EvidenceBasedStrokeRehab 6-10-2010No Notes

Evidence Based Stroke Rehabilitation

Scott Hardin MDMedical Director

of Rehabilitation Services, Aurora St. Luke’s

Clinical Safety Officer, Aurora St Luke’s

Vice Chief of Staff, Aurora St Luke’s


Disclosures

None


GoalsBriefly review the history of strokeLearn the pertinent epidemiological facts

of stroke now and into the futureGain an appreciation that, despite there being almost 1000 RCT regarding stroke outcomes, we are still in the infancy of understanding why we do what we do


Goals

Review data from the excellent resource Evidence Based Review of Stroke

Rehabilitation (EBRSR)


History

600 BC Hippocrates – 4 humours

160 AD Galen – advanced the humour theory

1599 “the stroke of God’s hand”

1732 Robinson described the typical apoplectic patient


History

Mid 1600s Jacob Wepfer

cerebral hemorrhage

blocked cerebral arteries

1920s cerebral angiography

1935 blood letting debunked


History

1950s first carotid endarterectomy

1960s Doppler ultrasound

1960s hypertension a modifiable risk

1970s aspirin

CT scanning

PET scanning


History

1980s

stroke prevention/risk modification

smoking identified as risk

1990s

endarterectomy proven to be effective

anticoagulants and a fib

blood pressure and cholesterol


History

1990s

tPA approved

combined dipyridimole and aspirin

2000s

acute cerebral artery thrombectomy

carotid artery stenting


Epidemiology >700,000 total strokes per year in the USMortality is still about 50% However, stroke mortality fell 12% between 1990 and 2000Men 1.25 x risk of womenBlacks have 2x risk of stroke vs white; Hispanic is in between


Epidemiology There are an estimated 5 million stroke survivors in the US

More than 1.1 million with some form of chronic disability

Baby boomers

Disability


Why does rehab work?

Neural Plasticity – the ability of the brain to reorganize and learn new functions


Evidence based/Outcomes based data

In its toddlerhood

Will be important to show we matter

Soon, doing things because we think it works won’t fly


Evidence based/Outcomes based dataIndredavik et al 1990

randomized 220 strokes to the IRF* unit or general medical unit

outcomes were home or not, mortality, BI at 6 and 52 weeks, 5 years and 10 years

*IRF = Inpatient Rehabilitation Facility



Indredavik et al 1990

Across all time frames statistically significant:

lower mortality in the IRF group

lower institutionalization in the IRF group

higher home living in the IRF group

higher BI scores in the IRF group



Ronning and Guldvog – 1998

randomized controlled trial

251 strokes

compared community care (no IRF) to IRF

outcome was dependence (BI<75) or death



Ronning and Guldvog – 1998

7 month follow up

23% IRF patients dead or dependent vs 38% community care (p=.01)

39% reduction in worse outcomes with IRF care



Foley, et al 2007 Meta analysis of IRF stroke unit trials

world wide

consistent statistical benefit of IRP units over other types of post stroke care in reductions in mortality and less dependency



EBRSR – Evidence Based Review of Stroke Rehabilitation

2001

systematically reviews all outcomes based stroke literature, summarizes and grades it

www.ebrsr.com



EBRSR reviews stroke literature relative to:

techniques

therapies

devices

procedures

medications


Evidence based/Outcomes based dataEBRSR

extensive and comprehensive database search strategies

3407 studies reviewed2000 in depth studies reviewed956 RCTMethodological quality assessed using the

PEDro scale



EBRSR

grading scale (based on the AHCPR)

Level 1a (strong)

Level 1b (moderate)

Level 2 (limited)

Level 3 (consensus)

Level 4 (conflicting)



EBRSR

only the data from the 956 RCTs are used for determination of evidenced based recommendations



Recommendations are broken into:Efficacy of Stroke Rehab Elements of Stroke RehabOutpatient Stroke Rehab Secondary PreventionMobility/Lower extremity Upper extremityPainful hemiplegic shoulder Cognitive/Apraxic disordersPerceptual disorders AphasiaDysphagia/Aspiration Nutritional interventionsMedical complications DepressionCommunity reintegration MiscellaneousYoung stroke Severe StrokeOutcome measures Stroke Triage



Stroke Triage

early screeningearly admission, butpatients with severe stroke better

managed in a less acute setting

younger (<55) patients with moderate to severe strokes should always be admitted to IRFs



Stroke Rehab Elementscare pathways don’t improve

outcomes or reduce costsgreater intensities of PT and OT

improve functional outcomesunclear intensive language therapythe greater functional improvements

from IRF care are maintained long term



EBRSRLower extremity and mobility

Bobath is as good but slower

focused balance training is beneficial

rhythmic auditory sensory stim helps

PBWS on treadmill questionable

strength training is beneficial



EBRSR

Lower extremity and mobility

cardiovascular training is good

WC self propel does not help

using canes enhances mobility

e stim with gait training improves gait

EMG/biofeedback improves gait training



EBRSR

Lower extremity and mobility

tilt table or night splinting prevent contracture

AFOs help

e stim and U/S reduce spasticity



Upper extremity

initial degree of motor impairment is the best predictor of motor recovery

NDT is not superioreffects of enhanced therapy, task

specific training, sensorimotor training and mental practiceunclear



EBRSR

Upper extremity

hand splinting does not help

robots help a little

CIT helps

virtual reality helps

Botox helps tone/spasticity but maybe not function



EBRSR

Upper extremity

PT may not reduce spasticity

IPC does not help edema

FES does improve function



EBRSR

Cognition

1/3 of stroke patients develop dementia

Stroke patients have 10x risk of developing dementia

Depression contributes to cognitive impairment in stroke



EBRSR

Cognition

treating hypertension in stroke patients reduces their dementia risk

gesture training is effective for treating ideomotor apraxia



EBRSR

Language therapy

is efficacious in aphasia when provided intensely for the first three months

group therapy may improve communicative and linguistic abilities



EBRSR

Language therapy

CPU-based aphasia therapy helps

forced use aphasia therapy helps

repetitive transcranial magnetic stimulation and polarity specific transcranial direct stimulation may help



EBRSR

Language therapy

piracetam, levodopa, memantidine, dextroamphetamine and donezepil may improve

language function

bromocriptine, cholinergics, dextran and moclobemide do not help



EBRSR

Dysphagia

VBMS is the only sure way to diagnose dysphagia and aspiration

Aspiration rates are high

risk of developing pneumonia is related to aspiration severity



EBRSR

Dysphagia

all stroke survivors should be npo until assessed

SLPs should see all patients who failed the swallow screen

dysphagic individuals should feed themselves



EBRSR

Dysphagia

a variety of treatments can be used to improve swallowing function post stroke



EBRSR

Medical complications

indwelling catheters should only be used in specific instances

timed voiding, biofeedback pelvic training, behavioral therapy

and weekly in home visits reduce incontinence



EBRSR


incidence of DVT is less than 10%

anticoagulation reduces DVT

LMW heparin is more effective than unfractionated heparin

compression devices don’t help reduce DVT




10% of post stroke patients have seizures

osteoporosis is common after stroke and can be reduced with ipiflavone, vit D + Ca, vit B12 + folate, sunlight, and bisphosphonates



EBRSR

Depression

1/3 develop depression

influence of stroke location and propensity to develop

depression not understood

depression negatively impacts recovery



Depression

depression is associated with cognitive impairment

early initiation of post stroke antidepressants is effective in preventing depression

various medication classes are effective in depression



EBRSR

Depression

pharmacologic treatment improves functional recovery

treatment with antidepressants improves long term survival

ECT and TCMS are effective

music therapy helps



EBRSR

Depression

exercise training does not help



EBRSR

Miscellaneous

unclear if acupuncture helps

Reikki does not help

HBO does not help



Summary

many of the treatments we provide stroke patients are proven to help them

many of the treatments we may be providing stroke patients have been shown not

to help (and yet we do them anyway!)

the EBRSR is an excellent resource to obtain data regarding the latest RCT evidence based outcomes information

Documents

EvidenceBasedStrokeRehab 6-10-2010No Notes