fluctuate.

Cognitive Disorders

Disorders in higher brain functions are common after stroke. The full picture of dementia is rare after a first event but does occur as a result of multiple strokes. A general impression of memory and the ability to acquire and retain new information can be obtained from observation of the patient's interactions with other persons and from observation of responses to questions on: orientation (name, place, day of week, etc.), current events, recent personal history, arithmetic, and simple tests of recall. Additional testing with a mental status screening test (discussed later) or a neuropsychological examination is needed to define cognitive or behavioral deficits more fully. Care must be taken to distinguish cognitive deficits from difficulties in communication.

Moderate to severe higher level cognitive deficits will markedly interfere with learning new skills during rehabilitation.

Motor Deficits

The nature and severity of motor deficits reflect the type, location, and extent of the vascular lesion. Motor deficits can occur in isolation or may be accompanied by sensory, cognitive, or speech deficits. Weakness and paralysis are the most common manifestations, but incoordination, clumsiness, involuntary movements, or abnormal postures also occur. The face, upper extremity, and lower extremity can be involved alone or in combination. Common patterns are hemiparesis (one arm and leg) and monoparesis (most commonly the upper extremity). Patients may also demonstrate apraxias of movements in which the individual does not have demonstrable muscle weakness but is unable to sequence movement patterns. Motor limitations may be subtle in some patients.

The position of involved limbs at rest and spontaneous limb movements should be noted and the strength of muscles recorded using a scale such as: grade 0 = no movement, 1 = palpable contraction or flicker, 2 = contraction with gravity eliminated, 3 = movement against gravity, 4 = movement against resistance but weaker than other side, and 5 = normal strength. Increased (spasticity) or decreased (flaccidity) muscle tone can be identified from the degree of resistance felt to rapid passive limb movement. Slow movements (bradykinesia) or motor abnormalities such as chorea, athetosis, or hemiballismus should be recorded. Examinations for abnormal muscle stretch reflexes or pathologic reflexes are traditional, but their presence does not predict recovery from stroke. The ability to walk and to perform skilled movements (e.g., handwriting or the use of utensils) also needs to be tested; standard instruments to aid in these assessments are discussed later.

Most patients experience some spontaneous improvement in motor deficits, but the degree of recovery varies widely. Persistent motor deficits are often the primary indication for rehabilitation because of their influence on the performance of daily activities.

Disturbances in Balance and Coordination

Motor or sensory deficits and dysfunction of the cerebellum or vestibular system can produce disturbances in balance or coordination. Incoordination in the absence of motor or sensory loss is known as ataxia. Disturbances in coordination can be examined at the bedside by performing finger-to-nose, heel-to-shin, and alternating movement tests. When possible, the patient's ability to stand and walk should be tested. If a patient can walk, additional examinations such as tandem walking or the Romberg test can provide helpful information.

Somatosensory Deficits

Somatosensory deficits can range from the loss of simple sensory modalities to complex sensory disorders. Patients complain of numbness, tingling, or abnormal sensations (dysesthesia), or they show excessive reactions to sensory stimuli (hyperesthesia). Interactions may occur between cognitive and somatosensory disturbances. The sensory examination is difficult to perform and may be unreliable in the confused or cognitively impaired patient. The bedside examination involves testing sensory modalities such as pain, temperature, touch, proprioception (sense of position), kinesthesia (sense of movement), and pallesthesia (sense of vibration). Complex somatic sensory testing includes stereognosis and graphesthesia.

Sensory deficits usually improve after stroke, although some residual loss is common. Profound sensory loss will hamper rehabilitation of motor impairments.

Disorders of Vision

Stroke can cause visual deficits, most commonly homonymous hemianopsia. Examination of pupillary responses and ocular motility, direct observation of the ocular fundus, and measurement of corrected visual acuity and visual fields are important. A visual-field defect in the nondominant field needs to be differentiated from visual neglect since the latter often improves spontaneously, while visual-field defects usually do not improve. Stroke can also lead to complex visual deficits or disturbances in color vision. Paralysis of conjugate gaze is an unfavorable prognostic sign for survival but usually improves spontaneously in survivors. Ocular motility disturbances due to brain stem strokes may produce symptoms such as diplopia, vertigo, oscillopsia, or visual distortions. Severe visual disturbances will increase the complexity of rehabilitation.

Unilateral Neglect

Neglect refers to a patient's lack of awareness of a specific part of the body or external environment and occurs primarily in nondominant (usually right) hemisphere strokes. In these patients, sensory stimuli (vision, hearing, somatosensory) in the left half of the environment are ignored or evoke muted responses. Severely afflicted patients will deny problems or illness or may not even recognize their own body parts. Bedside evaluation will find that the patient is turned to the right and will often not turn toward an observer on the left. Testing will demonstrate that the patient ignores items in the left visual field when asked to describe a complex picture and ignores sensory stimuli on the left. Neglect usually improves spontaneously and relatively quickly, but it will significantly complicate rehabilitation while it persists.

Speech and Language Deficits

Aphasia is frequent after vascular events in the language-dominant hemisphere and may cause disturbances in comprehension, speech, verbal expression, reading, and writing. Bedside evaluation includes naming of objects and observing patterns of fluency, adequacy of content, prosody of speech, use of grammatical forms, ability to repeat, and comprehension of spoken language. If possible, rudimentary writing and reading should be observed.

Neuromotor disturbances (dysarthria and apraxia of speech) need to be differentiated from aphasia. Dysarthria may be due to dysfunction of the larynx, pharynx, palate, tongue, lips, or mouth. It causes difficulty in making speech sounds clearly, abnormalities in prosody, or changes in voice quality. Observation of spontaneous speech needs to be supplemented by asking the patient to say words or phrases that test specific parts of the articulatory mechanism. In apraxia of speech, the patient is unable to program a sequence of volitional movements despite the absence of motor deficits. This results in difficulty in initiating speech, inconsistent speech patterns, and difficulty in positioning the articulatory mechanism for complex speech movements.

Apraxia of speech, dysarthria, and aphasia frequently coexist. Proper management depends on the ability to differentiate among the three conditions and determine the relative contributions of each to a patient's overall speech disorder. Language patterns and speech disturbances frequently improve during recovery from stroke.

Pain

Severe headache, neck pain, or face pain can result from either hemorrhagic or ischemic stroke. Pain can also be associated with complications of stroke such as adhesive capsulitis; a rotator cuff tear in the shoulder; reflex sympathetic dystrophy; entrapment of the ulnar, median, or peroneal nerves; decubitus ulcer; or contractures. Neurogenic pain after stroke is a particularly serious problem. This syndrome most commonly occurs with strokes involving the thalamus. It may not appear until weeks or months after the stroke's onset. It usually involves the contralateral half of the body and may be intense and relentless. On examination, patients will be very sensitive to touch. Spontaneous recovery is rare. Pain of any cause can greatly impede a patient's ability to participate in rehabilitation and may require treatment with medications, surgical procedures, or nerve blocks.

Diagnostic Tests

Diagnostic tests are used to supplement the patient's medical history and neurological and physical examinations in order to (1) confirm the diagnosis of stroke; (2) determine its cause (subarachnoid or intracerebral hemorrhage, embolism or thrombosis), location in the brain, and extent; (3) evaluate complications of stroke and cardiovascular and other comorbid diseases that will influence treatment or clinical outcomes; and (4) assess risk factors for recurrent stroke. Test results may have an important influence on treatment decisions during acute care and on assessment of needs for rehabilitation.

Some tests, such as CT of the brain, electrocardiogram, echocardiogram, coagulation studies, complete blood count, and blood glucose, are obtained on admission because their results may influence initial management. Other studies, such as MRI, cerebral arteriography, or cerebral spinal fluid examination, may be performed for specific indications to verify the etiology of stroke or assess changes in the patient's condition. Discussion of the indications for specific diagnostic tests is beyond the scope of this guideline.

Overall Measures of Stroke Deficits

The Glasgow Coma Scale (see Attachment 1) provides a systematic way to monitor changes in the level of consciousness.

Stroke deficit scales (see Attachment 2) provide a quick, reliable, and valid record of recovery from neurological deficits after a stroke. Stroke scales are based on information from the neurological examination and include measures of mentation, motor function, and language. Of available instruments, the National Institutes of Health Stroke Scale and the Canadian Neurological Scale are the best validated. Advantages of these instruments include brevity, reliability, and the fact that they can be administered by physicians, nurses, or therapists. A major limitation is that both rely on interval scales that are fairly insensitive to detecting changes. Use of a summation score can be misleading, since it combines several factors that may or may not be related.

Global Disability Measure

A global measure of disability can be used to measure stroke severity and to document recovery of function. The Rankin Scale (see Attachment 3) is the most commonly used global scale and provides a simple broad-based estimate of the amount of dependency resulting from stroke. It measures overall independence and allows comparisons to evaluate recovery over time. A limitation is that it measures only general domains of disability and lacks details to detect change.

Measures of Disability in Basic Activities of Daily Living

Measures of disability in basic ADL are used to determine the impact of impairments, establish therapeutic goals, and monitor progress in rehabilitation. They reflect both the impact of neurological impairments and the ability to compensate for losses. They focus on actual task accomplishment rather than on the theoretic ability to perform a task.

Most basic ADL scales measure multiple activities, including dressing, feeding, bathing, toileting, and mobility tasks. Some also include measures of cognition, communication, and social behavior. The information is obtained by observing performance. The Barthel Index and the Functional Independence Measure (FIM) (see Attachment 4) have been tested extensively in rehabilitation for reliability, validity, and sensitivity, and are by far the most commonly used measures. ADL measures have limitations because they are not sensitive to change in patients with high levels of functional disability (producing a ceiling effect); may fail to detect improvements in specific self-care activities (such as different aspects of dressing); and, by focusing on task performance, do not identify the effects of specific impairments or diseases. Also, use of summation scores can be misleading because they combine functions in different areas that are not necessarily associated.

Mental Status Assessment

Because cognitive deficits often are missed or their severity underestimated on routine neurological examinations, use of a simple, well-validated screening test can help to probe specific spheres of mental function in patients with global deficits. The Mini-Mental Status Examination (MMSE) and the Neurobehavioral Cognition Status Examination (NCSE) (see Attachment 5) are recommended. The MMSE has been used in a wide variety of populations. It has well-demonstrated validity and reliability and is brief. However, it has the disadvantage of being heavily language dependent. Therefore, it is likely to misclassify patients with aphasia. The NCSE samples a broad range of mental functions and has well-demonstrated validity, although it has not been tested for reliability in stroke.

Measures of Motor Function and Balance

The recommended instruments for measuring motor function (see Attachment 6) have been well characterized and are useful for capturing changes at the impairment level.

The Berg Balance Assessment (see Attachment 7) has well-demonstrated reliability, validity, and sensitivity to change in stroke patients.

Measures of Mobility

Physical performance measures provide insights into a patient's ability to perform basic mobility functions. They may be used for screening to determine the need for treatment, for measuring responses to treatment, and for discharge planning. The Rivermead Mobility Index (see Attachment 8) is recommended because it has been tested and used in stroke patients and is simple and reliable. Timed functional movements (e.g., time to walk 10 meters or the distance that can be walked in 6 minutes) should also be considered (Brandstater, de Bruin, Gowland, et al., 1983; Butland, Pang, Gross, et al., 1982; Lipkin, Scriven, Crake, et al., 1986; Wade and Hewer, 1987a; Wolfson, Whipple, Amerman, et al., 1990). Several instruments currently employed in geriatric screening and assessment, such as Tinetti Mobility Skills, Reuben Physical Performance, and Duke Mobility Skills, are promising but have not been evaluated in stroke populations.

Assessment of Speech and Language Function

The recommended instruments for the assessment of speech and language function (see Attachment 9) are well normed and constructed and are in wide use. These tests provide comprehensive information on speech and language disorders. They also provide a baseline against which to measure progress. Although they describe a profile of a patient's language disorder, they do not necessarily reflect measurement of functional abilities, as does the Communicative Abilities in Daily Living Test (Holland, 1980). The Functional Communication Profile (Sarno, 1969) is a rehabilitation-oriented rating scale.

Depression Scales

The instruments in Attachment 10 can be helpful in screening for depression and in monitoring responses to therapy. The instruments included are those which have been best validated in patients with stroke. Standard instruments supplement, but do not replace, the clinical interview in the diagnosis of depression.

Measures of Complex or Instrumental Activities in Daily Living

A return to independent living requires not only the ability to perform basic activities of daily living, but also the ability to carry out more complex activities (instrumental ADL) such as shopping, meal preparation, use of the telephone, driving a car, use of public transportation, money management, and desired leisure activities. The recommended instruments (see Attachment 11) are designed to measure performance of a wide range of activities in the person's living environment. Their use permits systematic monitoring of progress after the return home and provides useful measures of responses to continued outpatient or home rehabilitation.

The skills required by these complex activities are often taught during rehabilitation. Caution must be exercised, however, in extrapolating from performance in a highly supportive rehabilitation setting to the home. Structural features of the home environment, motivation, and the availability of support may each have important effects. Valid temporal comparisons must take account of these and other contextual factors.

Family Assessment Device

For assessing family functioning, a useful standardized instrument is the Family Assessment Device (FAD) (see Attachment 12). The FAD has demonstrated reliability and predictive validity (Byles, Bryne, Boyle, et al., 1988) and has been used frequently with families of stroke survivors. It contains 60 items that assess family problem solving, roles, communication, affective responsiveness, affective involvement, behavior control, and general functioning. Scores can be used to identify families that may benefit from further clinical evaluation, counseling, or education. A recent review concluded that another instrument, the DSM-IIIR Global Assessment of Functioning (GAF) Scale, is also useful in assessing the social functioning of family members (Goldman, Skodol, and Lave, 1992). This assessment device is also found in the DSM-IV[TM] published in 1994 (fourth edition) by the American Psychiatric Association.

Assessment of the Quality of Life

Quality of life includes the ability to engage in life's activities, the satisfaction derived from them, and overall perceptions of health status and well-being. The person's wishes and expectations, limitations in achieving these, and value system are all important factors.

Controversy continues over the ability to define quality of life, let alone measure it reliably. Nonetheless, the concept is sufficiently important and the state of the art of measurement sufficiently advanced to warrant inclusion of selected instruments as a complement to measures of IADL (in monitoring progress after a return to a community residence).

Many different measures of health status or quality of life have been developed, but only a few have been adequately validated. The recommended measures (see Attachment 13) assess a broad range of health dimensions and have been widely used. Both are generic and not specific to stroke patients. The Medical Outcomes Study 36-Item Short-Form Survey (SF-36) has the particular advantages of being brief and capable of being administered by telephone, administered in a face-to-face interview, or self-completed. Its major limitation in stroke patients is a floor effect which suggests that disability (ADL) measures should be added to adequately document severe disabilities. The Sickness Impact Profile (SIP) is more comprehensive and includes a broad range of items that mitigate floor or ceiling effects. Limitations are that its 136 items may take the patient 30 minutes or more to complete, and that health perception items are not included. Neither the SF-36 nor the SIP has well-documented sensitivity to detect change in stroke patients.

Managing Dysphagia and Preventing Aspiration

Dysphagia (impaired swallowing) occurs frequently in stroke patients and may result in aspiration and pneumonia if not diagnosed and appropriately managed (Horner, Massey, Riski, et al., 1988; Palmer and (DeChase, 1991). Aspiration is silent in as many as 40 percent of patients who aspirate. Fortunately, spontaneous improvement is frequent.

The clinical assessment of dysphagia is discussed in Chapter 3. The goals of management are to prevent aspiration, prevent dehydration and malnutrition from inadequate oral intake, and restore the patient's ability to chew and swallow safely. Compensatory treatments involve changes in posture and positioning for swallowing, learning of new swallowing maneuvers, changes in the texture of foods (e.g., thickening liquids and using pureed or semisolid foods), decreasing bolus size, and administering food by syringe. Patients who do not regain the ability to swallow safely will require parenteral or tube feeding. If long-term tube feeding is required, a gastrostomy is usually preferable to a nasogastric tube (Emick-Herring and Wood, 1990).

Evidence supporting the effectiveness of treatment is from observational studies. A carefully performed large case series found that 89 percent of patients were able to resume oral feeding and none developed aspiration pneumonia after a compensatory feeding program (Horner, Massey, Riski, et al., 1988). Controlled trials will be needed to compare the effectiveness of different treatment regimens.

Maintaining Skin Integrity

The National Survey of Stroke found that 14.5 percent of stroke patients develop pressure sores (Roth, 1991). Patients who are comatose, severely paralyzed, obese, or incontinent of bladder or bowel, or who have muscle spasticity are at unusually high risk. Steps to maintain skin integrity include:

• Systematic daily inspection of the skin to detect areas of incipient breakdown, paying particular attention to areas over bony prominences.

• Gentle routine skin cleansing.

• Protection from exposure to moisture (e.g., urine, perspiration).

• Avoidance of skin injury due to friction or excessive pressure through use of proper positioning, turning, and transferring techniques; and by judicious use of barrier sprays, lubricants, special mattresses, and protective dressings and padding.

• Careful attention to the maintenance of adequate hydration and nutrition.

• Efforts to improve the patient's mobility.

Preventing Falls

Falls are the most frequent cause of injury in patients hospitalized with strokes. Hip fracture is a common complication (Poplingher and Pillar, 1985). The risk of falls is increased by sensorimotor deficits that lead to problems with mobility, balance, or coordination; and by confusion, perceptual deficits, visual impairments, and problems with communication that interfere with a patient's ability to ask for assistance or make needs known. Acute illnesses, generalized weakness, and drug side effects compound risks due to neurological deficits. Patients with visual neglect and those who are slow in performing tasks are at unusually high risk of multiple accidents (Diller and Weinberg, 1970) and of running into obstacles (Webster, Rapport, Godlewski, et al., 1994). Behavioral impulsivity, older age, a history of previous falls, and multiple transfers increase the risk of falls in patients with right hemisphere strokes (Rapport, Webster, Fleming, et al., 1993).

Assessment should address the patient's risk factors and also potential hazards in the hospital environment (e.g., the surface of floors, lighting, and placement of and access to toilet facilities). The nursing staff usually has primary responsibility for assessment and for implementing preventive measures, but all clinicians should participate in fall prevention. A risk reduction program includes careful supervision of high-risk patients, toileting at regular intervals, supervised transfer and ambulation, nurse call systems suited to a patient's abilities, hospital-wide fall prevention programs, and--extremely important--adequate patient and family education.

Managing Bladder Function

Problems with bladder control and incontinence are common after stroke, but they resolve spontaneously in the large majority of patients (Brocklehurst, Andrews, Richards, et al., 1985). Causes include neurological deficits that lead to bladder hypertonicity, bladder hypotonicity with overflow incontinence, or cognitive or communication deficits with the resultant inability to recognize the need to void or to make the need known (Gelber, Good, Laven, et al., 1993). Persistent incontinence confers a poor long-term prognosis for functional recovery (Jongbloed, 1986; Reding, Winter, Hochrein, et al., 1987).

Use of an indwelling catheter should be limited to patients with incontinence due to urinary retention that cannot be otherwise treated, severely impaired patients with skin breakdown in whom frequent bed or clothing changes would be difficult or painful, and patients in whom incontinence interferes with monitoring of fluid and electrolyte balance. Chronic use of indwelling catheters increases the risk of bacteriuria and urinary tract infection (Bjork, Pelletier, and Tight, 1984; Sabanthan, Castleden, and Mitchell, 1985; Warren, Tenney, Hoopes, et al., 1982) and should be avoided (Sedrat and Hecht, 1993). Urinary retention can be safely managed with clean intermittent catheterization (Bennett and Diokno, 1984; Maynard and Diokno, 1984; Webb, Lawson, and Neal, 1990). Whether an indwelling or intermittent straight catheter is used, good catheter care is the best way to prevent urinary infection. Bacteriuria can be identified by urine cultures, but treatment with antibiotics should generally be reserved for patients with symptomatic urinary tract infections.

For further discussion of the management of urinary incontinence, see the AHCPR-sponsored guideline, Urinary Incontinence in Adults (Urinary Incontinence Guideline Panel, 1992).

Preventing or Controlling Seizures

Seizures are a potential complication of stroke and, if not controlled, can be potentially life threatening. Seizures can occur at the time of the acute stroke, during the first few days, or several months after the event. No study has specifically tested the usefulness of anticonvulsant medications in preventing or controlling seizures following stroke. Drugs that have been proven to be of value in preventing seizures of other causes, however, are recommended for patients who have had one or more seizures following stroke. The routine prophylactic administration of anticonvulsants to stroke survivors who have not had seizures should be avoided.

Early Mobilization and Return to Self Care

Table 9. Evidence on the benefits of early mobilization (more...)

Table 9. Evidence on the benefits of early mobilization of the stroke patient

Author, Year, Country	Purpose, Study design Duration of deficits Number of subjects	Outcome measures Maximum followup	Conclusions/Comments
Asberg (1989) Sweden	Test benefits of early activation of the patient after an acute stroke Non-RCT (two wards admitted on alternate days) Acute deficits N=63	Orthostatic tolerance ADL (Katz) F/U until 3 months	Early activation improved orthostatic tolerance and led to transient ADL benefit. Not clear whether ADL effects were due to early activation or to increased nurse contact.
Hayes and Carroll (1986) United States	Test benefits of early rehabilitation Non-RCT Acute deficits N=30	Ambulatory ability ADL F/U until discharge	Nonsignificant results to favor early intervention. No significant differences in outcomes.
Hamrin (1982a and 1982b) Sweden	Test early activation in daily nursing care Non-RCT Acute deficits N=112	Activity index Mortality F/U until 3 months	No significant differences at discharge or 3 months.

Note: ADL = activities of daily living, F/U = followup, RCT = randomized controlled trial.

Indirect evidence of the benefits of early mobilization and rehabilitation therapy is suggested by the superiority of acute care stroke units in reducing mortality and improving functional outcomes. Early mobilization and early implementation of therapy are intrinsic components of care on stroke units and may have contributed to improved outcomes.

Mobilization is recommended as soon as the patient's medical and neurological condition permits and, if possible, within 24 to 48 hours of admission. Mobilization will need to be delayed or approached with caution in patients with coma, severe obtundation, progressing neurological signs or symptoms, subarachnoid or intracerebral hemorrhage, severe or persistent orthostatic hypotension, and acute myocardial infarction.

The rate and extent of mobilization depend on the patient's condition. Frequent position changes in bed and daily passive and active range of motion exercises of limbs are part of care from the time of admission. Proper positioning helps reduce the risk of aspiration, skin breakdown, joint contractures, and injury to joints in involved limbs. Important considerations include using a pullsheet to pull a patient up in bed rather than lifting under the arms, ensuring maintenance of therapeutic positions and the support of limbs in anatomically normal positions, and adequate support in bed. Range of motion exercises of joints in involved limbs reduce the risk of contracture and DVT.

Assessment of mobility begins with evaluating the patient's ability to turn from side to side and move up and sit up in bed, and then progresses to examining the ability to sit on the edge of the bed. Assistance and guarding are required when sitting is begun to protect both the patient and provider. The possibility of orthostatic hypotension needs to be carefully monitored. Mobilization progresses to patient transfers to a chair, commode, sofa, or wheelchair (and sitting on these); and finally coming to a standing position, bearing weight, and walking. Decisions on appropriate seating depend on sitting balance, endurance, and the need for pressure reduction. Safety, comfort, and maximizing mobility and independence are each important considerations. Transfer techniques should be taught by rehabilitation professionals who are expert in them. These techniques need to be used consistently by all who transfer the patient.

Self-care activities such as eating, grooming, toileting, and dressing should also be encouraged as soon as possible. Active participation in self care helps the patient resume control and increase strength, endurance, and awareness of the environment. Compensatory training can facilitate progress by teaching adaptive techniques to overcome disabilities. Mental activity is as important as physical activities, and efforts to encourage communication, problem solving, and social activity are very much part of the acute care process in suitable patients.

Hospital Inpatient Rehabilitation

Programs of rehabilitation hospitals or rehabilitation units in acute care hospitals are staffed by the full range of rehabilitation professionals--nurses, physical and occupational therapists, speech-language pathologists, psychologists, social workers, recreational therapists, and physicians. A physician skilled in rehabilitation is available 24 hours a day. An interdisciplinary team drawing on these professionals provides a comprehensive rehabilitation program for each patient. Team conferences are held at least weekly to establish rehabilitation goals and develop a rehabilitation plan, assess patient progress, identify barriers or complications and revise the rehabilitation goals or plan accordingly, and develop a plan for discharge or transfer to another type of rehabilitation program (National Association of Rehabilitation Facilities, 1988).

Hospital-level rehabilitation is usually more intense and comprehensive than rehabilitation in other settings and requires greater physical and mental effort from the patient.

Rehabilitation in Nursing Facilities

Rehabilitation programs in nursing facilities vary widely in their capabilities. Traditionally, nursing homes have provided supportive care and low-level rehabilitation services. More recently, however, some nursing facilities have developed coordinated rehabilitation programs that are similar to, though usually less intense than, hospital programs. Physician coverage in nursing facilities varies.

Nursing facilities may be either hospital based or community based. Hospital-based nursing facilities are designed primarily for patients who have the potential to improve enough during 2 or 3 weeks of treatment to become suitable candidates for inpatient hospital, home, or outpatient rehabilitation. Community-based nursing facilities run the full gamut of comprehensiveness and intensity of services. Some offer comprehensive programs providing a thorough evaluation at the time of admission, medical management by a qualified rehabilitation physician, 24-hour nursing care, and interdisciplinary treatment. At the other end of the spectrum are nursing facilities with limited rehabilitation capabilities that provide physical therapy and occupational therapy for up to 1 hour a day, 5 days per week--are staffed with nurses who may or may not have special training in rehabilitation--and are usually covered by physicians with no specific training in rehabilitation.

This diversity among nursing facility programs underscores the need for referring clinicians to inform themselves about the capabilities of individual programs.

Outpatient Rehabilitation

Outpatient rehabilitation is provided by hospital outpatient departments and freestanding outpatient facilities. These facilities can provide either a comprehensive rehabilitation program or individual rehabilitation services. Intensity may range from occasional visits to three or four visits per week. Advantages of outpatient programs are the access they permit to an interdisciplinary program, the availability of rehabilitation equipment, and the opportunity for social contact and peer support while the patient lives at home. The availability of transportation is a prerequisite.

Day hospital programs are similar to outpatient programs though frequently more intense. The patient spends several hours, 3 to 5 days a week, in a typical day hospital program. Availability of transportation is a prerequisite for both outpatient and day hospital programs.

Home Rehabilitation

Home rehabilitation programs are expanding their capabilities. Most programs are designed for patients who are medically stable and require only intermittent contact with physical or occupational therapy or nursing services. However, some home health agencies provide the full scope of services including nursing, physical therapy, occupational therapy, speech therapy, medical social services and personal care services, as well as rehabilitation nursing and mental health nursing. Recently, some home rehabilitation programs have been developed that provide comprehensive services including 24-hour coverage by physicians (Portnow, Kline, Daly, et al., 1991). The usefulness and cost effectiveness of these programs have not been fully evaluated. In programs approved by Medicare, a physician and an interdisciplinary team develop the treatment plan and monitor medical stability.

Advantages of home care programs are that rehabilitation takes place in the same environment where the skills learned will be applied, and that many patients function better in a familiar environment. Disadvantages include an increased burden on caregivers, less availability of physician monitoring, absence of peer support from fellow patients, and limited availability in the home of equipment used in facility-based inpatient or outpatient rehabilitation programs. Home rehabilitation may be the only choice for patients who would be suitable for outpatient rehabilitation but lack transportation. For some patients, a combination of outpatient and home rehabilitation may be beneficial.

The Need for Accurate Program Information

Rehabilitation decisions will better serve the needs of patients if they are based on objective information on the capabilities and actual performance of rehabilitation facilities. In spite of efforts to establish standards, the capabilities of programs in each type of setting vary widely.

Freestanding rehabilitation hospitals, rehabilitation units of acute care hospitals, and nursing facility programs that have been certified by the Commission on Accreditation of Rehabilitation Facilities (CARF) ¹ and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) 2 are required to meet specific structural, staffing, and program standards. However, the ability to satisfy these accreditation standards does not guarantee uniform capabilities and quality of care.

Rehabilitation hospitals or nursing facility programs that have not been certified by CARF or JCAHO, outpatient departments, and home care agencies currently lack uniform standards. Local initiatives to obtain information about these programs will be especially important until regional or national standards can be developed and implemented. ^[3]

Medical Stability

Medical stability is an important consideration affecting the patient's readiness for rehabilitation and the choice of rehabilitation setting. Degrees of medical stability are defined as follows:

• Stable.

• Patient is afebrile, has stable vital signs, and has had no important changes in medical conditions, nor required changes in treatments within the preceding 48 hours. Neurological deficits are unchanged or improving. The patient can take adequate nutrition orally or an enteral route for nutrition and hydration has been established.

• Moderately stable.

• One or more medical problems has required a change in medications within the preceding 48 hours, but symptoms or clinical findings have not changed significantly. An adequate route for nutrition and hydration has not been established. Neurological deficits are unchanged or improving.

• Unstable.

• Patient has undiagnosed or inadequately treated cardiac arrhythmia, congestive heart failure, or other condition that requires the diagnostic or treatment capabilities of an acute care hospital. The condition may be life threatening, may lead to severe morbidity if not promptly treated, or will interfere with rehabilitation. Neurological deficits or state of consciousness have fluctuated within the preceding 48 hours.

Functional Disabilities

The functions considered here are mobility (e.g., getting out of bed, walking or climbing stairs, using a wheelchair) and performance of basic ADL (e.g., eating, grooming, and dressing). Levels of disability are classified as:

• Complete independence

• . Ability to perform the activity safely and within a reasonable period of time with no assistance.

• Modified independence

• . Activity performance requires specialized equipment or takes more than a reasonable time or requires safety precautions, but no helper is needed.

• Supervision or setup

• . Activity requires verbal encouragement or instructions or assistance with preparation (such as opening containers or applying toothpaste to a brush), but no contact assistance.

• Minimal contact assistance

• . Ability to perform 75 percent or more of the activity unassisted; physical assistance required for the remainder.

• Moderate assistance

• . Ability to perform 50 to 74 percent of the activity unassisted; physical assistance required for the remainder.

• Maximal assistance

• . Ability to perform 25 to 49 percent of the activity unassisted; physical assistance required for the remainder.

• Total assistance

• . Ability to perform less than 25 percent of the activity unassisted; physical assistance required for the remainder.

Mental Status

Mental status affects the patient's ability to learn and retain the lessons being taught during rehabilitation. Mental status includes the degree of alertness, orientation, memory, control of behavior, and problem-solving ability. Levels of impairment are classified as:

• Normal or minimal deficit

• . Patient is alert and fully oriented, performs well on simple tests of recent memory, is consistently in control of behavior and emotions, and is easily able to follow 2-step directions.

• Moderate deficit

• . Patient is intermittently confused in time or place, or recent memory is impaired but patient is able to retain simple messages after multiple repetitions, or patient makes frequent mistakes in following 2-step directions.

• Severe deficit

• . Patient is consistently disoriented in time and place, or recent memory is severely impaired, or patient is unable to follow 2-step directions.

Physical Activity Endurance

The physical demands of rehabilitation are substantial, particularly in light of the increased effort required by the presence of hemiparesis. Physical endurance is categorized by the time a person is able to engage in physically demanding activity equivalent to that required during active rehabilitation interventions:

• 3 or more hours of physical activity per day.

• 1 to 3 hours.

• Less than 1 hour.

Caregiver Support

The patient's previous living environment and the availability of family or friends to provide assistance after discharge may influence rehabilitation decisions. Assessing the adequacy of caregiver support requires a qualitative judgment by the screening clinician.

The Need for Consensus

Rehabilitation is fundamentally a patient-centered process that also intimately involves the family (using the term "family" broadly to include other involved persons as well). This requires the full support and active participation of the patient and family. Hence, rehabilitation decisions need to be mutually acceptable to all involved parties. Patient and family education about stroke rehabilitation, its goals and procedures, available programs, and their outcomes provide important inputs. Sensitivity to language problems and to cultural differences is important. In making a recommendation about rehabilitation to the patient and family, clinicians need to explain clearly the reasons for the recommendation and listen carefully to any concerns the patient or family have that may dictate a different choice. For example, the program that is best from a clinical point of view might be unaffordable, might be located too far away for frequent family visits, or might have characteristics or sponsorship with which the family is not comfortable.

Threshold Criteria for Admission to a Rehabilitation Program

Selection of setting for rehabilitation program after (more...)

   Selection of setting for rehabilitation program after hospitalization for acute stroke

[This figure is in two parts, see printed version pages 80 and 81]

[left half of figure]

[right half of figure]

Figure 5.

Patients who are too debilitated to participate in an active rehabilitation program may benefit from a brief interdisciplinary program designed to educate the family and provide "hands-on" training in the skills needed to maintain a severely disabled patient at home. Objectives of such a program are to ensure that the family has a thorough understanding of the patient's impairments, the risks they entail, and opportunities and techniques for maximizing function. This type of program can be conducted in a rehabilitation facility (hospital or nursing facility), a day program, or at home. A facility-based program makes it easier to involve multiple professional disciplines and provide access to needed equipment; a home program has the advantage of enabling the training to be adapted to the actual home environment.

An isolated disability can usually be treated by services rendered by an individual rehabilitation discipline and does not require the involvement of an interdisciplinary team. Examples would be treatment of isolated motor weakness of the leg or the arm, or treatment of aphasia. The presence of cognitive, emotional, or other problems that increase the complexity of rehabilitation may require an interdisciplinary approach even though physical disabilities are mild.

The Choice of Rehabilitation Setting

Figure 5.

Few rehabilitation settings have the capability to manage patients who are acutely ill or medically unstable. Patients who develop acute problems during rehabilitation, including worsening of the stroke or a new stroke, will often require transfer to an acute facility that can adequately treat the problem. An exception would be a rehabilitation program that is so closely linked to an acute care facility that adequate diagnosis and treatment can be provided without transfer. This type of linkage is more likely if the rehabilitation program is located in or adjacent to an acute care hospital.

Inpatient rehabilitation facilities that are certified by CARF and JCAHO are required to have 24-hour coverage by skilled rehabilitation physicians and nurses. Coverage in nursing facilities, even those with "intense" programs, is variable and usually less comprehensive. Intense home programs, while they have skilled rehabilitation physicians and nurses on staff, serve the patient on an intermittent or "on-call" basis. Hence, the patient who requires close observation to detect incipient problems, or frequent adjustment of medications, is better suited for a rehabilitation hospital or unit.

As previously discussed, intense rehabilitation can be provided in an inpatient rehabilitation unit or hospital, selected nursing facilities, or selected home programs. The choice depends on the desired degree of intensity and the patient's medical needs. Even nursing facilities and home care providers with "intense" programs usually do not provide the same level of services as a rehabilitation hospital. The availability and commitment of a caregiver to support the patient and participate in rehabilitation are critical to providing intense home-based rehabilitation.

The choice of rehabilitation program for patients needing moderate to total physical assistance will depend on their ability to tolerate the physical activity required by rehabilitation. Patients who can tolerate 3 or more hours of activity a day, or would be expected to do so within a few days in the program, are candidates for an intense rehabilitation program; while those who tolerate only lower levels of activity are usually better served by more slowly paced programs in a nursing facility, an outpatient facility, or the home.

An important consideration is that the energy costs of a physical activity are directly related to the severity of motor disabilities. Hence, a patient with reduced physical activity endurance but less severe motor disability may be able to tolerate intense therapy, while a patient with similar endurance but a more severe disability may not. Some patients who initially have limited physical endurance will improve sufficiently to permit more intense therapy at a later time.

This recommendation applies to patients who are only mildly disabled but are not able to live independently. Safety as well as performance of the essential ADL are concerns. Some patients who need only minimal assistance may be appropriate for inpatient hospital or nursing facility programs if they have complex, multiple functional deficits from physical and/or cognitive impairments, even if home support is adequate. A relatively brief period of rehabilitation in an inpatient program that is targeted at specific disabilities may be sufficient to permit people to live independently.

People who do not require assistance in ambulation or in performing basic personal care activities may still have difficulty performing more complex activities such as housekeeping, meal preparation, use of public transportation, leisure activities, or returning to work. Furthermore, some people may have communication problems but no motor deficits. Rehabilitation services targeted at problem areas may help to increase independence and improve quality of life for those patients, but an interdisciplinary program is rarely needed. Services can be provided on an outpatient basis or at home if a person has adequate support. If, however, a person does not have adequate support, services can be provided in a nursing facility or other supervised living setting.

Baseline Assessment on Admission to a Rehabilitation Program

Timing and Content

Recommendation: A complete baseline assessment by the rehabilitation team should be completed for most patients within 3 working days after admission to an intense rehabilitation program in an inpatient rehabilitation facility or nursing facility, within 1 week of admission to a low-intensity nursing facility program, or within three visits for an outpatient or home rehabilitation program. Initial evaluation by a physician and a nurse, including medical and neurological examinations and development of a medical care plan, should be completed within 24 hours of admission or, in the case of outpatient and home programs, on the first visit. All information should be fully documented in the patient's record. (Research evidence = NA; expert opinion = consensus.)

Table 12. Baseline assessment on admission to a (more...)

Table 12. Baseline assessment on admission to a rehabilitation program

Historical information Discharge summary from acute hospitalization. Complete profile from screening examination. General clinical assessment: neurological and medical examinations and selected laboratory tests Type(s) and severity of neurological deficits. Type(s) and severity of comorbid diseases. Complications of stroke. Functional health patterns: nutrition and hydration, ability to swallow, bowel and bladder function, skin integrity, activity tolerance, sleep patterns. Functional status prior to stroke. Social and environmental factors Presence of spouse or significant other. Previous living situation. Ethnicity and native language. Adjustment of patient and family to stroke. Patient and family preferences for and expectations of rehabilitation. Extent of support by family or involved others (relationships, number, health, availability). Characteristics of potential postdischarge environments. Standardized instruments Stroke deficit scale and mental status screening if not done as part of the screening examination. Impairment measures (individualized to patient's deficits): Motor function. Mobility. Balance. Language and speech. Measure of disability (ADL). Family assessment.

Note: ADL = activities of daily living.

The baseline assessment reaffirms the referral decision, provides the information needed to develop rehabilitation goals and a management plan, and serves as the starting point for monitoring progress. The recommended content is summarized in Table 12.

Evaluation by a physician and a nurse on the day of admission to an inpatient rehabilitation program is essential to determine the patient's current clinical status, identify current medications, assess ability to perform basic ADL (such as feeding, toileting, and transfers), observe behavioral patterns, and identify safety risks. Home and outpatient rehabilitation programs should perform this initial evaluation during the first visit. Any discrepancies with the acute hospital's records should be noted and resolved as soon as possible. A thorough medical history, medical and neurological examinations, and evaluation of functional health patterns provide the foundation. Particular attention should be paid to detecting signs of incipient complications such as DVT, recurrent stroke, or skin breakdown.

The use of standardized instruments facilitates reliable documentation of functional disabilities. This helps to increase the consistency of treatment decisions, facilitates communication among therapists, and provides a reliable basis for monitoring progress. A stroke deficit scale and a mental status screening test need not be repeated if they were administered during a recent rehabilitation screening examination, unless findings of the neurological examination suggest changes in levels of impairment. A broad-based disability scale should be used with all patients. The choice of specific impairment measures will depend on the deficits of the individual patient.

The 3-day, 1-week, or three-visit limit for completing the baseline assessment reflects both cost and quality of care considerations. These limits, though somewhat shorter than the norm of current practice, are reasonable for all except the most complex patients. People with multiple deficits in sensorimotor, cognitive, perceptual, language, and behavioral areas may require longer periods of evaluation.

Setting Rehabilitation Goals

Overly ambitious goals for rehabilitation will set the patient (and family) up for failure and may lead to unwarranted use of rehabilitation facilities. However, goals that are too modest may not make full use of the patient's potential.

Four considerations are especially important. First, recovery after stroke is highly variable and only partly predictable. Even carefully conceived goals may be inaccurate. For this reason, goals that are set at the time of admission to a rehabilitation program need to be reevaluated at regular intervals and modified to reflect the rate of a patient's progress.

Second, the time since stroke onset is important. Recovery due to neurological healing is most rapid during the first 1 to 3 months after a stroke and then plateaus. Significant functional improvement is less common after 6 months, although it can occur (Kelly-Hayes, Wolf, Kase, et al., 1989; Skilbeck, Wade, Hewer, et al., 1983). Expectations for further improvement might therefore be more optimistic in a patient with a recent stroke and a favorable initial recovery trajectory--than in a patient whose stroke occurred 2 or 3 months before--or one who has improved little during the post-stroke period.

Third, rehabilitation goals need to take into account patient characteristics that have been associated with poor functional prognoses (see Chapter 2). For example, persistent urinary incontinence often portends a poor outcome. The absence of any volitional movement in a limb 2 to 4 weeks after a stroke suggests that significant neurological recovery is unlikely, and that rehabilitation goals might better be focused on training in compensatory techniques, or the use of adaptive equipment.

Finally, rehabilitation goals need to address the full range of factors that influence functional performance, including psychological and social adjustment and physical conditioning.

Developing the Rehabilitation Management Plan

As a general principle, medical problems or complications of stroke that increase patient risk or interfere with rehabilitation should be addressed first. Examples include congestive heart failure, urinary tract infections, and musculoskeletal pain. High priority is also given to the prevention of thromboembolism and recurrent stroke (as discussed in Chapter 4), and the maintenance of functional health patterns such as nutrition and bowel and bladder control.

Rehabilitation therapies then target impairments in mobility and motor control and disabilities in ADL performance. Treatments for depression or other emotional problems, perceptual deficits, and speech and language problems are added in patients who need them.

Decisions on the intensity and frequency of interventions depend heavily on the patient's physical endurance, level of motivation, and attention span. The patient's ability to tolerate physical activity will often be limited by preexisting health problems, age-related physiologic changes, or deconditioning effects of immobility (Mol and Baker, 1991). As discussed in Chapter 3, there is currently no standard approach to evaluating physical activity endurance. Patients with severe limitations in exercise tolerance may be best served by a slowly paced program or even by delaying rehabilitation until after a further period of recuperation.

The patient's motivation to participate in rehabilitation is also an important consideration. Assessment of motivation is complex and imprecise. Apparent motivational problems may actually reflect communication deficits or lack of clarity in instructions by staff. Poor motivation may be due to modifiable causes such as depression, incongruence between the patient's goals and those of the rehabilitation program, or a failure of the rehabilitation team to make clear the connection between interventions and goals that are valued by the patient. Motivation may also be affected by neurological deficits that lead to hypoarousal, apathy, or a lack of awareness of disabilities. Mood or memory disorders are especially likely to be denied by patients (Anderson and Tranel, 1989; Hibbard, Gordon, Stein, et al., 1992).

The family may play a pivotal role in helping to identify depressive symptoms or areas of misunderstanding or dissatisfaction with the rehabilitation program and may also help the patient cope with the effects of the stroke and develop the motivation to make a maximal effort to recover (Phipps, 1990). If, despite all efforts, the patient is not able to participate actively, rehabilitation may have to be deferred.

The Interdisciplinary Team Approach

The varied and complex manifestations of stroke often require the services of specialists from several disciplines. The team approach facilitates coordination of care; simultaneous treatment of motor, cognitive, and speech and language deficits; and tailoring of treatment schedules to the patient's priorities and responses to treatment.

Composition of the team varies with the patient's needs and the available resources. In comprehensive inpatient programs, participants include a physician expert in rehabilitation, a rehabilitation nurse, a physical therapist, an occupational therapist, a clinical psychologist, a social worker, and often a therapeutic recreation specialist. A speech-language pathologist will often become involved if the patient has speech, language, or swallowing problems. Other participants may include a psychiatrist, other medical or surgical specialists, and a physician assistant, respiratory therapist, registered dietitian, vocational counselor, chaplain, orthotist, or rehabilitation engineer.

Effective teamwork is not easy. Conflicts arise when communication breaks down or when differences of opinions or interpretations of the patient's behavior are not resolved (Rothberg, 1981). Strong leadership, clarity of roles and responsibilities, and a willingness to devote time and effort to communication are essential. The team leader, who may be from any discipline, is the central figure and assumes primary responsibility for coordinating services and facilitating communication among team members, the patient, and the family. Team conferences, frequent contacts among team members, and complete and intelligible entries in the patient's medical record are important.

The conceptual appeal of the team approach for coordinating stroke care has led to its widespread adoption. However, concrete evidence supporting its effectiveness and cost effectiveness is limited. A literature review concluded that team care resulted in better control or less deterioration in patients with chronic illnesses--but also in more utilization of health services and higher costs (Halstead, 1976). Controlled studies of team care in stroke rehabilitation are limited to the previously discussed (see Chapter 4) stroke unit studies, in which the "team" is one aspect of a multidimensional intervention. Ultimately, the greater expense of the team approach needs to be justified by documentation of greater patient benefits.

Implementation Principles

Patient and Family Education

Recommendation: Patients, families, and involved others should be given information and provided with ample opportunity to learn about the causes and consequences of stroke and the goals, process, and prognosis of rehabilitation. Family members and other potential caregivers should receive thorough training in techniques and problem-solving approaches required to provide effective support. (Research evidence = B; expert opinion = strong consensus.)

Table 13. Issues for patient and family/caregiver (more...)

Table 13. Issues for patient and family/caregiver education

What is stroke? Etiology of stroke. Effects of stroke on the patient. Effects of stroke on the family.

Routine care in the hospital, rehabilitation setting, or home Maintenance of nutrition and hydration. Bowel and bladder care. Sleep and rest. Reliable medication taking. Behavioral issues and how to deal with them. Positioning and moving in bed. Prevention of blood clots. Prevention of skin breakdown. Safety measures to prevent falls. Exercise during and after rehabilitation. Techniques for performing specific tasks, such as transfers, personal hygiene, etc. Training in specific skills for which patient needs assistance. Optimizing social functioning.

Complications of stroke (tailored to patient's specific circumstances) Swallowing problems. Care/use of indwelling bladder catheter or feeding tube. Respiratory complications. Care of tracheostomy/use of respiratory equipment. Speech or language deficits; facilitating communication. Depression and other psychological disturbances.

Prevention of recurrent stroke Monitoring blood pressure. Medical or surgical interventions to prevent recurrent stroke. Lifestyle modification.

After hospital care Caregiver concerns. Family functioning. Support groups, respite care. Sexual functioning. Recreational and vocational pursuits. Automobile driving. Vocational counseling.

Patient and family education is an integral part of rehabilitation. It greatly contributes to achieving improved outcomes (Evans, Matlock, Bishop, et al., 1988). Education begun during the acute hospitalization is reinforced early and often during rehabilitation through discussions among the patient, family, and therapists; didactic sessions; family participation in therapy sessions; and the use of books, brochures, and videotapes. Potential topics are listed in Table 13.

Education should be adapted to the educational and cultural background of the patient and family, the mental status of the patient, and emotional factors that may interfere with learning. Experiential learning is often more effective than didactic learning, and repetition is important.

Monitoring Progress During Rehabilitation

Regular evaluation of progress is needed to obtain the information required to adjust treatment regimens and also to justify continued rehabilitation. Under most circumstances, it is reasonable to expect that measurable (and meaningful) improvement will occur over 1 week during an intense program or over 1 month during a less intense program. An exception would be if rehabilitation were interrupted by an acute illness or for other reasons.

Changes in regimens may address specific medical, emotional, or cognitive problems that are impeding physical rehabilitation or may modify the type or intensity of specific treatments or educational interventions.

Associated Medical Conditions

Most patients with strokes have other medical conditions that require treatment during rehabilitation. Severe illnesses may limit the patient's ability to participate in therapeutic exercise and reduce the likelihood of favorable rehabilitation outcomes (Lehmann, DeLateur, Fowler, et al., 1975; Roth, Mueller, and Green, 1988). Common diseases are hypertension, ischemic heart disease, congestive heart failure, chronic pulmonary disease, and diabetes mellitus. Goals of treatment include adjusting antihypertensive medications to control blood pressure while avoiding postural (orthostatic) hypotension, treating angina pectoris and congestive heart failure with medications while adjusting exercise to the patient's abilities, and adjusting diet and medications (insulin, oral agents) in diabetics to accommodate changes in blood sugar that may occur during increased physical activity. A full discussion of the management of these and other comorbidities is beyond the scope of this guideline.

Acute Illnesses

Few rehabilitation programs have adequate diagnostic or treatment capabilities to care for acute medical illnesses such as acute myocardial infarction, pulmonary embolus, or gastrointestinal bleeding. These patients will require transfer to an acute care facility. Close cross-coverage arrangements with an acute care facility will, in some cases, reduce the need for transfer. The ability of rehabilitation facilities to care for other acute (but less life-threatening) illnesses such as urinary tract infection, pneumonia, or thrombophlebitis, varies widely. Decisions on the need for transfer should be individualized to the capabilities of the program. In general, rehabilitation programs should have a low threshold for obtaining consultations or initiating transfer when acute problems arise.

Managing Dysphagia

The assessment of swallowing disorders (dysphagia) is discussed in Chapter 3, and management is discussed in Chapter 4. Swallowing problems frequently resolve spontaneously; however, the condition should be reassessed at the time of admission to rehabilitation and treatments continued or modified, if necessary.

Maintaining Nutrition and Hydration

A significant number of patients have evidence of dehydration or inadequate nutrition at the time of admission with a stroke, and one report indicates that as many as 22 percent of patients evidence deficiencies by the time of discharge (Axelsson, Asplund, Norberg, et al., 1988). Possible causes of inadequate oral intake are dysphagia, an inability to chew or feed oneself, lack of interest in food, cognitive deficits such as inability to recognize hunger or thirst, and inability to make hunger or thirst known because of problems with communication. Possible effects are generalized weakness, increased risk of skin breakdown and pressure ulcers, electrolyte imbalance, and reduced ability to participate in rehabilitation.

To reduce the risk of malnutrition or dehydration, food and fluid intake should be monitored daily in all patients, and body weight should be determined regularly. Opportunities to improve intake include catering to a patient's food preferences, arranging for company during meals, providing assistance in feeding or otherwise encouraging intake, and treating specific problems that interfere with intake. If such measures are unsuccessful, feeding by a feeding gastrostomy may be necessary.

Managing Bladder Function

Urinary incontinence that persists after a stroke is often associated with severe motor, proprioceptive, and visual deficits and a poor long-term prognosis (Reding, Winter, Hochrein, et al., 1987). Causes include damage to neural centers that govern bladder function, immobility that prevents timely access to toileting facilities, cognitive deficits that prevent recognition of the need to void, and communication problems that interfere with making needs known to others. Fecal impaction may also predispose to incontinence by causing pressure on the bladder. Potential complications include urinary tract infection, skin breakdown, social embarrassment, depression, and the need for institutionalization.

Documentation of the duration and pattern of urinary incontinence should include frequency of urination, timing, amount, whether voiding was preceded by the urge to urinate, discomfort on voiding (dysuria), and fluid intake patterns.

Management is cause-specific. In most cases, efforts should be made to remove an indwelling catheter, if one has been placed, in conjunction with a bladder training program that includes timed voiding and use of a commode or toilet instead of a bedpan. Intermittent catheterization may be indicated if postvoid residual volumes (PVR) greater than 50 cc are associated with symptomatic urinary tract infections. However, many patients tolerate increased PVRs without developing urinary tract infections and do not require intermittent catheterization. Bladder training is especially useful in patients who are alert and cooperative but may also be helpful in the cognitively impaired patient (Engel, Burgio, McCormick, et al., 1990; McCormick, Scheve, and Leahy, 1988; Schnelle, 1990). A clamping regimen prior to removal of an indwelling catheter does not appear to be helpful (Gross, 1990). Attention by staff to voiding needs and adequate access to toileting facilities are both essential.

Patient and family education in the management of bladder function is an important part of discharge planning.

Managing Bowel Function

Fecal incontinence occurs in a substantial proportion of patients after a stroke but clears within 2 weeks in the majority (Brocklehurst, Andrews, Richards, et al., 1985). Continued fecal incontinence signals a poor prognosis. Diarrhea, when it occurs, may be due to medications, initiation of tube feedings, or infection. It can also be due to leakage around a fecal impaction. Treatment should be cause-specific.

Constipation and fecal impaction are more common after stroke than incontinence. Immobility and inactivity, inadequate fluid or food intake, depression or anxiety, a neurogenic bowel or the inability to perceive bowel signals, lack of transfer ability, and cognitive deficits may each contribute. Goals of management are to ensure adequate intake of fluid, bulk, and fiber and to help the patient establish a regular toileting schedule. Bowel training is more effective if the schedule is consistent with the patient's previous bowel habits (Venn, Taft, Carpentier, et al., 1992). Stool softeners and judicious use of laxatives may be helpful.

Managing Sleep Disturbances

Sleep patterns may be altered by the effects of the stroke or by routines of a hospital or nursing facility. Inverted sleep-wake rhythms with lethargy during daytime hours and agitation at night, sleep apnea (Culebras, 1992), and reduced sleep efficiency with a suppression of REM sleep and increased non-REM sleep (Korner, Flooh, Reinhart, et al., 1986) have been reported to result from hemisphere strokes. Depression or anxiety may interfere with sleep (Chenelly, 1989). Muscle spasms, pain, inability to move in bed, and urinary frequency or incontinence can interrupt sleep. The unfamiliar environment of a hospital, noise, and awakenings for medications or vital signs also create problems for some patients (Beyerman, 1987).

Lack of adequate sleep can interfere with a patient's ability to participate in an intense rehabilitation schedule. Daytime rest periods may be needed because of fatigue due to vigorous activities, but these must be weighed against the ability of the patient to sleep at night.

Assessment of sleep problems includes the patient's sleep history, observation of sleep and waking behaviors, evaluation of medications, and examination of environmental factors. Management should address the cause of the sleep problem and treat the appropriate disability or symptom; change the environment to reduce disturbances during sleep or adjust the type, timing, and dose of the offending medication. Hypnotics should be used only if all else fails. In this regard, a small controlled trial found that flurazepam produced more daytime sedation than triazolam in patients with strokes (Woo, Proulx, and Greenblatt, 1991).

If sleep medications are used, side effects such as daytime sedation, paradoxical agitation, confusion, or memory problems need to be carefully monitored. Moreover, there is suggestive evidence that agents such as benzodiazepines may slow sensorimotor recovery (Goldstein, 1993), and these agents should be used only if all else fails. Interventions to keep the patient active and minimize daytime sleep, relaxation and other behavioral techniques to help induce sleep, and devices to prevent sleep apnea should also be considered.

Introduction

Sensorimotor deficits and restricted physical mobility are common after stroke. These problems may be complex in their own right and are made even more so by coexisting cardiovascular disease, arthritis, or physical deconditioning. A patient's movement problems may involve muscle weakness, abnormal synergistic organization of movements, altered temporal sequencing of muscle contractions, impaired regulation of force control, delayed responses, abnormal muscle tone, loss of range of motion, altered biomechanical alignment, and sensory impairments.

The first challenge facing a therapist is to determine which factors are contributing to movement or functional deficits. Assessment begins by observing a patient's attempts to accomplish functional tasks. Apparent disabilities are then examined using standardized measures of deficits in movement, posture, and physical performance. Thorough knowledge of the cause of impaired motor performance is needed to select appropriate exercises, treatment modalities, and activities.

The three philosophies that guide treatment choices for sensorimotor deficits are remediation or facilitation, compensation, and motor control (Duncan, 1992). The remediational approach is exemplified by traditional physical therapy exercises and neuromuscular facilitation. This approach uses forced sensory stimulation modalities, exercises, and resistive training to enhance motor recovery. Some degree of volitional movement in the involved limb is required.

In the compensatory model, the therapist emphasizes achieving independence in basic activities of daily living by attempting to improve function rather than enhancing motor recovery or minimizing impairments. Some therapists avoid the compensatory approach for fear that reliance on the noninvolved side to accomplish daily tasks will suppress recovery and contribute to learned nonuse of the impaired side ). Evidence supporting this conclusion is provided by studies showing that forced use of the impaired limb improves motor control in some patients (Taub, Miller, Novack, et al., 1993; (Wolf, Lecraw, Barton, et al., 1989). However, the compensatory strategy may be the only way to improve function after motor recovery has plateaued. Moreover, it may be preferred in patients with severe motor deficits who have a poor prognosis for recovery of sensorimotor function.

The third model is relatively new and incorporates theories of motor control and motor learning (Carr and Shepherd, 1989; Gordon, 1987; Winstein, 1987). Major tenets of this approach are that motor control represents a complex interaction of the neurological and musculoskeletal systems and the environment to enhance performance. This theory holds that motor control is task-specific, and hence, if one practices under one condition, the effects do not necessarily carry over to another condition. This concept is appealing, but evidence is lacking to support the superiority of treatments based on this view of motor control.

Table 14. Examples of therapies for sensorimotor deficits (more...)

Table 14. Examples of therapies for sensorimotor deficits and physical mobility

Impairments	Treatments
Sensory deficits	Teach compensatory strategies. Patient accommodates to diminished sensory input during movement and functional activities.
Range of motion	Passive and active range of motion. Joint mobilization. Splinting or casting.
Pain	Positioning (e.g., slings, wheelchair tray, arm supports). Reduction of edema (elevation, pressure gloves or stockings, continuous passive motion, etc.). Modalities (ice, heat, ultrasound, etc.). Proper range of motion (techniques and sequence of exercises to avoid shoulder impingement syndrome).
Force control-voluntary control	Facilitory modalities as patient attempts to contract muscles (e.g., quick stretch, vibration, electrical stimulation). Select optimal biomechanical position or position in point of range of motion for patient to initiate movement (e.g., to facilitate hip flexion, have patient assume side lying and place patient's hip in 90 degrees of flexion; also, therapist quick stretches the hip flexors as the patient attempts to contract the muscle). Isometric, eccentric, concentric exercises. Select eccentric exercises prior to concentric exercises. Assistive, active, and resistive exercises. Functional activities (e.g., bridging exercises, sit to stand, dressing, and other daily tasks, etc.). Train the patient in context-specific environments.
Force control--speed	Isokinetic exercise training. Functional tasks requiring quick contractions (postural perturbations, kicking a ball, etc.).
Tone-- spasticity	Stretching, prolonged stretching, passive manipulation by therapists (e.g., slow rhythmic rotation), weight bearing, ice, contraction of muscles antagonistic to spastic muscles, splinting, and casting.
Tone-- prolonged recruitment and lack of reciprocal inhibition	Exercise muscle groups antagonistic to muscle that will not turn off with the correct timing. Slow active reciprocal contraction of agonist andantagonist muscles.
Synergistic organization	Select exercises, movement patterns, and activities that require increasingly more complex combinations of muscle contractions and sequencing (e.g., ankle dorsiflexion and eversion with hip and knee extended, prehensile patterns of hand with wrist extension, elbow extension, and shoulder flexion). Vary conditions of performance so that patient will be able to adapt to speed and other environmental stresses. Functional use of available controlled movement. Goal is developing a variety of movement patterns and purposeful activities.
Mobility	Practice moving in bed, rolling, coming to sit, sit to stand, transfers, standing, walking (activities may be done by encouraging as much use of involved extremities as possible, or patient may be taught to compensate with noninvolved extremities).
Balance	Weight-shift training with and without feedback. Selecting activities that require automatic weight transfer (e.g., reaching). Practice a variety of activities under different conditions that require sitting, standing, and walking balance (reaching, turning, changing directions, carrying objects, going up and down hills, catching, throwing, and reaching in various directions). Patient practices restoring balance as his/her balance is perturbed.
Gait	Consultation with orthotist to select appropriate orthosis. Select assistive devices. Practice swing, stance, weight shift components with and without feedback from therapists. Vary conditions of performance (speed, sensory conditions, different surfaces).
Impaired ADL	Practice all basic activities of daily living (patient may be taught compensatory strategies with or without adaptive equipment). Practice all instrumental activities of daily living that the patient needs to be able to do (telephoning, using checkbook, shopping, etc.). Compensatory strategies with or without adaptive equipment. Practice home and community activities (independent walking in the home and community, home management tasks, etc.).

Table 15. Evidence on the effectiveness of different (more...)

Table 15. Evidence on the effectiveness of different types of physical therapy

Author, Year, Country	Purpose, Study design Duration of deficits Number of subjects	Outcome measures Maximum followup	Conclusions/Comments
Sunderland, Tinson, Bradley, et al. (1992 and 1994) United Kingdom	Compare enhanced PT to orthodox PT RCT with stratification on side of hemiplegia and severity of upper extremity impairments Acute deficits N = 432	Extended Motricity Index Motor Club Assessment Passive movement and pain Frenchay arm test Nine-hole peg test Sensory loss ADL (Barthel) F/U until 1 year	Improved arm function in enhanced therapy group at 6 months that was not sustained at 12 months.
Jongbloed, Stacey, and Brighton (1989) British Columbia	Compare functional and sensorimotor occupational therapies RCT Acute deficits N = 90	ADL (Barthel) Meal preparation Sensorimotor Integration Test F/U until 8 weeks	No significant differences among groups.
Dickstein, Hocherman, Pillar, et al. (1986) Israel	Compare 3 therapeutic approaches RCT Acute deficits N = 131	ADL (Barthel) Muscle tone Active ROM Strength Ambulatory status F/U until 6 weeks	No significant differences among groups. No difference in functional recovery or stress on caregivers.
Lord and Hall (1986) United States	Compare neuromuscular retraining (NRT) and traditional functional rehabilitation (TFR) Retrospective F/U study with matching Acute deficits N = 39	NA F/U until 8 months	No significant differences except NRT improved more on feeding (p < 0.05).
Logigian, Samuels, Falconer, et al. (1983) United States	Compare traditional PT and neurofacilitation RCT Acute deficits N = 42	ADL (Barthel) Manual Muscle Test F/U until discharge	No differences between groups.
Stern, McDowell, Miller, et al. (1970) United States	Compare neuromuscular reeducation and traditional PT RCT with patients added to "balance" groups Acute deficits N = 62	Strength Mobility Index Kenny Self-Care Index F/U until discharge	No differences between groups.

Note: ADL = activities of daily living, F/U = followup, NA = not available, PT = physical therapy, RCT = randomized controlled trial, ROM = range of motion.

Rehabilitation programs do not typically employ cardiovascular training techniques, but many patients experience some degree of physical conditioning by engaging in rehabilitation activities. Patients with coexisting cardiovascular disease will require evaluation before rehabilitation and monitoring during treatment to minimize the risk of complications. The benefits of incorporating cardiovascular training programs in stroke rehabilitation need to be evaluated.

Exercise and Functional Training for Remediation of Sensorimotor Deficits

Table 16. Evidence on the effectiveness of biofeedback (more...)

Table 16. Evidence on the effectiveness of biofeedback

Author, Year, Country	Purpose, Study design Duration of deficits Number of subjects	Outcome measures Maximum followup	Conclusions/Comments
Mandel, Nymark, Balmer, et al. (1990) Canada	Compare rhythmic positional BFB to EMG BFB RCT Chronic deficits N = 37	Active ROM of ankle Dynamic dorsi- and plantar flexion Gait analysis Energy expenditure F/U until 3 months	Walking speed of both BFB groups improved more than controls, but differences significant only for positional BFB. Energy expenditure decreased in both BFB groups.
Wolf, LeCraw, and Barton (1989) United States	Compare effects of motor copy and conventional BFB RCT N = 26	Functional tasks Active ROM Integrated EMG levels Chronic deficits F/U until 9 months	Significant functional improvements in both groups.
Basmajian, Gowland, Finlayson, et al. (1987) Canada	Compare integrated behavioral PT with BFB to traditional PT Mix of acute and chronic deficits N = 29	UEFT Finger oscillation Health Belief Survey Mood and affect F/U until 9 months	No significant differences between groups. Both groups improved significantly on UEFT and finger oscillation.
John (1986) United Kingdom	Examine benefits of EMG BFB in the legs RCT with crossover at 3 weeks Acute deficits N = 24	ROM Gait speed Static contraction F/U until 6 weeks	No significant differences in function.
Mulder, Hulstijn, and van der Meer (1986) Holland	Examine benefits of EMG BFB in the legs RCT Duration of deficits not available N = 12	ROM Gait velocity	No differences among groups.
Inglis, Donald, Monga, et al. (1984) Canada	Examine benefits of EMG BFB in the arm ROM RCT with crossover of control group Deficits < 6 months N = 30	Strength Brunnstrom stages Post-test	No significant differences.
Basmajian, Gowland, Brandstater, et al. (1982) Canada	Compare effects of PT plus EMG BFB to PT alone RCT Deficits 2 to 5 months N = 37	UEFT Post-test	No significant differences on any groups.
Burnside, Tobias, and Bursill (1982) United Kingdom	Compare BFB to exercise therapy for foot drop Non-RCT; matched control group Deficits > 3 months N = 22	Strength ROM Gait (video) F/U until 6 weeks	BFB group improved significantly more on strength, ROM, and gait.
Greenberg and Fowler (1980) United States	Compare effects of kinetic BFB on elbow extension to OT alone RCT Chronic deficits N = 20	Active elbow extension Post-test	No differences among groups.
Hurd, Pegram, and Nepomuceno (1980) United States	Compare EMG BFB to PT only and PT plus simulated BFB RCT Patients and muscles within patients randomly assigned Mean > 60 days N = 44	Muscle activity Active ROM Post-test	Both BFB groups improved more than control "PT only" groups. No differences between BFB and simulated BFB groups.
Shiavi, Champion, Freeman, et al. (1979) United States	Compare effects of EMG BFB in the leg to sham BFB and PT alone RCT Acute deficits N = 22	Muscle control Manual muscle test	Results difficult to interpret.
Basmajian, Kukulka, Narayan, et al. (1975) United States	Compare effects on foot drop of BFB to PT alone RCT Deficits > 3 months N = 20	Strength Active ROM Gait analysis F/U up to 16 weeks	Trends favor BFB but differences not significant

Note: BFB = biofeedback, EMG = electromyographic, F/U = followup, OT = occupational therapy, PT = physical therapy, RCT = randomized controlled trial, ROM = range of motion, UEFT = Upper Extremity Function Test.

Patients with mild sensorimotor deficits following stroke may not require any therapeutic intervention. However, evidence from the geriatric literature suggests that accumulated mild deficits in strength, mobility, and coordination contribute to limited physical performance in the elderly (Duncan, Chandler, Studenski, et al., 1993) and increase the risk of falls (Bergstrom, Aniansson, Bjelle, et al., 1985; Jette and Branch, 1981; Lord, Clark, and Webster, 1991; Lundgren-Linquist, Aniansson, and Rundgren, 1983; Studenski, 1992; Studenski, Duncan, and Chandler, 1991; Whipple, Wolfson, and Amerman, 1987). Increasing strength and balance may improve function and reduce falls in these patients (Fiatarone, Marks, Ryan, et al., 1990; Judge, Lindsey, Underwood, et al., 1993; Tinetti, Baker, McAvay, et al., 1994; Tinetti and Ginter, 1988).

Another important issue is that of sustaining levels of function achieved during rehabilitation. Most studies report only short-term outcomes. Those that examine longer-term outcomes reach mixed conclusions. Some of these studies indicate that functional gains are maintained (Indredavik, Bakke, Solberg, et al., 1991; Smith, Goldenberg, Ashburn, et al., 1981; Strand, Asplund, Eriksson, et al., 1985), and others do not (Garraway, Akhtar, Hockey, et al., 1980; Garraway, Akhtar, Prescott, et al., 1980; Garraway, Walton, Akhtar, et al., 1981; Sivenius, Pyorala, Heinonen, et al., 1985; Stevens, Ambler, and Warren, 1984; ; Wade, Collen, Robb, et al., 1992). Failures to maintain functional gains appear to underscore the need for continued practice after the patient returns home. The importance of encouragement by family and involved others and the need for the patient to accept progressively more responsibility for independent function can hardly be overemphasized. Continued rehabilitation or "tuneups" may be indicated in some cases, but need to be justified by evidence of progress during treatment and deterioration in its absence.

Evidence on Specific Interventions for Sensorimotor Deficits

Table 17. Evidence on the effectiveness of functional (more...)

Table 17. Evidence on the effectiveness of functional electrical stimulation with or without biofeedback

Author, Year, Country	Purpose, Study design Duration of deficits Number of subjects	Outcome measures Maximum followup	Conclusions/Comments
Kraft, Fitts, and Hammond (1992) United States	Compare two types of FES, proprioceptive PT, and no treatment in the arm Non-RCT with matched control groups Chronic deficits N = 18	Fugl-Meyer Grip strength F/U up to 9 months	Results favor EMG stimulation group.
Levin and Hui-Chan (1992) Canada	Test effectiveness of transcutaneous electrical nerve stimulation (TENS) in chronic spasticity of lower extremities RCT with placebo control Chronic deficits N = 13	Spasticity score Reflex profile Maximal contraction F/U at 3 weeks	Significant differences in outcomes favored TENS.
Cozean, Pease, and Hubbell (1988) United States	Compare the effects on gait of FES, BFB, and the combination RCT Mixed acute and chronic deficits N = 36	Quantitative gait analysis (videos) F/U at 6 weeks	Results favor combined BFB and FES.
Winchester, Montgomery, Bowman, et al. (1983) United States	Compare effects of positional feedback plus FES to PT alone on knee extension RCT Deficit < 6 months N = 40	Passive and active ROM Maximum isometric knee extension torque F/U at 4 weeks	Differences on knee extension torque favor BFB plus FES group.
Bowman, Baker, and Waters (1979) United States	Compare effects on wrist extension of positional BFB and FES to PT alone RCT 3 weeks to 4 months N = 30	Wrist extension torque Active ROM F/U at 4 weeks	Differences on both outcomes favor BFB plus FES group.
Merletti, Zelaschi, Latella, et al. (1978) Italy	Compare effects on ankle dorsiflexion of FES to PT alone RCT Deficits 1 to 15 months N = 49	Maximum voluntary movement F/U at 4 weeks	Improvement greater in FES group (p = 0.007).
Takebe, Kukulka, Narayan, et al. (1976) United States	Compare effects of FES, PT plus BFB, and PT alone in spastic lower extremity Deficits > 3 months N = 15	Gait analysis Ankle dorsiflexion ROM Post-test	Qualitative analysis favors BFB and FES groups.

Note: BFB = biofeedback, EMG = electromyographic, FES = functional electrical stimulation, F/U = followup, PT = physical therapy, RCT = randomized controlled trial, ROM = range of motion, TENS = transcutaneous electrical nerve stimulation.

Table 18. Evidence on the effectiveness of treatment (more...)

Table 18. Evidence on the effectiveness of treatment of disturbed balance

Author, Year, Country	Purpose, Study design Duration of deficits Number of subjects	Outcome measures Maximum followup	Conclusions/Comments
Tangeman, Banaitis, and Williams (1990) United States	Test whether rehab improves balance and function Time series Chronic deficits N = 40	Weight-shift balance ADL F/U until 3 months	Significant improvement on all measures that was sustained at 3 months.
Winstein, Gardner, McNeal, et al. (1989) United States	Compare effect of PT plus retraining to PT alone Non-RCT with matched control group Acute deficits N = 42	Static center of pressure position Weight distribution Locomotor performance, gait pattern, coordination F/U at 3 to 4 weeks	Better standing symmetry in experimental group, but no differences in stability during locomotor performance.
Shumway-Cook, Anson, and Haller (1988) United States	Compare PT plus balance retraining and static force platform BFB to PT alone RCT Deficits < 6 months N = 16	Lateral sway displacement Sway area F/U at 2 weeks	Lateral sway displacement reduced in experimental group, but no differences in total sway area.
Hocherman, Dickstein, and Pillar (1984) Israel	Compare PT plus platform training to PT alone Non-RCT with matched control group Acute deficits N = 24	Maximal Movement Amplitude (MMA) Weight distribution F/U at 3 weeks	Experimental group improved stance stability and weight distribution more.

Note: ADL = activities of daily living, BFB = biofeedback, F/U = followup, PT = physical therapy, RCT = randomized controlled trial, Rehab = rehabilitation

Table 19. Evidence on the effectiveness of other interventions (more...)

Table 19. Evidence on the effectiveness of other interventions to treat sensorimotor deficits

Author, Year, Country	Purpose, Study design Duration of deficits Number of subjects	Outcome measures Maximum followup	Conclusions/Comments
Taub, Miller, Novack, et al. (1993) United States	Examine the effects of restraining the unaffected arm RCT Chronic deficits N = 9	Emory Motor Function Test Arm Motor Activity Test (AMAT) Motor Activity Log Videotaped Motor Test F/U until 2 years	Restraint group improved more on multiple measures. Effects maintained at 2 years.
Yekutiel and Guttman (1993) Israel	Evaluate effects of sensory retraining Non-RCT with matched controls Chronic deficits N = 39	Location of touch Elbow position 2-point discrimination Stereognosis F/U at 6 weeks	Significant differences favored sensory retraining group on all measures.
Wolf, LeCraw, Barton, et al. (1989) United States	Examine effects of "forced use" on the paretic arm Time series Chronic deficits N = 21	21 timed activities 3 force measures F/U until 12 months	Forced use led to significant improvement in timed tasks. Effect maintained at 1 year.
Glasser (1986) United States	Compare effects on ambulation of PT plus isokinetic exercise to PT alone RCT Deficits 3 to 6 months N = 20	Functional Ambulation Profile Ambulation time F/U at 5 weeks	No differences among groups.
Trombly, Thayer-Nason, Bliss, et al. (1986) United States	Compare different types of exercises on finger extension RCT Acute deficits N = 20	ROM Tapping Grasp/release Daily pre- and post-tests	No significant differences among groups.
Inaba, Edberg, Montgomery, et al. (1973) United States	Compare functional training, active exercise, and restrictive exercise RCT Deficits < 4 months N = 77	ADL Extension strength F/U until 2 months	No significant differences among groups at 2 months.

Note: ADL = activities of daily living, F/U = followup, PT = physical therapy, RCT = randomized controlled trial, ROM = range of motion

• Biofeedback

• . Results of biofeedback studies (see Table 16) are inconclusive. Two studies have demonstrated sustained functional benefits (Burnside, Tobias, and Bursill, 1982; Mandel, Nymark, Balmer et al., 1990). Other studies have shown transient or no effects. Two meta-analyses have also come to conflicting conclusions. (Schleenbaker and Mainous) (1993) found that biofeedback is an "effective tool for neuromuscular reeducation" while (Glanz, Klawansky, Stason, et al. (1994a)) found an insignificant positive effect in pooled studies. Differences in the criteria for selecting studies to be pooled, and differences in the outcome measures used, account for the differing results in these two meta-analyses.

• Functional electrical stimulation

• . Functional electrical stimulation (FES) has been shown to produce short-term increases in muscle strength and motor control in selected patients (see Table 17); however, effects on function have not been adequately studied (Glanz, Klawansky, Stason, et al., 1994b).

• Balance training.

• Computerized biofeedback training designed to improve balance (see Table 18)has been shown to have greater effects on impairment measures (lateral sway, stance symmetry, etc.) than physical therapy alone, but carry over to improved locomotor performance has not been demonstrated.

• Different types of exercise

• . No clear advantage has been demonstrated of adding isokinetic, resisted, or active exercise regimens to functional therapy alone (see Table 19).

• Sensory retraining

• . Chronic sensory deficits are often refractory and one recent study (see Table 19) found that sensory retraining improved performance on tests of impairment; however, the study did not examine measures of function (Yekutiel and Guttman, 1993).

Compensatory Techniques To Improve Functional Performance

Compensatory treatments address the tasks and activities that comprise meaningful roles for a person. Examples are:

• Self-care tasks or basic ADL

• . The ability to take care of basic personal needs including feeding, bathing, toileting, dressing, and grooming.

• Complex tasks, or IADL

• . The ability to perform more complex daily activities such as using the telephone, writing, cutting fingernails, driving a car, managing the home, and managing finances.

• Social, recreational, and spiritual roles

• . Examples are maintaining friendships, being an active parishioner, and pursuing valued hobbies.

• Work

• . The ability to engage in activities for financial remuneration.

• Inability to use an arm or hand to stabilize an object or perform an activity that requires the use of both arms or hands.

• Disturbed sensation or astereognosis (inability to perceive an object by feel alone), which prevents doing activities with tools or utensils out of the line of vision.

• Disturbed body scheme or spatial relationships which interfere with manipulating objects in the environment or in relation to one's own body. Unilateral neglect is particularly limiting because the person fails to pay attention to anything in the neglected space and will, for example, eat only food on one side of the plate, shave only one side of the face, fail to dress one side of the body, and bump into objects on one side.

• Topographic agnosia, a perceptual impairment that limits independent mobility by preventing the person from finding the way from one place to another.

• Limited mobility, which interferes with turning over in bed, making transfers between bed and chair or toilet, or negotiating stairs.

• Communication problems that interfere with family relationships or are deterrents to the resumption of social and vocational roles.

• Alexia (inability to read) and agraphia (inability to write), which interfere with home management, financial management, some social roles, and work.

• Apraxia (inability to do purposeful movement that is not attributed to sensory or motor deficits), which can interfere with all tasks and activities, although the ability to do habitual tasks may be preserved enough in some patients to allow semi-independence in self care.

• Cognitive deficits that prevent the patient from understanding even one-step commands and preclude independence in most role functions.

• Incoordination or lack of dexterity in the nondominant hand when the dominant hand was the one affected by the stroke. This can severely limit independence. Practice and perseverance are needed to learn to use the nonaffected arm.

• Perceptual deficits and problems with motor learning, which have deleterious effects on the ability to perform tasks of daily living.

The objective of compensatory treatment is to help patients learn new skills that permit them to perform desired activities despite persisting motor, sensory, or cognitive deficits. Training begins with relatively simple tasks and progresses gradually to more difficult ones until the patient's limits are reached. Graduated challenges offer the opportunity for success and with it an increasing sense of competency, mastery, and self-esteem. Many adaptive methods aim to teach patients to perform tasks with one hand. Examples include ways to stabilize objects or clothing while working on them with the unimpaired arm or ways to fasten clothing with one hand.

Achievements are highly individual. Even patients who only have the ability to follow one-step commands and must use a wheelchair can achieve some independence in simple self-care tasks in a supportive environment. Without support, such patients are likely to require custodial care.

Most evidence supporting the effectiveness of compensatory techniques is indirect and depends on studies that show improvement in patient function during rehabilitation, but either do not test a particular technique or do not control for the effects of spontaneous neurological recovery. Exceptions are controlled studies that have found short-term increases in walking speed in response to training regimens (Cozean, Pease, and Hubbell, 1988; Mandel, Nymark, Balmer, et al., 1990; Wade, Collen, Robb, et al., 1992).

Adaptive Devices, Durable Equipment, and Orthotic Devices

Table 20. Examples of adaptive devices and durable (more...)

Table 20. Examples of adaptive devices and durable equipment

Eating devices Built-up handles on utensils for weak or incomplete grasp. Rocker knife for one-handed cutting. Nonskid mats to stabilize plate for eating with one hand. Plate guards or scoop dishes for scooping food off the plate when eating one-handed. Cups that hold liquid in the upper part and reduce the need to tilt the head when drinking, for patients with a swallowing problem who are at risk of aspiration. Bathing and grooming devices Long-handled sponge for limited reach. Washcloth or sponge mitt for patients with a weak grasp. Electric razors with specially adapted heads (e.g., at 90 degrees to the handle). Hand-held shower nozzle. Nonskid mats secured in tub or shower to prevent slipping and falling. A wide selection of grab bars for use in tub or shower that require assessment of the patient's level of need, and the architectural limitations of the bathroom before selecting the design. Toileting aids Bedside commode, urinal, bedpan. Elevated toilet seat. Toilet seat with rails. Grab bars next to the toilet. Shower and tub aids Shower and tub seats designed for decreased ability to stand in shower or sit down in or rise from the tub. Shower and tub transfer seats for difficulty with shower and tub transfers and difficulty with standing in shower or sitting in tub. Shower chairs that can be pushed into wheelchair-accessible shower for inability to transfer or stand while showering. Hydraulic and motorized tub lifts if the patient is unable to get into or out of tub; use depends on architecture of bathroom. Dressing equipment Velcro closures for one-handed dressing. Elasticized shoestrings for one-handed dressing. Long-handled shoe horn when reach is limited. Walking devices Cane with a single point of contact that improves stability of gait when leg is weak. Cane should be fitted to the patient and have a rubber tip to improve traction. Tripod or quad cane with three or four points of contact. These provide greater stability but are bulkier and more difficult to handle. Folding cane chair, allowing the user to walk and then sit and rest. Walkers that differ according to structure and purpose but must be lightweight and fold if the patient is to use them outside the home. Adjustable pickup walkers for patients who need support to stand and walk, and are able to lift the walker and maintain balance. Reciprocal walkers for patients who might lose their balance when lifting a regular walker. Rolling walkers that increase energy-efficient walking, but may be too unstable for some patients. Wheelchair and wheelchair cushions Wheelchair. Wheelchair selection is based on body measurements, specific needs (e.g., elevating leg rests), safety, comfort, and maneuverability. A wheelchair for patients with hemiplegia may have a lowered base of support and lowered seat to permit the patient to use the uninvolved foot to propel the wheelchair or a one-armed drive that allows maneuvering with one arm and hand. Wheelchair cushion. This is important for comfort and to prevent skin breakdown; selection is based on the patient's mobility status, body build, nutrition, and skin condition. Transfer devices Plastic or wooden transfer board to assist the patient who is unable to stand to perform bed, chair, shower, tub, or car sliding transfers. Gait/transfer belt for use by caregiver, if indicated. Hydraulic lifts for bed, chair, tub, or car transfers. Hydraulic or electric stair lifts for patients unable to climb stairs. Chairs modified to have higher seats for patients unable to lift out of seat. Electrically or mechanically powered chairs with seats that raise are available but are rarely indicated. Leisure and recreation devices Automatic card shufflers. Card holders. Large-faced cards. Books on audio tape. Swimming flotations. Fishing pole harnesses. Gardening tools with builtup handles. Specially designed golf clubs.

Use of a device should not substitute for reasonable efforts to teach a patient a method for performing the task in question. In most instances, mastery of the method will allow greater flexibility, satisfaction, and independence. The device may serve as a useful supplement, however, or permit a function to be performed if the adapted method cannot be learned or requires too much effort.

The patient and family/caregivers should be involved in the selection of adaptive devices and should be thoroughly trained in their use. Adequate attention to these matters will increase the likelihood that the device is wanted, is sufficient to meet needs, and will be fully used. Since some of these devices are expensive, the patient's financial circumstances and insurance coverage also need to be explored.

Wheelchair designs vary widely and need to be adapted to the patient's special needs. Comfort, safety, proper posture, and access to home and community resources are important considerations. These objectives can be achieved only through careful assessment of both the patient and the environment, and through responsiveness to the wishes of patient and family.

Timely use of orthotic devices can facilitate ambulation, permit gait training to be conducted simultaneously with muscle control exercises, and reduce the energy cost of ambulation in the presence of hemiparesis (Corcoran, Jebsen, Brengelmann, et al., 1970). Use of orthotic devices should not, however, be substituted for functional exercise directed at improving muscle strength and control, if the prognosis for recovery of motor control is good.

Fall Prevention

Patients with strokes have 61 to 83 percent of all falls that occur in rehabilitation hospitals (DeVincenzo and Watkins, 1987; Mion, Gregor, Chwirchak, et al., 1989). Many of the same considerations concerning fall prevention apply as discussed previously in Chapter 4. The major difference is that the patient's risk of falling is increased by rehabilitation treatments aimed at increasing mobility. Safety measures need to anticipate these risks and ensure environmental precautions and adequate supervision.

Muscle weakness, problems with gait or balance, difficulties with transfers, altered sensation, postural hypotension, impaired vision, and confusion or disorientation each increase the risk of falls. Falls are particularly likely when the patient tries to reach the toilet without assistance. Acute illnesses, generalized weakness, and drug side effects compound risks due to neurological deficits. Patients with visual neglect who are slow in performing tasks are at high risk of multiple accidents (Diller and Weinberg, 1970); and wheelchair users with visuospatial deficits are at increased risk of running into obstacles (Webster, Rapport, Godlewski, et al., 1994). Behavioral impulsivity, older age, a history of previous falls, and multiple transfers are associated with an increased risk of falling (Rapport, Webster, Fleming, et al., 1993). Equally important as injuries from falls is the possibility that fear of falling may compromise a patient's confidence and reduce motivation to walk or attempt self-care activities.

Facilitywide fall prevention programs need to address environmental hazards such as accessibility of toileting facilities, inadequate lighting, and wet and slippery floors. Patient risk profiles for falling should be updated at regular intervals to reflect changes in functional status and activity level. Timely assistance to satisfy bathroom needs, adequate supervision during rehabilitation sessions and intervening periods of practice, and patient and family education in fall prevention strategies are all important. Medication regimens should be adjusted to avoid sedation, confusion, or postural hypotension. Technologic approaches such as antitipping devices on wheelchairs, bed and chair alarm systems, wedge seat cushions, and--as a last resort--use of restraints are helpful in some patients.

Despite preventive measures, falls do sometimes occur. It is important that patients be taught how to get up after a fall and that family members be taught how to evaluate the possibility of a fracture, and if a fracture has not occurred, to help the patient get up. Most falls can be managed without outside assistance.

Spasticity and Contractures

Table 21. Evidence on the effectiveness of treatment (more...)

Table 21. Evidence on the effectiveness of treatment for spasticity

Author, Year, Country	Purpose, Study design Duration of deficits Number of subjects	Outcome measures Maximum followup	Conclusions/Comments
Katrak, Cole, Poulos, et al. (1992) Australia	Examine effects of dantrolene sodium on spasticity and muscle strength Double-blinded RCT with crossover Acute deficits N = 31	Motor Assessment Scale (MAS) Cybex isokinetic dynamometer ADL (Barthel) F/U until 13 weeks	Dantrolene sodium decreased strength in unaffected limbs but had no effect in impaired limbs.
Carey (1990) United States	Examine effects of manual stretch on finger control RCT Chronic deficits N = 24	EMG ratios of flexor and extensor muscles Joint Movement Tracking Test (JMTT) Force Tracking Test (FTT) Immediate post-test	Stretch group improved more than stroke controls on JMTT but not on FTT.
Poole, Whitney, Hangeland, et al. (1990) United States	Test effects of inflatable pressure splints on upper extremity function RCT with matched pairs design Duration of deficits not available N = 18	Fugl-Meyer F/U at 3 weeks	No significant differences.

Note: ADL = activities of daily living, EMG = electromyographic, F/U = followup, RCT = randomized controlled trial.

If a contracture interferes with function, corrective measures include splinting or casting involved joints into progressively more anatomically correct positions and surgical corrections. One study that used inflatable splints in the arm was inconclusive (Poole, Whitney, Hangeland, et al., 1990). Motor-point nerve blocks using phenol or botulinum toxin may have roles in selected patients (Awad and Dykstra, 1990), but their effectiveness in stroke has not been studied in controlled trials.

Shoulder Injury and Pain Syndromes

The patient with a stroke may experience pain from arthritis, peripheral vascular disease, or osteoporosis; may develop pain from muscle spasms or soft tissue or joint injury in a paretic limb; or may experience specific types of pain syndromes such as reflex sympathetic dystrophy or the thalamic pain syndrome.

Some degree of shoulder pain has been reported in as many as 70 to 84 percent of patients with a paralyzed upper extremity (Brandstater and Basmajian, 1987; Roy, 1988) but is severe in only a small percentage of patients. The shoulder is especially vulnerable to injury because the joint capsule depends on the surrounding muscle cuff for support. Flaccid paralysis permits gravitational pull to stretch the joint capsule. Prolonged pain, "frozen" shoulder, and decreased functional independence are potential results of shoulder injury.

Prevention, first and foremost, requires awareness of susceptibility to shoulder injury. Preventive measures include supporting the shoulder in a position that maintains a normal scapulo-humoral orientation, using lap trays on wheelchairs, using a pull sheet rather than lifting under the arms to pull the patient up in bed, and maintaining proper positioning and support in bed and while sitting or standing. Range-of-motion exercises should not carry the shoulder beyond 90 degrees of flexion and abduction unless there is upward rotation of the scapula and external rotation of the humeral head. Patients who are taught self-range of motion should be cautioned to avoid excessive shoulder flexion. Use of an overhead pulley appears to increase the frequency of pain (Kumar, Metter, Mehta, et al., 1990). The use of slings or arm supports is controversial because of the potential complications from immobilization.

Reflex sympathetic dystrophy (RSD), which has been reported in 12 to 25 percent of patients with hemiplegia (Brandstater and Basmajian, 1987), is characterized by pain, swelling, stiffness, and discoloration of the involved limb and shoulder. Its cause is not fully understood, but immobility, venous pooling, altered muscle tone, and inflammation of the shoulder joint appear to contribute. Treatment of RSD involves graded and carefully selected range-of-motion exercises, heat, compression, high-dose anti-inflammatory agents, pulse steroid therapy, pain medications, sympathetic nerve blocks, and therapeutic positioning (Borgman and Passarella,1991; Brandstater and Basmajian, 1987; Johnston and Olson, 1980).

Diagnosing and Treating Depression

Depression is common after stroke, either as a direct biologic effect of the brain damage or as a reaction to disabling illness, and has been reported in 11 to 68 percent of patients, including major depression in 10 to 27 percent of patients (Eastwood, Rifat, Nobbs, et al., 1989; Ebrahim, Barer, and Nouri, 1987; Gordon, 1992; House, Dennis, Morgridge, et al., 1991; Morris, Robinson, and Raphael, 1990; Robinson and Benson, 1981; Robinson, Starr, Kubos, et al., 1983; Robinson and Szetela, 1981; Wade, Legh-Smith, and Hewer, 1987). Estimates vary with the diagnostic criteria used (Gordon, 1992). The time since stroke onset is also a factor, since depression tends to develop over time and is more likely to be diagnosed as rehabilitation proceeds than during the acute hospitalization or at the time of the baseline evaluation.

Depression in stroke can have many etiologies. These include (1) a normal reaction to the losses caused by a stroke, (2) an exacerbation of preexisting depressive personality features, (3) a specific psychiatric disorder such as major depression, (4) a medical condition (e.g., hypothyroidism or Addison's disease), (5) a medication (sedatives, antihypertensives), or (6) organic brain damage. Depression can produce cognitive deficits including problems with orientation, language, visual construction, motor function, and frontal lobe tasks (Bolla-Wilson, Robinson, Starkstein, et al., 1989), especially after left hemisphere injury (Downhill and Robinson, 1994; House, Dennis, Warlow, et al., 1990). Major depression has been linked to infarcts in the left anterior cerebral cortex and basal ganglia, minor depression to right-side posterior lesions and apathy, and paradoxical cheerfulness to right anterior lesions (Robinson and Benson, 1981; Robinson and Szetela, 1981). Often, depression in stroke is associated with more than one etiology. Only a weak relationship has been shown between the severity of depression and the severity of motor or cognitive impairment after stroke (Depression Guideline Panel, 1993 [sponsored by AHCPR]).

A diagnosis of depression should be considered when the patient persistently appears depressed; gives evidence of diminished interest in activities, loss of energy, loss of appetite, sleep disturbances, or an agitated state; or expresses feelings of worthlessness, impaired concentration, or suicidal thoughts. Changes from pre-stroke behaviors observed by family members and a history of previous depression may provide valuable clues.

A clinical interview by a knowledgeable mental health professional is the most effective method of diagnosis (assessment is discussed in Chapter 3).

Depression may adversely affect both participation in rehabilitation and long-term outcomes and may compound cognitive dysfunction (Bolla-Wilson, Robinson, Starkstein, et al., 1989). Documented effects include a higher 10-year mortality than that of nondepressed patients (Morris, Robinson, Andrzejewski, et al., 1993), longer lengths of stay in inpatient rehabilitation programs (Schubert, Burns, Paras, et al., 1992b), greater disability in ADL (Parikh, Robinson, Lipsey, et al., 1990; Schubert, Taylor, Lee, et al., 1992c), higher rates of discharge to an institution (Cushman, 1988), and lower levels of social activities (Gordon, Hibbard, Egelko, et al., 1985) and sexual functioning (Monga, Lawson, and Inglis, 1986). Fortunately, symptoms tend to resolve spontaneously during recovery; however, they may last for 2 years or more (Morris, Robinson, and Raphael, 1990; Robinson, Bolduc, and Price, 1987).

Table 23. Evidence on the effectiveness of drug treatment (more...)

Table 23. Evidence on the effectiveness of drug treatment of post-stroke depression

Author, Year, Country	Purpose, Study design Duration of deficits Number of subjects	Outcome measures Maximum followup	Conclusions/Comments
Reding, Orto, Winter, et al. (1986) United States	Examine effectiveness of trazodone in post-stroke depression Triple-blinded RCT Acute deficits N = 27	ADL (Barthel) F/U at 4 to 5 weeks	Treated group improved more, but results significant only for patients with a positive dexamethasone suppression test.
Lipsey, Robinson, Pearlson, et al. (1984) United States	Examine effectiveness of nortriptyline in post-stroke depression Double-blinded RCT Acute deficits N = 34	Hamilton Depression Studies (HDS) Zung Depression Scale (ZDS) Present State Examination (PSE) Mini-Mental State (MMS) John Hopkins Functioning Inventory (JHFI) Social Ties Checklist (STC) F/U at 6 weeks	Treated group improved more on depression scales but not in functional abilities.

Note: ADL = activities of daily living, F/U = followup, RCT = randomized controlled trial.

Side effects from antidepressant medications are common in patients with strokes. When medications are used, drugs with favorable side-effect profiles are preferable. Alternatives include serotonin reuptake inhibitors and tricyclic antidepressants. Initial doses should be small and side effects should be closely monitored. Patients with major depression usually require treatment with medication. Regardless of which treatment modality is chosen, the patient's response should be assessed and treatments adjusted accordingly.

Evidence supporting methods of diagnosing and treating depression has been well documented in the literature and is summarized in an AHCPR-sponsored guideline on depression (Depression Guideline Panel, 1993) and in a review article (Starkstein and Robinson, 1994).

Other Emotional Reactions to Stroke

Emotional disturbances such as apathy, mania, delusions, hallucinations, personality changes, and obsessive-compulsive disorders occur in patients with strokes (but are relatively rare). Emotional responses such as grief or anger over the losses of function due to stroke, anxiety, altered body image and self-esteem, emotional lability, and impulsive behaviors are more common. Diagnosis depends primarily on the clinical interview. Recognition of these problems is important so that precautions can be taken to protect patient safety, and treatment with behavioral approaches or medications can be given. The effectiveness of treatment has been well demonstrated for pathologic laughing and crying after stroke (Robinson, Parikh, Lipsey, et al., 1993).

Introduction

Speech or language disorders occur in as many as 40 percent of patients with strokes. Rapid spontaneous improvement is common; however, persisting problems may have pervasive consequences for the quality of a person's life, ranging from loss of employability to feelings of social isolation. Reactive depression, withdrawal, disruption of family roles, and loss of income are common.

Assessment of speech and language function is discussed in Chapter 3. Accurate documentation of deficits is required to guide the choice of treatments. For this reason, all patients with speech and language disorders should have a hearing evaluation, and the use of standardized tests ">(see Attachment 9) is strongly recommended.

Aphasia

Goals of treatment for aphasia are to (1) reinstate (remediate) the aphasic patient's ability to speak, comprehend, read, and write; (2) assist the patient in developing strategies that compensate for or circumvent language problems; (3) address associated psychological problems that compromise the quality of life of aphasic patients and their families; and (4) help the family and involved others to communicate with the patient.

A large number of techniques are used by speech-language pathologists. The following interventions have been studied experimentally or have been developed and tested in at least one treatment or treatment comparison study.

• Traditional stimulus-response modality-specific treatments and drills such as Language Oriented Treatment (LOT) (Shewan and Bandur, 1982), direct stimulus-response treatment (Wertz, Collins, Weiss, et al., 1981; Wertz, Weiss, Aten, et al., 1986), and Melodic Intonation Therapy (Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology, 1994).

• Methods that work on deficits that underlie language disorders such as perseveration and difficulties in symbol use, including Treatment of Aphasic Perseveration (TAP) (Helm-Estabrooks, Emery, and Albert, 1987) and Visual Action Therapy (VAT) (Helm-Estabrooks, Fitzpatrick, and Barresi, 1982).

• Methods that teach compensatory strategies designed to circumvent language deficits, such as Conversational Coaching (Holland, 1980) and Promoting Aphasic Communicative Effectiveness (Davis and Wilcox, 1985).

• Methods that teach alternative and augmentative communication systems to aphasic adults. The best example is C-Vic (Weinrich, Steele, Carlson, et al., 1989).

• Developmental methods that represent attempts to apply emerging concepts from cognitive neuropsychology to the remediation of aphasia (Byng, 1988; Mitchum, Handiges, and Berndt, 1993).

• Programmatic approaches that combine features of all of the above. An illustration is furnished by Springer, Glindemann, and Huber (1991).

Treatment for aphasia can be integrated with treatments for sensorimotor or cognitive deficits or can be provided separately. Treatment should involve family and caregivers so that effective communication can be reestablished, and family members can be instructed in communication techniques.

Table 24. Evidence on the effectiveness of treatment (more...)

Table 24. Evidence on the effectiveness of treatment of speech and language deficits

Author, Year, Country	Purpose, Study design Duration of deficits Number of subjects	Outcome measures Maximum followup	Conclusions/Comments
Poeck, Huber, and Willmes (1989) West Germany	Compare intense language treatment to spontaneous recovery and examine benefits of treatment 12 months post-stroke Non-RCT (unselected retrospective control group) Acute and chronic deficits N = 229	Aachen Aphasia Test 8 week post-test	Differences significant in patients treated < 4 months after strokes, but not in patients treated later. 68% of chronic patients (> 12 months after stroke) improved significantly.
Hartman and Landau (1987) United States	Compare traditional language therapy to supportive counseling RCT Acute deficits N = 60	PICA change score F/U until 10 months post-stroke	No significant differences between treatment groups.
Wertz, Weiss, Aten, et al. (1986) United States	Compare treatment to no treatment and treatment by speech and language professionals to trained volunteers; examine effects of delaying treatment RCT Acute deficits N = 121	PICA scores F/U until 24 weeks	Differences between treatment and no treatment groups were significant, but not those between home treatment and no treatment, home treatment and clinic treatment, or earlier and deferred treatment.
Lincoln, McGuirk, Mulley, et al. (1984) United Kingdom	Compare speech treatment to natural recovery RCT, but analysis confined to patients who completed 24 weeks of treatment and matched controls Acute deficits N = 191 (327 randomized, but only 191 completed analysis)	PICA Functional Communication Profile F/U to 34 weeks post-stroke	No significant differences among groups. Only 27 subjects received > 36 treatment sessions.
Shewan and Kertesz (1984) N/A	Compare treatment by speech-language pathologists (SLPs) to treatment by trained volunteers; compare treatment to no treatment Partial RCT--random assignment to treatment groups; self-selected control group Acute deficits N = 100	Western Aphasia Battery Auditory Comprehension Test for Sentences F/U until 1 year	Significantly greater improvement in treated group than (noncomparable) controls. No significant differences between treatment by SLP and trained volunteers or between language-oriented treatment and stimulus-facilitation treatment by SLP.
Wertz, Collins, Weiss, et al. (1981) United States	Compare individual with group treatment RCT Acute deficits N = 67	PICA scores Token Test Word Fluency Test Colored Progressive Matrices Informant's rating Conversational rating F/U until 44 weeks	Significant differences favored individual for some PICA subtests but not other outcome measures.
Basso, Capitani, and Vignolo (1979) N/A	Compare treatment to spontaneous recovery Non-RCT Mixed acute and chronic deficits N = 281	Standard language exam F/U until 6 months	Treated patients improved more. Increased time post-onset and aphasia severity negatively associated with improvement.
Butfield and Zangwill (1946) N/A	Examine treatment outcomes Observational study Mixed acute and chronic deficits N = 65	Clinical staff opinion, testing, and clinical records Varied F/U	Patients with less severe aphasia improved more. 78% of subjects improved with treatment. Study primarily of historic interest.

Note: ADL = activities of daily living, F/U = followup, PICA = Porch Index of Communicative Abilities, RCT = randomized controlled trial.

Right Hemisphere Communication Disorders

Goals of treatment for right hemisphere communication disorders are to increase awareness of deficits, reinstate communicative behaviors that have been disrupted, and provide compensatory techniques when restoration is not possible. Treatments are directed at the organization of language, its use in context, learning to interpret figurative language, and learning to use language in problem solving. Because right hemisphere language disorders are complex and their treatment is a relatively new field, the effectiveness of treatment has not been fully evaluated.

Dysarthria and Apraxia of Speech

Goals of treatment for dysarthria and apraxia of speech are to reinstate normal intelligibility to the dysarthric or apraxic person's speech or to use compensatory strategies or devices when intelligibility remains limited. Apraxia of speech, dysarthria, and aphasia often coexist. In such cases, the goal is to determine the contribution of each type of deficit to problems in functional communication and to develop an integrated treatment plan.

For dysarthric speakers, indirect treatment methods include sensory stimulation, exercises intended to strengthen speech musculature or modify muscle tone, modifying positioning and posture for speech, and improving respiratory capacity and efficiency. Direct methods include helping dysarthric speakers to produce speech under carefully arranged and controlled conditions. Because speech production typically encompasses respiration, phonation, resonation, articulation, and prosody, each may be the target of direct manipulation and modification.

Treatment for apraxia of speech focuses on the articulatory aspect of speech production. Emphasis is on relearning articulatory patterns and sequences of gestures, often hierarchically arranged to begin at relatively automatic levels and progress to more purposive communication. Intra- and intersystemic reorganization of the speech act is a programmatic approach based on learning to intone speech that has been used successfully in apractic speakers (Rosenbek, 1985; Wertz, 1984). Evidence supporting the effectiveness of treatments for dysarthria and apraxia of speech are limited to single-subject studies and case series.

Severely impaired dysarthric and apraxic speakers may benefit from alternative forms of communication or augmentative devices such as communication boards and books, pacing boards, and sophisticated electronic communication devices.

Indications for Discharge

The term "reasonable treatment goals" is used to emphasize the importance of not underestimating or overestimating the patient's capabilities. When reasonable goals have been achieved, the patient is better served by moving to the next stage of recovery.

Lack of objective evidence of progress at two successive evaluations (i.e., over a period of 2 weeks in an intense program and 4 weeks in a less intense program) often indicates that a functional ceiling has been reached. Unless there is a good reason for the plateau in functional gain, transfer to a different level of care may be in the patient's best interests, and may also represent cost-effective use of rehabilitation resources.

Assessment Prior to Discharge

The predischarge assessment provides essential information for discharge planning, both about the patient and about the environment to which the patient will return. The assessment also provides a summary measure of gains achieved during the rehabilitation program and a baseline for monitoring subsequent progress. Performance of both basic and instrumental ADL is an important component of the assessment.

Discharge Planning

Fall Prevention

The efforts of stroke survivors to increase mobility inevitably increase the risk of falls. The goal is to minimize these risks while encouraging efforts to achieve independence. Potentially remediable risk factors include residual muscle weakness, problems with balance or gait, problems with vision, orthostatic hypotension, overuse of sedatives, medication side effects, and inappropriate assistive devices or inadequate training in their use (Rubenstein, Robbins, Josephson, et al., 1990). Environmental hazards such as scatter rugs, elevated thresholds, unsafe placement of furniture, and inadequate lighting are also important.

Fall prevention may include exercise regimens that increase muscle strength and improve postural control, modification of medication regimens, careful attention to the selection and use of assistive devices and wheelchairs, and home modifications to reduce the risk of tripping and increase the ease with which a person can perform daily activities. Improved access to bathroom facilities will be particularly helpful in reducing the risk of falls. A well-designed fall prevention program has been shown to reduce falls by 9 percent, rehospitalization by 26 percent, and hospital days by 52 percent (Rubenstein, Robbins, Josephson, et al., 1990).

Injuries from falls and the fear of falling may both impede recovery. Fall prevention needs to aim at both physical and psychological outcomes. Teaching the stroke survivor and family members techniques for getting up after a fall can help reduce anxiety.

Health Promotion

The risk of suffering a second stroke averages 7 to 10 percent per year, and the risk of complications remains high, especially in severely disabled people with limited mobility. Interventions to prevent stroke recurrence and complications of stroke such as urinary tract infections, aspiration, pressure ulcers, DVT, and pulmonary emboli were discussed in Chapter 4. Continued efforts to prevent recurrent strokes are essential. The choice of therapies will depend on the etiology of the stroke and the stroke survivor's risk-factor profile. Steps to control risk factors such as hypertension, tobacco use, diabetes mellitus, hyperlipidemia, and drug abuse should be pursued. Timely vaccinations to prevent influenza and pneumococcal infection are very important in older patients.

Leisure and Recreational Activities

Participation in leisure activities is closely related to both health status and quality of life (Drummond, 1990; Jongbloed and Morgan, 1991; Krefting and Krefting, 1991; Shank, 1992; Sjogren, 1982). Emphasis on leisure activities during rehabilitation can reinforce treatments directed at physical, emotional, and cognitive impairments or disabilities (MacNeil and Pringnitz, 1982). After return home, interest in leisure and recreational activities may provide a strong motivation to resume an active lifestyle. The support of family members and friends should be mobilized to influence a person's self-appraisal, roles, and participation in leisure activities.

Several measures of leisure activities have been developed (Holbrook and Skilbeck, 1983; (Wade, Legh-Smith, and Langton-Hewer, 1985). Broadly, efforts to assess, encourage, and enable leisure and recreational activities after the stroke survivor returns home should include:

• Assessment of pre-stroke interests and activities.

• Agreement on short-term and longer-term goals.

• Review of valued activities against current functional levels.

• Evaluation of the suitability of current adaptive equipment.

• Development of strategies to overcome physical barriers in the home and community.

• Identification of new leisure activities to match functional abilities.

• Education concerning available community resources.

• When needed, advocacy for the development of community programs.

Sexuality

Sexual issues relate both to sexual function and to changes in body image as a result of stroke. Sexual activity usually diminishes and sometimes ceases after stroke (Bray, DeFrank, and Wolfe, 1981; Coslett and Heilman, 1986; Kalliomaki, Markkanen, and Mustonen, 1961), but sex remains important to the majority of stroke survivors. Decreases in libido or the ability to achieve orgasm are common after stroke (Coslett and Heilman, 1986; Garlinghouse, 1987). Men may experience difficulty in achieving an erection or ejaculating due to neurological impairments or the effects of medications, most notably those used to treat hypertension and cardiac disease; and women may experience changes that cause them to feel equally impotent. Psychological factors, dependency in self-care activities, and changes in sexual roles each may be important.

Sexual issues are often not adequately addressed despite evidence that patients and their partners welcome frank discussions. The most important message is that sexual activity is not contraindicated after stroke. However, both parties need to recognize and adjust for the effects of motor, sensory, and attentional deficits, easy fatigability, changes in body image, and self-esteem. Interventions that stress the importance of effective communication, sharing of concerns, and development of adaptive strategies such as positioning, foreplay, and timing to avoid fatigue are often helpful (McCormick, Riffer, and Thompson, 1986; Sjogren, Damber, and Liliequist, 1983; Sjogren and Fugl-Meyer, 1982).

Automobile Driving

More than half of stroke survivors who drove a car before their strokes stop driving afterwards (Legh-Smith, Wade, and Hewer, 1986). Factors that are most commonly associated with driving cessation are older age and the presence of cognitive deficits. The ability to resume driving promotes independence and can also help greatly to avoid a sense of isolation.

Studies have come to mixed conclusions about the relative merits of neuropsychological examinations and standardized driving tests in evaluating persons with disabilities who wish to resume driving. Some studies suggest that persons who pass tests for cognitive deficits (including visuospatial deficits) do not require a road test (Nouri, Tinson, and Lincoln, 1987; Sivak, Olsen, Kewman, et al., 1981). Other studies find that cognitive testing alone is insufficient and recommend that a standardized driving test be mandatory (Brooke, Questad, Patterson, et al., 1992; Katz, Golden, Butter, et al., 1990; van Zomeren, Brouwer, and Minderhoud, 1987).

The panel's recommendations reflect the fact that stroke survivors may be able to pass a driving test despite having visuospatial deficits or problems with easy distractibility, impulsive behaviors, or slowed decisionmaking that may impair their ability to drive safely under unpredictable road conditions. These problems will usually be detected during rehabilitation. If questions persist, however, a neuropsychological evaluation should be obtained prior to the driving test.

Decisions on a stroke survivor's ability to drive also need to take account of medical problems such as the control of seizures, and must satisfy local regulations that govern driving with an impairment or medical condition. Referral to an adaptive driving instruction program should be considered in appropriate patients. The only study that has examined the effectiveness of cognitive potential training concluded that training may improve perceptual skills and driving performance (Sivak, Hill, Henson, et al., 1984).

The final authority on whether a person is allowed to drive is the bureau or department of motor vehicles or other agency responsible in each State for issuing driver's licenses. The person who has had a stroke and wishes to resume driving should inform that agency and seek validation of his or her ability to drive safely. The person's insurance company should also be notified both about the stroke and about the subsequent validation of driving ability from the State agency.

Returning to Work

The ability of a person to pursue a vocation is an important determinant of the quality of life. This is as true for older people who would like to work as it is for younger people. The 1986 ICD Survey of Disabled Americans, in fact, stated that "not working is perhaps the truest definition of what it means to be disabled" (Louis Harris and Associates, 1986). The Americans with Disabilities Act of 1990 prohibits discrimination in employment against people with disabilities.

Vocational rehabilitation has been congressionally mandated for over 50 years to provide permanently disabled people with whatever assistance is necessary to prepare them for work that they can do successfully. However, a population survey published by the U.S. Census Bureau in 1988 revealed that only 32 percent of working-age adults with disabilities were working or actively seeking employment.

Medical Specialties

All physicians have completed 3 or 4 years of undergraduate college education and 4 years of medical school, and most have completed residency training in a specialty. During rehabilitation, the physician treats medical problems and often functions as the team leader. Physiatry and neurology are the medical specialties most commonly involved in rehabilitation. Geriatricians, internists, family physicians, and psychiatrists may also be involved.

Neurologist.: Specializes in the diagnosis and treatment of diseases of the nervous system and has completed a minimum of 4 years of residency training after medical school.

Physiatrist.: Specializes in physical medicine and rehabilitation and has completed a minimum of 4 years of residency training in physical medicine and rehabilitation after medical school.

Geriatrician.: Specializes in internal medicine or family practice and has completed a minimum of 3 years of residency training after medical school, with additional training in the care of the elderly.

Occupational Therapy (OT)

Occupational therapists are primarily concerned with helping the patient learn to perform tasks and activities required by daily life.

Registered occupational therapist (OTR).: Has completed 4 years of college and a 6-month supervised internship, and has been examined and certified by the American Occupational Therapy Certification Board (AOTCB).

Certified occupational therapist assistant (COTA).: Has completed a 2-year or associate degree and a 12-week supervised internship, and has been examined and certified by the AOTCB.

Occupational therapy aide.: Has been trained by the institution in which he or she works.

Physical Therapy (PT)

Physical therapists work with patients disabled by strokes to help them regain motor control, strength, physical conditioning and mobility, and return to independent living.

:

Physical therapist.: Has completed at least 4 years of college, and many have completed a master's degree (6 years of higher education); all have successfully passed a State licensure examination.

Physical therapy assistant.: Has completed 2 years of education after high school.

Physical therapy aide.: Is trained by the institution in which he or she works.

Psychology

Psycho logists assess the mental, cognitive, and emotional status of patients, work with the rehabilitation team to design treatment, and often provide treatment.

Clinical psychologist.: Has completed a doctoral program in psychology and a 1-year internship.

Neuropsychologist.: A specialized psychologist who emphasizes understanding and treatment of the cognitive, psychological, and behavioral problems that occur after damage to specific areas of the brain.

Recreational Therapy

Recreational therapists work with the rehabilitation team to assess functional and leisure abilities and to promote recovery through physical conditioning and leisure activities. Certification is offered by the National Council for Therapeutic Recreation Certification (NCTRC).

Certified therapeutic recreation specialist (CTRS).: Has completed 4 years of college with a degree in therapeutic recreation (recreational therapy) or a degree in recreation with an emphasis in therapeutic recreation, has completed a supervised recreational therapy field-work placement of 36 hours, and has passed the national certification examination administered by NCTRC.

Certified therapeutic recreation assistant (CTRA).: Has completed a 2-year or associate degree with a major in recreation or therapeutic recreation; a 10-week field placement may be required.

Rehabilitation Nursing

Rehabilitation nurses are specifically trained by experience, continuing education, or graduate education to provide nursing services to patients disabled by strokes or other chronic diseases, with the goals of restoring and maintaining health, function, independence, and quality of life for the patient and family, and the cost-effective use of resources.

Registered nurse (RN).: Has completed a 2- or 3-year hospital-based program in nursing or a 2- or 4-year college program in nursing, and has successfully passed an examination by the State board of nursing.

Certified rehabilitation registered nurse (CRRN).: A registered nurse (RN) with at least 2 years of experience in rehabilitation nursing who has been examined and certified by the Rehabilitation Nursing Certification Board.

Nurse practitioner.: An RN who has met advanced educational and clinical practice requirements. A nurse practitioner conducts physical examinations, takes medical histories, orders and interprets laboratory tests and x-rays, diagnoses and treats common illnesses; and, in 43 States, prescribes medications.

Social Work

Social workers are integral members of the rehabilitation team with special responsibilities for working with patients and families to evaluate community and family resources, obtain necessary community services, and facilitate discharge planning. Social workers will also often provide counseling and education.

Licensed clinical social worker (LCSW).: Typically, has completed 4 years of college and a 2-year master's program in social work (MSW) and has been licensed by a State examining board. Requirements vary by State.

Speech Therapy

Speech-language pathologists work with patients with aphasia, dysarthria, and dysphagia.

Speech-language pathologist (SLP).: Has completed 4 years of college, a master's degree in speech-hearing-language pathology, 375 hours of supervised clinical observation, and a 36-week clinical fellowship. SLPs obtain a Certificate of Clinical Competence (CCC) from the American Speech-Language-Hearing Association (ASHA).

Dietitians

The dietitian assesses the nutritional status of the patient and provides diet therapy, counseling, or specialized nutritional supplements.

Registered dietitian.: Has completed a baccalaureate degree granted by a U.S. regionally accredited college or university; has met current academic requirements as approved by the American Dietetic Association; has successfully completed the Registration Examination for Dietitians; and has accrued 75 hours of approved continuing education every 5 years.

Consultants

• Robert F. Berrian, MA, CTRS

• Director of Recreational Therapy Services

• Health South Rehabilitation Center

• Mechanicsburg, PA

• Specialty: Therapeutic Recreation

• Richard W. Bohannon, EdD, PT, NCS

• Professor

• School of Allied Health

• University of Connecticut

• Storrs, CT

• Therapist

• Hartford Hospital

• Hartford, CT

• Specialty: Physical Therapy

• James S. Liljestrand, MD, MPH

• Medical Director

• Braintree Hospital

• President

• National Association of Rehabilitation Facilities

• Braintree, MA

• Specialty: Internal Medicine

• Fay W. Whitney, RN, PhD, FAAN

• Assistant Professor

• School of Nursing

• University of Pennsylvania

• Philadelphia, PA

• Specialty: Rehabilitation Nursing

Peer Reviewers, Guideline Technical Report

• Michael Alexander, MD

• Director, Stroke Rehabilitation

• Braintree Hospital

• Braintree, MA

• Associate Professor of Neurology

• Boston University

• Boston, MA

• Stephen N. Berk, PhD

• Director

• Department of Psychology

• Moss Rehabilitation Hospital

• Philadelphia, PA

• Murray E. Brandstater, MBBS, PhD

• Professor and Chairman

• Department of Physical Medicine and Rehabilitation

• School of Medicine

• Loma Linda University

• Loma Linda, CA

• Kathryn S. Bronstein, PhD, RN

• Clinical Nurse Specialist

• Cerebrovascular Neurosurgery

• Northwestern Medical Facility/Foundation

• Chicago, IL

• Bruce M. Caplan, PhD

• Chief Psychologist and Associate Professor

• Thomas Jefferson University Hospital

• Department of Rehabilitation Medicine

• Philadelphia, PA

• Catherine A. Clancy, PhD, CSW-ACP

• Director

• Social Service Department

• St. Luke's Episcopal Hospital

• Houston, TX

• Catherine Coyle, CTRS, PhD

• Associate Professor

• Temple University

• Philadelphia, PA

• Mary Dombovy, MD

• Assistant Professor of Neurology and Rehabilitation

• University of Rochester

• New York

• Chair

• Department of Physical Medicine and Rehabilitation

• St. Mary's Hospital

• Rochester, NY

• Nancy Doolittle, PhD, RN

• Research Nurse

• Department of Physiological Nursing

• University of California, San Francisco

• San Francisco, CA

• Ron L. Evans, ACSW

• Clinical Assistant Professor

• University of Washington School of Medicine

• Department of Rehabilitation Medicine

• Seattle, WA

• Mary M. Evert, MBA, OTR, FAOTA

• President

• American Occupational Therapy Association

• McLean, VA

• Carol Frattali, PhD

• Director

• Health Services Division

• American Speech-Language-Hearing Association

• Rockville, MD

• Marcus J. Fuhrer, PhD

• Director

• National Center for Medical Rehabilitation Research

• National Institute of Child Health and Human Development

• Rockville, MD

• Kenda Fuller, PT, NCS

• Lutheran Hospital

• Wheat Ridge, CO

• Gary Goldberg, MD

• Associate Professor

• Department of Physical Medicine and Rehabilitation

• Temple University School of Medicine

• Consultant

• Stroke Center

• Moss Rehabilitation Hospital

• Philadelphia, PA

• Wayne A. Gordon, PhD

• Professor and Associate Director

• Mt. Sinai School of Medicine

• New York, NY

• Mark V. Johnston, PhD

• Director of Outcome Research

• Kessler Institute for Rehabilitation

• University of Medicine and Dentistry of New Jersey

• New Jersey Medical School

• West Orange, NJ

• Lyn Jongbloed, OTR, PhD

• Associate Professor

• School of Rehabilitation Sciences

• University of British Columbia

• Vancouver, BC, Canada

• Richard B. Lazar, MD

• Executive Vice President, Medical Director

• Schwab Rehabilitation Hospital

• Departments of Neurology and Physical Medicine and Rehabilitation

• Northwestern University Medical School

• Chicago, IL

• Jeri A. Logemann, PhD

• Professor and Chairman

• Department of Communication Sciences and Disorders

• Northwestern University

• Evanston, IL

• James Malec, PhD, LP, ABPP

• Neuropsychologist

• Mayo Medical Center

• Rochester, MN

• Richard S. Materson, MD

• National Rehabilitation Hospital

• Washington, DC

• John Melvin, MD

• Vice President of Medical Affairs

• Moss Rehabilitation Hospital

• Chairman

• Physical Medicine and Rehabilitation

• Albert Einstein Medical Center

• Professor and Deputy Chairman

• Department of Physical Medicine and Rehabilitation

• Temple University

• Philadelphia, PA

• Christina M. Mumma, PhD, RN, CRRN

• Associate Professor and Chair

• Graduate Nursing Program

• University of Alaska

• Anchorage, AK

• Kenneth Ottenbacher, PhD, OTR

• Professor and Associate Dean

• School of Health-Related Professions

• State University of New York at Buffalo

• East Amherst, NY

• Walter Panis, MD

• Assistant Director of Neurology

• Spaulding Rehabilitation Hospital

• Boston, MA

• Frances Pendergraft

• Executive Director of Counseling Services

• Institute for Rehabilitation and Research

• Houston, TX

• Judith M. Popovich, DNSc, RN, CRRN

• Assistant Professor

• College of Nursing

• University of Kentucky

• Lexington, KY

• Thomas R. Price, MD

• Professor of Neurology, Epidemiology, and Preventive Medicine

• University of Maryland Hospital

• Baltimore, MD

• Michael J. Reding, MD

• Associate Professor of Neurology

• Cornell University Medical College at Burke Rehabilitation Hospital

• White Plains, NY

• J. Scott Richards, PhD

• Director of Psychology

• Spain Rehabilitation Center

• Birmingham, AL

• Jay H. Rosenberg, MD

• Chairman, Quality Standards Subcommittee

• American Academy of Neurology

• Clinical Associate Professor of Neurology

• University of California at San Diego School of Medicine

• Staff Neurologist

• Southern California Permanente Medical Group

• San Diego, CA

• Shirley A. Sahrmann, PhD, PT

• Associate Professor, Physical Therapy and Neurology

• Washington University School of Medicine

• St. Louis, MO

• Margaret Stinemen, MD

• Assistant Professor of Rehabilitation Medicine

• University of Pennsylvania

• Philadelphia, PA

• J. Paul Thomas, PhD

• Director, Medical Sciences Programs

• National Institute on Disability and Rehabilitation Research

• U.S. Department of Education

• Washington, DC

• James F. Toole, MD

• Director, Stroke Research Center

• Bowman Gray School of Medicine

• Winston-Salem, NC

• Karin Mueck Vecchione, MEd, CTRS

• Administrator

• Senior Network, Inc.

• Oxon Hill, MD

• Derick T. Wade, MD

• Consultant in Neurological Disability

• Rivermead Rehabilitation Centre

• Oxford, United Kingdom

• Robert T. Wertz, PhD

• Professor

• Hearing and Speech Sciences

• Vanderbilt University School of Medicine

• VA Medical Center

• Nashville, TN

• Jack Whisnant, MD

• Chair

• Department of Health Services Research

• Professor of Neurology

• Mayo Medical School

• Rochester, MN

• Anne M. Woodson, OTR

• University of Texas Medical Branch at Galveston

• Galveston, TX

• Kathryn M. Yorkston, PhD

• Professor of Rehabilitation Medicine

• University of Washington

• Seattle, WA

• Mark A. Young, MD

• Department of Rehabilitation Medicine

• Johns Hopkins University School of Medicine

• Baltimore, MD

• Richard Zorowitz, MD

• Assistant Professor

• Department of Physical Medicine and Rehabilitation

• University of Medicine and Dentistry/New Jersey Medical School

• Newark, NJ

• Clinical Chief

• Stroke Services

• Kessler Institute for Rehabilitation

• West Orange, NJ

Peer Reviewers: Clinical Practice Guideline, Quick Reference Guide for Clinicians, and the Patient and Family Guide

• Vivian Beyda, DrPH

• Director

• Barrier Free Design and Communication

• New York, NY

• Eastern Paralyzed Veterans Association

• Joseph Bleiberg, PhD

• Director of Psychology

• National Rehabilitation Hospital

• Washington, DC

• American Psychological Association

• Laura Todd Brown, PA-C

• American Academy of Physician Assistants

• Aledo, TX

• American Academy of Physician Assistants

• Louis R. Caplan, MD

• Department of Neurology

• New England Medical Center

• Boston, MA

• American Academy of Neurology

• Pat Carter

• Associate Administrator

• Hebrew Home of Greater Washington

• Rockville, MD

• American Association of Homes for the Aging

• Randall Cebul, MD

• Associate Professor of Medicine and Epidemiology, Biostatistics

• Case Western Reserve University

• MetroHealth Medical Center

• Cleveland, OH

• Society of General Internal Medicine

• Gregg R. Clifford, MD

• Consultants in Internal Medicine, Ltd.

• Norfolk, VA

• American College of Physicians

• Steven Cohen-Cole, MD

• Wesley Woods Geriatric Hospital

• Atlanta, GA

• American Psychiatric Association

• Gregory Jay Darby, PA-C

• Rehabilitation Medicine Association

• Gainesville, FL

• American Academy of Physician Assistants

• Susan Dean-Baar, PhD, RN, CRRN

• Wheeling, IL

• American Nurses Association

• Alicejean L. Dodson, RN, MN

• Washington, DC

• American Health Care Association

• Wayne R. English, DO, FAOCRM

• Sportsmedicine Rehabilitation Center

• Bedford, TX

• American Osteopathic Association

• Bruce M. Gans, MD

• President and CEO

• Rehabilitation Institute of Michigan

• Detroit, MI

• American Hospital Association

• Arthur M. Gershkoff, MD

• Clinical Director

• Moss Rehabilitation Stroke Center

• Philadelphia, PA

• Moss Rehabilitation Hospital

• Mary Jo Gibson

• Senior Analyst

• Public Policy Institute

• Washington, DC

• American Association of Retired Persons

• Gary Goldberg, MD

• Philadelphia, PA

• American Academy of Physical Medicine and Rehabilitation

• Elizabeth Gresch

• President

• Dow Chemical Company

• Midland, MI

• American College of Occupational and Environmental Medicine

• Michael Hagen, MD

• Associate Professor and Interim Chair

• Department of Family Practice

• University of Kentucky

• Lexington, KY

• American Academy of Family Physicians

• Carolyn J. Harris, RN, BSN, MEd, NHA

• Marlin Management Services, Inc.

• Burlington, VT

• American Health Care Association

• Melinda Harrison

• Director

• Watson Clinic Center for Rehabilitative Medicine

• Lakeland, FL

• American Speech-Language-Hearing Association

• Jim Hinojosa, PhD, OTR, FAOTA

• Associate Professor and Director of Post-Professional Graduate Program

• Department of Occupational Therapy

• New York University

• New York, NY

• American Occupational Therapy Association

• Gary R. Houser

• President

• National Stroke Association

• Englewood, CO

• National Stroke Association

• Jeanette Hoyt, CRRN

• Willamette Falls Hospital--Home Health Agency

• Oregon City, OR

• National Association for Home Care

• Katherine F. Jeter, EdD, ET

• Executive Director

• Help for Incontinent People, Inc.

• Spartanburg, SC

• Help for Incontinent People, Inc.

• Philip W. Kassirer, PT

• Director of Therapeutic Services

• HCR--Home Health Agency

• Rochester, NY

• National Association for Home Care

• Kathleen Kelly

• Executive Director

• Family Caregiver Alliance

• San Francisco, CA

• Family Caregiver Alliance

• Evelyn Kennedy

• Executive Director

• Promote Real Independence for the Disabled and Elderly

• Groton, CT

• Promote Real Independence for the Disabled and Elderly

• Corinne Kirchner, PhD

• Director of Social Research

• American Foundation for the Blind

• New York, NY

• American Foundation for the Blind

• Paul Leung, PhD

• Division of Rehabilitation Education Services

• University of Illinois

• Champaign, IL

• American Psychological Association

• Sharon M. Lyke, RN, BSN, CRRN

• Hilltop Home Care

• Grand Junction, CO

• National Association for Home Care

• Marjorie A. Maddox, ARNP, ANP-C

• University of Louisville School of Nursing

• Louisville, KY

• American Academy of Nurse Practitioners

• Jane Mathews-Gentry, PT, MPH, DSc

• Rehabilitation Supervisor

• VNA/North Shore, Inc.

• Danvers, MA

• National Association for Home Care

• John L. Melvin, MD

• Philadelphia, PA

• National Association of Rehabilitation Facilities

• Stephanie Mensh

• Falls Church, VA

• American Urological Association

• John Murphy, MD

• Washington, DC

• Gerontological Society of America

• Jonathan Musher, MD

• Vice President of Medical Affairs

• Beverly Enterprises

• Fort Smith, AR

• American Health Care Association

• Glenn E. Nancarrow, PT

• Santa Fe Home Care

• Gainesville, FL

• National Association for Home Care

• Jane M. O'Toole, ARNP

• Santa Fe Home Care

• Gainesville, FL

• National Association for Home Care

• Alberta Orr, MSW

• National Program Associate American Foundation for the Blind

• New York, NY

• American Foundation for the Blind

• Robin J. Patterson, BSN, RN

• Quality Validation Specialist

• Unicare Health Facilities, Inc.

• Spokane, WA

• American Health Care Association

• Kriste Petite, RN, MSN, COHN

• Intel Corporation

• Santa Clara, CA

• American Association of Occupational Health Nurses

• Marcia B. Richards, RN, RS

• Washington, DC

• American Health Care Association

• Robert Robinson, MD

• Department of Psychiatry

• University of Iowa Hospitals and Clinics

• Iowa City, IA

• American Psychiatric Association

• H. Denman Scott, MD, FACP

• Philadelphia, PA

• American College of Physicians

• Thomas K. Skalko, PhD, CTRS

• Florida International University

• Miami, FL

• American Therapeutic Recreation Association

• Andrew H. Smith

• Research Analyst

• American Association of Retired Persons

• Washington, DC

• American Association of Retired Persons

• Mary T. St. Pierre

• Associate Director of Regulatory Affairs

• National Association for Home Care

• Washington, DC

• National Association for Home Care

• Joan Unger, RN/ARNP-C, MS, CNA

• Land O'Lakes, FL

• American Academy of Nurse Practitioners

• Donna L. Wagner, PhD

• Vice President of Programs

• National Council on the Aging, Inc.

• Washington, DC

• National Council on the Aging, Inc.

• Sandra M. Watchous, MN, RN

• Hays, KS

• National Association for Home Care

• Barb Wegener, RN, BSN, MPA, CNAA

• Program Manager: Specialty Services

• Brevard Home Care

• Wuestoff Health Systems

• Melbourne, FL

• National Association for Home Care

• Leon A. Weisberg, MD

• Tulane University School of Medicine

• Department of Psychiatry and Neurology

• New Orleans, LA

• American Society of Internal Medicine

• Rita Wray, BSN, CNA

• Brandon, MS

• National Black Nurses Association

• Kathleen Wreford, RD

• American Dietetic Association

• Clinical Dietitian

• Rehabilitation Institute of Michigan

• Detroit, MI

• American Dietetic Association

Site Testers

• Helen S. Philliou, RN, BS

• Case Management Consultant

• Winchester, MA

• LaDonna Reading

• Director of Clinical Services

• Continental Medical Systems

• Mechanicsburg, PA

• Joseph W. Vick Roy, MD

• HEALTHSOUTH

• Rehabilitation Hospital of Utah

• Sandy, UT

• Joanne Buttery, MSc

• Stroke Team Coordinator

• Timothy Meagher, MD

• Christiane Gauthier, PhT

• Physiotherapy

• Lawrence Green, MD

• Lilian Heimbach, OT, BSc

• Occupational Therapy

• Diane Larochelle, BSW

• Louisette LaRochelle, BSW

• Social Work

• Annick Leboeuf-Lorange, BSc

• Nursing

• Judith Robillard Shultz, MSc

• Speech-Language Pathology

• Montreal General Hospital

• Montreal, Quebec, Canada

• John B. Anderson, MD, FRCP

• Department of Neurology Permanente Medical Group, Inc.

• Oakland, CA

• G. Nancy McGowan, RN, BSN, CRRN

• Director of Utilization Management

• Olsten Kimberly Quality Care

• Westbury, NY

• John A. Schuchmann, MD

• Chairman

• Scott and White Clinic

• Temple, TX

• Mary Finn, OTR/L

• Coordinator of Program Evaluation

• Spaulding Rehabilitation Hospital

• Boston, MA

• Catherine Kroll, DO

• Gwinn Medical Center UPRNet

• Gwinn, MI

• Marcie Barnette, RN, MSN, FNP

• Director of Clinical Services

• VNA of Washington, DC

• Keith Rafal, MD

• Regional Medical Director

• Susan Anderson, MS, CCC

• Speech-Language Pathologist

• Mindy Grodofsky-Gilmore, LICSW, BCD

• Nancy A. Lowenstein, MS, OTR

• Jeanne Stack, RN

• Senior Resource Clinician

• Wellmark Health Care Services

• Wellesley, MA

Organizations and Individuals Providing Additional Scientific, Technical, and Administrative Support