Cerebrovascular Event Rehabilitation

All patients with a cerebrovascular event (CVE) or transient ischaemic attack (TIA) should be admitted to hospital.¹ Preferably this should be a specialist CVE unit, as the outcome is better both in terms of immediate survival and functional outcome after rehabilitation.²

The main burden of stroke (to individuals and societies) is disability - about 40% of stroke survivors are left with some degree of functional impairment.³ Reducing this burden requires optimising stroke prevention and improving acute care but rehabilitation is equally essential.

Rehabilitation is a complex set of processes usually involving several professional disciplines and aimed at improving quality of life for people facing daily living difficulties caused by chronic disease.
Rehabilitation starts in hospital, but continues after the individual has returned to the community. It is extremely important in terms of making the patient as independent as possible with enormous implications for the physical and psychological wellbeing of the person and cost to the community.

This record is based on the Royal College of Physicians 3rd edition of National Clinical Guidelines for Stroke.⁴

• Rehabilitation after a CVE is a multidisciplinary function. It is also important to remember that the disease affects not just the individual but the whole family.
• Secondary prevention of CVE must not be overlooked.

CVE affects between 174 and 216 per 100,000 population in the UK each year.⁵It tends to be thought of as a disease of the elderly and incidence certainly rises with age but about 30% occur under the age of 65.

• The incidence doubles for every decade after 45 years.
• It rises from 104 per 100,000 per year age 45 to 54 to 1,113 per 100,000 per year age 75 to 84.
• In the younger age group aetiology other than atheroma should be sought and rehabilitation produces different challenges.

It accounts for 11% of all deaths in England and Wales.

After an initial mortality rate of 20% it is estimated that:

• 10% are unable to participate in rehabilitation
• 10% have no residual defect
• 80% are amenable to rehabilitation

These figures do not account for age.
In survivors:

• Maximum neurological recovery has been achieved by 11 weeks in 95%
• Maximum functional recovery by 12½ weeks

By the end of the 1st year:

• 75 to 85% are walking
• 48 to 58% are independent in activities of daily living
• 10 to 29% require residential care

A longitudinal study from 1951 is still quoted as a classic.⁶
Recovery is fastest in the first 3 months but may continue after a year.⁷

• Motor recovery tends to reach a plateau faster than functional recovery and this is often reached at 8 to 12 weeks.
• Arm recovery tends to be less satisfactory than leg recovery. This may be because paresis tends to be denser or it may be that the arm is involved in finer movements that are more demanding. Lack of early improvement and grip strength at 4 weeks has a poor prognosis for functional recovery but measurement of finger tapping is not useful.⁸ Early evaluation of paresis of the arm or leg is a simple way of making a fairly reliable assessment of functional prognosis.⁹
• Language improves unevenly. Different types of aphasia have different prognoses. The worst is global aphasia that usually takes 6 to 12 months, and the best is anomic aphasia. Recovery from aphasia appears to occur independently of recovery from hemiparesis.
• Persistence of poor swallowing ability at 3 weeks carries a high mortality rate, probably because of inhalation.¹⁰

Outcome tends to be worse in those with:

• Diabetes
• Heart disease
• An abnormal ECG
• Previous CVE
• Previous dependence
• Sensory and visual loss
• Severe motor deficit
• Loss of consciousness
• Cognitive defects
• Incontinence

The use of certain drugs may have an adverse outcome on recovery from CVE. These include a few hypotensive agents like clonidine and prazosin, benzodiazepines, phenytoin and barbiturates. Even single doses may have long-term harmful effects.¹¹
Treatment and secondary prevention of CVE would seem to be cost effective.¹²

These contain 21 main recommendations covering all aspects of stroke care and are aimed at improving the quality of care delivered to everyone who has a CVE in the UK, regardless of age, gender, type of stroke, location or any other feature.
The key recommendations around rehabilitation are:⁴

• All patients not suitable for transfer home after completion of their acute diagnosis and treatment should be treated in a specialist stroke rehabilitation unit with expert staff, a multidisciplinary team and educational programmes for staff, patients and carers.
• Patients should have as much therapy as they are willing and able to cope with and should have 45 minutes a day of each appropriate therapy in the early stages.
• All patients discharged home directly after acute treatment but with residual problems, should be followed up by specialist stroke rehabilitation services.
• Hospital services should ensure that patients, families and primary care teams are fully prepared for the patient’s discharge.
• Service commissioners should ensure that they commission services for the full stroke pathway, from prevention through acute care, early rehabilitation, later rehabilitation and initiation of secondary prevention on to palliation, later rehabilitation in the community and long-term support.

This includes disturbance of mood, cognitive impairment and communication.

Disturbance of mood

• This is very common. Problems of communication may make this difficult to assess and it is natural to be upset after such a devastating event.
• Crying and emotional lability is very common.¹³ Patients should be given the opportunity to talk and the social situation should be examined.
• If there is minor depression it is worth watching and waiting but more severe illness requires antidepressants. Pathological crying may respond to citalopram.¹⁴

Cognitive processes

• CVE can disrupt a wide range of cognitive processes. Neglect, apraxia and difficulties with attention, memory and executive function may occur. Different types of cognitive impairment can occur simultaneously.
• Cognitive impairments may adversely affect a person's ability to participate in therapy, perform activities of daily living and live independently.
• They may be confusing and distressing for patients and carers.
• People with impaired executive functions should be taught compensatory techniques,such as using electronic organisers, pagers or written checklists, to increase their ability to perform daily activities

Communication

CVE can affect communication in many ways.

• There may be impaired motor speech production (dysarthria) or impaired planning and execution of motor speech (articulatory dyspraxia) resulting in changes to their intelligibility.
• They may have impaired language skills (aphasia or dysphasia) resulting in difficulties in generating or understanding words, reading and/or writing.
• Every patient with a dominant hemisphere stroke should be assessed for speech and language difficulties by a speech and language therapist, using a reliable and valid method.
• If the patient has aphasia, the staff and relatives should be informed and trained by the speech and language therapist about appropriate communication techniques.

There is strong evidence to support the effect of rehabilitation in terms of improved functional independence and reduced mortality, but some techniques (like treadmill training and robotic-assisted therapy) are costly options, with little evaluation of effects on longer-term function, activity and participation.

• Patients should be assessed by a physiotherapist within 72 hours of admission. Intensive therapy for the upper limb should be considered to improve arm function in patients with mild impairment
• The role of orthotics in the form of braces and supports is controversial and good evidence is required. On the one hand they may improve posture in the short term but they may reduce tone and power. Evidence is contradictory.
• Spasticity may need treatment with baclofen or botulinum toxin. This is gaining popularity.¹⁵ Spasticity should not limit the use of strength training and it does not necessarily impair walking.¹⁶

Pain may result from lack of mobility, perhaps aggravated by existing arthritis.

• People with CVE who have musculoskeletal pain should be assessed by therapists for potential alleviation through exercise, passive movement, better seating or other procedures. They should also be prescribed appropriate analgesics where non-pharmacological treatments are ineffective
• Pain in the shoulder of the affected arm occurs in at least 30% of all patients after CVE. It is associated with severity of disability and is commonest in patients in rehabilitation settings. It is not related to subluxation of the shoulder. Its relationship to handling and positioning remains uncertain. Studies have shown no benefit for shoulder strapping or intra-articular injections of steroid.
• In central, post-CVE neuropathic pain, there may be response to tricyclic antidepressants like amitriptyline or anticonvulsants like gabapentin. Intractable pain requires referral to a specialist clinic.

This term encompasses therapies which are designed to help patients adapt to their impairments, so that they may participate as fully as possible in life. Adaptive therapies include teaching of new skills, the provision of information, the use of problem-solving aids or appliances and environmental modification. Activities of daily living (ADL) include dressing, cooking and shopping.

• Patients with difficulties in ADL should be assessed by an occupational therapist.
• Unexplained persistent difficulties may be due to perceptual impairments.
• The need for special equipment should be assessed on an individual basis and once provided the value and need for equipment should be evaluated on a regular basis.
• Patients should be supplied as soon as possible with all aids, adaptations and equipment they need.
• The suitability and use of equipment should be reviewed over time as needs will change.

The time of transfer from hospital to home, residential or nursing home care is important. There is some research-based evidence that this is often poorly managed.

• Hospital services should have a protocol and local guidelines to ensure that, before discharge occurs patients and families are prepared and fully involved in plans for transfer.
• General practitioners, primary healthcare teams and community social services departments must be informed and all necessary equipment and support should be in place.
• Other recommendations include that early hospital discharge, before the end of acute rehabilitation, should only be undertaken if there is a specialist CVE rehabilitation team in the community and if the patient is able to transfer safely from bed to chair.
• Early discharge from hospital to non-specialist community services should not be undertaken.

(Both these last 2 recommendations are grade A. Early discharge can be cost-effective and without compromising outcomes but it puts more strain on carers. It should probably best be reserved for milder cases).^17,18
Long term management follows discharge from active rehabilitation and usually starts 3 to 6 months after the CVE. Although the benefit of further rehabilitation has been doubted there is now strong evidence that any patient with reduced activity at 6 months or later after CVE should be assessed for a period of further targeted rehabilitation. This may include speech and language therapy. Social rehabilitation should be encouraged.