Blueprint for Post-Stroke Care




To rehabilitate a stroke patient, it takes a village — one that extends far beyond patient and physician, family and friends.

From physical, speech, occupational and other therapists to health aides, psychologists, nurses, nutritionists and social workers, a diverse team is essential in stroke rehabilitation, according to the American Heart Association/American Stroke Association’s new guidelines for stroke rehabilitation and recovery. That team, including the patient and caregivers, needs to put forth a “sustained and coordinated effort” to optimize recovery, the guidelines say. And that effort should begin as soon as the patient is able.

Each year almost 800,000 Americans experience a stroke. For the more than 80 percent who survive, rehabilitation professionals should aim to ensure patients’ abilities are aptly assessed, suitability for discharge to different settings is evaluated, and that patients continue to get comprehensive therapy, said Carolee Winstein, Ph.D., P.T., chair of the guidelines’ writing group and director of the Motor Behavior and Neurorehabilitation Laboratory at the University of Southern California.

To help healthcare providers, patients and loved ones navigate stroke rehabilitation, the guidelines spotlight which types of care are most likely to be effective, according to research. Depending on each patient’s circumstances, various factors could improve health and future quality of life. These include:

  • medicine to prevent dangerous clots,
  • fall prevention education and balance training,
  • drugs for depression,
  • evaluation of osteoporosis risk,
  • screening and treatment for swallowing problems,
  • coaching in strategies to aid memory,
  • speech therapy to improve communication,
  • mobility training,
  • regimens to strengthen use of arms and hands,
  • exercises for problems with eye movement,
  • enriched surroundings to enhance brain activity, and
  • fitness guidance after rehab to improve cardiovascular health

The newest guidelines “provide a comprehensive and current guide not only to best practices in stroke rehabilitation interventions and medical management, but also to the complex American system of post-acute care for stroke,” noted Randie M. Black-Schaffer, M.D., medical director of the Stroke Program and director of the Stroke Research and Recovery Institute at Spaulding Rehabilitation Hospital in Boston.

As the new guidelines make clear, the U.S. has a multi-level model of inpatient care for patients after stroke, said Black-Schaffer, who was not part of the group that developed the guidelines.

“Patients often progress from level to level before being well enough to return to the community,” she said. “Many of us would like to see a shift to a single level of inpatient post-acute care, where the intensity of rehabilitation and medical care could be varied depending on the patient’s needs at different phases of their recovery.”

After initial hospitalization, patients might be directed to an inpatient rehabilitation facility or to a skilled nursing facility, nursing home, long-term acute care hospital, or outpatient or in-home care, depending on medical circumstances. Patients, caregivers and healthcare providers should use the new guidelines to ease transitions into these community-based settings, said Winstein.

The guidelines say that, when available in a patient’s area, inpatient rehabilitation centers are preferable for survivors who are able to do three hours of rigorous therapy. Those facilities are well-designed to provide complex care, offering patients a broad, integrated team of experts who coordinate treatment, Winstein said.

Outside such a setting, “it’s like building a house without a contractor — you have to go to each person for their individual skill,” she said. “We need a contractor who’s going to put together a group who’s going to follow this person after discharge.”

The new guidelines also represent a wider focus in the realm of post-stroke care, Black-Schaffer said — beyond just acute care and rehabilitation in the stroke’s immediate aftermath.

“We are beginning to focus on the fact that many stroke patients will survive for decades after their stroke, with ongoing impairment and functional limitation,” Black-Schaffer said. “It is incumbent on the rehabilitation community to develop standards of care for the long-term management of these issues so that survivors can live as well as possible. They don’t just ride off into the sunset after stroke.”

Source: American Heart Association News

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