ATrain Education

 

Continuing Education for Health Professionals

Stroke: Emergency Care and Rehabilitation

Module 21

Additional Issues in Stroke Care

Unfortunately, many problems exist in the provision of stroke care in the United States. Specialized stroke services are lacking in many areas of the country and are unavailable to many segments of society. Stroke care—both acute care and rehabilitation—is often provided by nurses and rehab therapists who lack education and training specific to stroke. Disparities also exist, in the incidence of stroke and in the provision of care, that profoundly affect ethnic and racial minorities.

Within stroke rehab programs, sedentary time is a serious issue and may work against desired outcomes. Additionally, the effort by patients and their families to manage a serious illness creates what is referred to as a “treatment burden.” Not surprisingly, additional physical therapy has been shown to improve post stroke outcomes.

Specialized, Interdisciplinary Care

Stroke rehabilitation ideally involves an interdisciplinary team working together to provide a comprehensive treatment program for each patient. In spite of this expertise varies widely, with the greatest concentration in formal hospital-based, inpatient stroke rehabilitation units. When compared to “usual” care provided on a general medical unit, specialized interdisciplinary stroke rehabilitation provided by an interdisciplinary stroke-specific team results in improved functional outcomes (Teasell et al., 2013). A 2013 Cochrane Review concluded that patients who received more-organized care are more likely to survive their stroke, return home, and become independent compared to those receiving less-organized care (SUTC, 2013).

This holds true for outpatient services as well. Enhanced outpatient rehabilitation and discharge services, when provided in conjunction with stroke-specific inpatient care, improve functional outcomes, reduce length of hospital stay, and increase the number of patients discharged home. Enhanced rehabilitation and discharge services have a particularly strong impact on those who have suffered a moderate to severe stroke (Teasell et al., 2013).

Sedentary Time, Lack of Activity, and Isolation

Following a stroke, a large percentage of inpatient time is spent inactive or involved in non-therapeutic activity. Comparatively little time is spent in moderate- to high-level physical activities such as standing and walking. Additionally, hospitalized stroke patients tend to spend most of their time alone in their room (West & Bernhardt, 2012).

Lack of activity and isolation are especially prevalent for patients within 14 days of stroke compared to those at later stages of recovery. Hospitalized stroke patients are involved in an average of approximately one hour per day each of formal physical therapy and occupational therapy. Even during this time a number of studies have reported that patients were involved in little or no physical activity for part of the session. Patients frequently spent less than half their therapy time involved in moderate to high physical activities such as standing and walking, and even less time was spent on therapy for the upper limb (West & Bernhardt, 2012).

Even in a specialized rehabilitation facility, the amount of time a post stroke patient is sedentary is high. Australian and Swedish researchers looked at sedentary behavior and physical activity among patients in rehabilitation hospitals. In both countries, stroke survivors on average are involved in non-therapeutic or low physical activity for as much as 76% of the day (Sjöholm et al., 2014).

In a Norwegian acute stroke unit, sedentary time accounted for 77% of the day. In community settings, a recent systematic review found that in the few studies where sedentary time was reported, it was estimated to be between 63% and 87% of the day (Sjöholm et al., 2014).

A study of patients in physical and occupational therapy between 2 and 14 weeks after stroke, during which heart rate was monitored, found that therapy is of insufficient intensity to produce a cardiorespiratory training effect. On average, in a physical therapy session, 42% of the time was spent inactive in lying, 11% active in lying, 16% active in sitting, and 31% active in standing. If it was present, the aerobic component of a typical physical therapy session lasted less than 3 minutes. Although one might expect progressively higher exercise intensities over time as functional status improved, any increase in heart rate mean and heart rate peak did not reach statistical significance. During occupational therapy a considerable percentage of time was spent in sitting, discussing issues related to discharge, equipment needs, and home management (Carr & Sheperd, 2011).

This has led researchers and clinicians to consider new and different approaches to post stroke rehab that are intended to decrease sedentary activity. Clearly, if meaningful, challenging physical and mental activities play a critical part in driving optimal brain reorganization, there is a need for patients to be more active during their hospital rehab stay than they currently tend to be. However, it is not only the time spent in active exercise that is significant but whether what the individual is doing in that time is sufficiently vigorous and relevant to induce a training effect not only on motor skill but also on level of fitness (Carr & Sheperd, 2011).

Extra Physical Therapy

An interesting review of 16 randomized controlled studies involving nearly 1700 patients being treated in an acute or rehabilitation setting for a number of acute conditions (including stroke), found that an increase in the amount of physical therapy:

  • Reduced length of stay by a small but significant amount
  • Significantly improved walking ability
  • Resulted in significantly fewer non-serious adverse events
  • Improved mobility, activity, and quality of life (Peiris et al., 2011)
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