Outpatient Stroke Rehabilitation

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Outpatient Stroke Rehabilitation

• Ben Braxley, PT, DPT

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OSR roadmap

• General definitions
• Components of Care
• Patient Needs
• Therapeutic Goals
• Methods
• A possible paradigm

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Google Anecdote

• Outpatient Cardiac Rehabilitation
• 866,000 hits
• Outpatient Stroke Rehabilitation
• Did you mean inpatient stroke rehabilitation
• 151,000 hits
• Inpatient Stroke Rehab
• 122,000 hits

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Outpatient Rehabilitation

• rehabilitation performed in an outpatient
  facility that is either freestanding or attached
  to an acute care or rehabilitation hospital. Day
  hospital care is a subset of outpatient
  rehabilitation in which the patient spends a
  major part of the day in an outpatient
  rehabilitation facility.
• Agency for Health Care Policy and Research

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Stroke Rehabilitation

• Assessment of the effect of stroke care
  organization and settings is difficult because of
  the extreme variability of organizational
  settings.
• Management of Adult Stroke Rehabilitation Care
  A Clinical Practice Guideline

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Outpatient Stroke Rehabilitation is a moving
target.

• Current descriptions include lists of goals and
  possible components but rarely reflect the scope
  or variability of the field.

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Stroke Rehabilitation

• Components typically identified include
• A multidisciplinary team
• Variable time course
• Variable settings
• Variable outcome
• Most often characterized as a constellation of
  services, each provided on an as needed basis
  given a particular clinical presentation

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Who are the patients?

• At 795,000 strokes per year
• With an estimated survivorship of 85
• Of which only 10 recover completely
• OSR candidates include an estimated 608,000
  Americans per year with stroke related deficits
• Of total stroke incidence between 80 and 87 are
  Ischemic, the remainder being Hemorrhagic.

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Referral and Utilization of OSR services

• Acute care physicians, neurologists, and
  frequently physiatrists (following a period of
  inpatient rehabilitation)
• Approximately 31 of stroke survivors eventually
  participate in OSR
• Suggests 246,000 new OSR participants each year
  at current rate

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What are the treatment goals?

• To prevent complications
• Second stroke, DVT, pneumonia
• To minimize impairments
• Balance, endurance, cognition, and safety
• To maximize function
• Societal role, return to independence with
  mobility, self-care, and driving

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NSA controllable risk factors for secondary
prevention

• Hypertension reduction
• Atrial Fibrilation control
• Cholesterol management
• Diabetes management
• Smoking cessation
• Weight management
• Alcohol moderation

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Why are they referred to OSR?

• Location of damaged tissue dictates deficits and
  impairments
• Language centers
• Motor control
• Motor planning
• Emotional centers
• Visual processing
• Memory
• Balance centers

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From Stroke to Rehabilitation

• Post-stroke rehabilitation begins in the
  inpatient setting, generally within 24-48 after a
  stroke, as soon as medical stability is achieved.
• Factors affecting the next level of care
• Stroke related deficits
• Insurance coverage
• Personal Budget
• And available rehabilitation options

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Divergence from the OCR model

• OSR may appear as early as Phase 2 or as late
  as Phase 5 for some stroke survivors.
• Survivors with variable degrees of impairment
  respond variably to rehabilitation setting, thus
  complicating the decision matrix.

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What does OSR entail?

• Patients typically spend several hours, often 3
  days each week, at a facility taking part in
  coordinated therapy sessions and return home at
  night.
• Team members may include Physicians, Nurses,
  Physical Therapists, Occupational Therapists,
  Speech and Language Pathologists, Recreational
  Therapists, Kinesiotherapists, and
  Neuropsychiatrists.

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Methods

• Physical Therapy
• Gross motor and sensory skills acquisition and
  maintenance
• Strength
• Endurance
• Gait
• Balance
• Typically involves goal oriented behavior and
  shaping to accomplish a desired mobility task.

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Methods

• Occupational Therapy
• Fine motor and sensory skill acquisition and
  maintenance
• Grooming
• Hygiene
• Activities of Daily Living (ADLs)
• Compensatory strategies/Adaptive techniques
• Typically involves repeated practice of daily
  routines with increased emphasis on problem
  solving and facilitatory techniques.

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Methods

• Speech-Language Therapy
• Cognitive and Oromotor rehabilitation
• Aphasia
• Swallow Therapy
• Problem Solving
• Coping
• Typically involves individualized
  critical-thinking and/or oromotor practice
  sessions

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Methods

• Recreational Therapy
• Return to leisure activities with emphasis on
  practicing impaired tasks
• Kinesiotherapy
• Movement and exercise therapy directly prescribed
  by a physician

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Other aspects of OSR

• Within the past decades many believed that all
  post-stroke recovery was spontaneous and natural.
• Eventually greater intensity specialized care
  was shown to be associated with improved
  post-stroke outcome.
• Unfortunately, the mechanisms remain unclear and
  techniques remain variable.

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Pathways versus Guidelines

• An extensive literature review has shown that to
  date Care Pathways do not improve outcomes or
  reduce costs.
• However, compliance with stroke rehabilitation
  guidelines does improve outcome.
• ?Structured individualization within a specific
  set of circumstances seems to reflect current
  best practice.

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Pathways

• Pathways seek to prescribe a set of interventions
  to a population with a certain qualifying
  condition.
• Again, a problem of scale. Writ large pathways
  seem a hindrance.
• Fine tuning pathways to specific stroke locations
  may eventually demonstrate improvements in
  outcome.

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An Emerging ParadigmElements of the perfect
storm

• Coordinated multidisciplinary staff
• Regularly scheduled meetings
• Routine involvement of carers
• Staff specialization
• Standardized and early assessments

• Better diagnostic procedures
• Early mobilization
• Prevention of complications
• Better application of best practice
• Attention to Secondary Prevention

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Barriers to OSR

• Transportation issues
• Environmental constraints
• Depression
• Fatigue
• Financial constraints