Mednotes

L24 RDA Stroke recovery

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tagsrda, lecture
aliasesL24 RDA Stroke recovery

21 min read

Overview

This lecture covers recovery and rehabilitation after Stroke rather than acute management. It sets out what recovery is made of (restitution, substitution, compensation), the aims of rehabilitation, how stroke type is classified and what each type predicts for mortality, function and recurrence, how spontaneous recovery behaves and what predicts outcome, how rehabilitation is delivered (stroke teams, stroke units, early supported discharge) and measured (FIM, Modified Rankin Scale), the prediction tools PREP2 and TWIST, the common challenges to recovery with the team member to refer to for each, and finally life after stroke, where supported self-management carries the person’s long-term recovery.

Stroke recovery: what it is made of

Stroke recovery is a complex process combining spontaneous and learning-dependent processes:

  • Restitution: restoring the functionality of damaged neural tissue.
  • Substitution: reorganisation of partly spared neural pathways to relearn lost functions.
  • Compensation: improvement of the disparity between the impaired skills of the patient and the demands of their environment.

Rehabilitation is framed as a journey the person takes for the rest of their life, towards a “new me”. A patient quote in the lecture describes life after stroke as picking up the supermarket trolley with the crook wheel every single morning, so that all day you are working around your disabilities.

Aims of stroke recovery and rehabilitation

The aims split into an acute phase (emergency management; investigation and treatment) and rehabilitation. The lecture explicitly sets acute investigation and treatment aside (struck through on the slide) and focuses on rehabilitation.

Rehabilitation aims to optimise:

  • Community reintegration
  • Participation
  • Quality of life
  • Health

This is achieved by:

  • Addressing body structure and function limitations as appropriate (the “impairments”)
  • Optimising function (activity)
  • Adaptation, as appropriate
  • Enabling participation and community reintegration
  • Supporting and enhancing the person and their whanau’s self-efficacy (confidence) and skills to self-manage their recovery
  • Maximising health

These map onto the ICF framework shown on the slide: a health condition (disorder or disease) sits above body functions and structure, activity, and participation, which are mutually linked to each other and each connected below to environmental factors and personal factors.

Types of stroke and what they predict

Overall distribution:

  • Ischaemic stroke: about 80%, classified by syndrome using the Oxfordshire Community Stroke Project (OCSP) classification
  • Haemorrhagic stroke: about 15%, of which intracerebral about 10% and subarachnoid about 5%
  • Not otherwise specified: about 5%

OCSP classification of ischaemic stroke:

TypeIn fullDefinitionMortality at 6 monthsFunctional outcomeRisk of recurrence
TACITotal anterior circulation infarctHemiparesis (2/3 of face, arm and leg) and 2 cortical signsHigh, 56%Poor, <5% independentLower
PACIPartial anterior circulation infarctIn between TACI and LACI10%55% independentHigh early
LACILacunar infarctPure motor, pure sensory, or sensory-motor stroke7%66% independentConstant over time
POCIPosterior circulation infarctBrainstem and/or occipital signs14%68% independentHigh early and continues

The lecture highlights each of the mortality, functional outcome and recurrence columns in turn: TACI has by far the worst mortality and functional outcome but the lowest recurrence risk, LACI and POCI the best functional outcomes, and PACI and POCI a high early recurrence risk.

Infarction versus haemorrhage: the jury is out. Recent studies show little difference in outcome after acute rehabilitation at 3 and 6 month follow-up (Oosterveer et al. 2022; Paolucci et al. 2003; Perna and Temple 2015; Salvadori et al. 2020).

Local data from a Christchurch stroke unit shows admissions by type: PACI 346 (28%), LACI 233 (19%), POCI 222 (18%), TACI 134 (11%), haemorrhage 108 (9%), TIA 105 (9%), unknown or other 68 (6%), multiple emboli 3 (0%). Discharge destination: home 66% (the highlighted figure), HLOC 12%, died 8%, rehabilitation hospital 7%, family 4%, transferred out 3%.

Predicted recovery after stroke

Key points:

  • Most strokes show some spontaneous recovery, and most of it occurs inside 3 months.
  • Rule of thumb: impairment at presentation predicts impairment at discharge.
  • Post-stroke, patients recover 70% of the movement (at an impairment level) that they lost due to the stroke (Prabhakaran et al. 2008).
  • Stroke units improve outcomes.
  • Recovery takes time.

Spontaneous recovery and neuroplasticity (Cramer 2008):

  • Some degree of spontaneous behavioural recovery is usually seen in the weeks after stroke onset.
  • Variability in recovery is substantial across patients.
  • Recovery is slowest in those who will ultimately have less successful outcomes.
  • Generally, the best outcomes are associated with the greatest return of the normal state of brain functional organisation.
  • Reorganisation of surviving CNS supports behavioural recovery, through changes in interhemispheric lateralisation, activity of association cortices linked to injured zones, and organisation of cortical representational maps.

Variables that influence stroke recovery (Cramer 2008): infarct size; infarct location; prestroke medical comorbidities; prestroke disability; prestroke experience and education; age; severity of initial stroke deficits; breadth of stroke deficits; acute stroke interventions; medications during the stroke recovery period; amount of post-stroke therapy; type(s) of post-stroke therapy; medical complications after stroke; socioeconomic status; depression; caregiver status; genetics (listed with a question mark).

Outcome predictors:

  • Good: social interaction; previous independence; absence of depression; improvements at 2 weeks in speech, motor function and activities of living.
  • Poor: increasing age; confusion, incontinence, neglect or conjugate gaze abnormality at 2 weeks.

Functional recovery curves plot function against time: an acute drop from 100% function at the time of stroke, then a bracketed period of the first 2 to 3 months in which most change happens, with several different trajectories (better, moderate, and one with a late dip and recovery pattern) illustrating how variable recovery is between patients.

Modes of delivery: teams, stroke units, early supported discharge

Stroke teams are vital to stroke rehabilitation. Members include physiotherapy, occupational therapy, speech and language therapy, social work, neuropsychology, medical, nursing, dietician, pharmacist, the Stroke Foundation, and family/whanau. The team is interdisciplinary and referral should be immediate.

Stroke units: organised stroke unit care is provided by interprofessional teams that exclusively manage patients with stroke, delivered in a ward dedicated to stroke, with a mobile stroke team, or within a generic disability service (mixed rehabilitation ward). Conclusions of the Stroke Unit Trialists’ Collaboration (Cochrane 2013):

  • Patients receiving organised inpatient care in a stroke unit are more likely to be alive, independent and living at home one year after the stroke.
  • Benefits were most apparent in units based in a discrete ward.
  • There was no systematic increase in length of inpatient stay.

Early supported discharge (Langhorne et al. 2017): a community stroke rehabilitation service giving earlier return home, delivered by an interdisciplinary team, and best in mild to moderate stroke.

Measuring functional outcome

Outcomes are tracked nationally through the Australasian Rehabilitation Outcomes Centre (AROC), the national rehabilitation medicine clinical registry of Australia and New Zealand, whose data-submitting members include most NZ hospitals and rehabilitation units (for example Burwood, Dunedin Hospital OPH, Auckland City Hospital, Middlemore ATR Unit), paediatric hospitals across NZ and the Australian states, and non-facility members such as ACC (NZ) and state health departments.

FIM (Functional Independence Measure)

  • A basic indicator of severity of disability, used to track change in functional ability across a rehabilitation episode, and a key outcome measure of rehabilitation.
  • 18 items, each scored on a seven-point ordinal scale; higher item score means more independent performance.
  • Total score ranges from 18 to 126.
  • Items split into 13 motor items and 5 cognitive items, giving a motor subtotal, a cognitive subtotal and a total FIM score, recorded at admission, discharge and follow-up.
  • Domains: self-care (eating, grooming, bathing, dressing upper body, dressing lower body, toileting); sphincter control (bladder, bowel management); transfers (bed/chair/wheelchair, toilet, tub/shower); locomotion (walk/wheelchair, stairs); communication (comprehension, expression); social cognition (social interaction, problem solving, memory).
  • Scale levels: independent = 7 complete independence, 6 modified independence with a device (no helper); modified dependence = 5 supervision (100%+), 4 minimal assist (75%+), 3 moderate assist (50%+); complete dependence = 2 maximal assist (25%+), 1 total assist (<25%) (helper required).
  • Leave no blanks; enter 1 if the patient is not testable due to risk.

Modified Rankin Scale (mRS), scored 0 to 6

  • 0: no symptoms at all.
  • 1: no significant disability despite symptoms; able to carry out all usual duties and activities.
  • 2: slight disability; unable to carry out all previous activities, but able to look after own affairs without assistance.
  • 3: moderate disability; requires some help, but able to walk without assistance.
  • 4: moderately severe disability; unable to walk without assistance and unable to attend to own bodily needs without assistance.
  • 5: severe disability; bedridden, incontinent, requiring constant nursing care and attention.
  • 6: dead.

Predicting motor recovery: PREP2 and TWIST

Recovery of motor function differs by phase (Hale and Piggot 2005): in the acute stage patients appear to most want to walk again, linked to discharge; inpatient rehabilitation is focused on “preparation for discharge”, meaning mobility; on discharge, home-based stroke rehabilitation is focused on “preparation for life”, meaning upper limb function.

PREP algorithm (upper limb recovery) (Stinear 2010; Stinear et al. 2012). Sequential assessment predicting potential for upper limb recovery, each category carrying a rehabilitation focus:

  1. At 72 hours, test shoulder abduction and finger extension, each scored out of 5 and summed to give the SAFE score.
  2. SAFE 8 to 10 = Complete potential; rehabilitation focus is to promote normal use.
  3. SAFE 5 to 7 = Notable potential; focus is to promote function.
  4. SAFE 0 to 4 goes on to TMS at 5 to 7 days for the presence of motor evoked potentials (MEPs). MEPs present = Notable.
  5. No MEPs goes on to MRI at 10 to 14 days for the asymmetry index. Asymmetry index <0.15 = Limited potential, focus is to promote movement; >0.15 = None, focus is to promote compensation.

TWIST tool (Smith et al. 2022, 2024). Predicts time to walk independently after stroke, with all assessments made at 1 week post-stroke, giving three outcome categories (6 weeks, 12 weeks, or dependent at 12 weeks):

  1. Trunk Control Test (TCT, out of 100) > 40: yes gives independent walking at 6 weeks.
  2. If TCT is not > 40, test hip extension strength (MRC grade). Grade >= 3 gives 12 weeks.
  3. Hip extension below grade 3 predicts dependent.

TWIST is more accurate than physiotherapists at predicting whether a patient will achieve independent walking by 4, 6 or 9 weeks post-stroke, but not for 16 or 26 weeks. It may be useful to inform early rehabilitation and discharge planning.

Challenges to recovery, and who to refer to

Motor and sensory (physiotherapy and occupational therapy aids include hoists and slings, rollator frames, ankle-foot orthoses for foot drop, reachers, grab rails, crutches, wheelchairs and raised or commode-style chairs):

  • Motor: weakness impairing mobility or function; altered muscle tone, which can vary between spasticity and flaccidity; muscle contractures (shortening).
  • Sensory: loss of proprioception affecting gait and balance; sensory neglect; agnosias.
  • Apraxias.

Pain, vision and hearing:

  • Pain: central post-stroke pain syndrome; shoulder subluxation. Refer to physiotherapy, and medication/pharmacist.
  • Vision and hearing: hemianopia, quadrantanopia, neglect, hearing loss. Refer to occupational therapy and for specific visual testing.

Emotional and dyspraxia:

  • Emotional barriers: grief, anxiety, depression (20 to 30%), delirium, cognitive change, “emotionalism”. Refer to occupational therapy and neuropsychology.
  • Dyspraxia/sequencing: impaired programming and execution of motor function, affecting gait, speech and dressing; can be due to specific cortical functions. Refer to physiotherapy and occupational therapy.

Left-sided neglect and constructional apraxia are demonstrated by a clinical test image: a hand-drawn circle with an attempted line-cancellation and number-writing task, with the numbers 1 to 8 attempted and becoming increasingly distorted toward one side, and the drawings clustered to one side of the circle.

Warning

The background journal text on that scanned neglect/apraxia image (a line-bisection test description) is illegible in the slides and could not be transcribed.

Swallow and nutrition (refer to SALT, nursing, dietician, dentist):

  • Swallow is impaired in up to 50% of strokes; most recover in 2 to 3 weeks.
  • Aspiration risks; oral hygiene may also help.
  • Nutrition is impaired for multiple reasons, but an unsafe swallow demands alternative feeding strategies, with nasogastric or PEG feeding an option.
  • Dental hygiene matters.

Speech (refer to speech and language therapy, SALT):

  • Dysarthria, dysphasia (expressive and receptive), dysphonia.
  • Language problems need to be recognised: there are classic cases of aphasia being labelled “dementia”.
  • Speech therapy has an important role in assessing speech recovery and swallow strategies.

Agnosia, the inability to interpret sensory information (refer to occupational therapy, neuropsychology):

  • Tactile: inability to discern an object without a visual cue.
  • Sensory: neglect.
  • Left/right agnosia.
  • Body image: for example “missing limb” or “limb not belonging to me”.

Physical activity and health

The lecture flags physical activity as extremely important, quoting the American Heart Association scientific statement (Gordon et al. 2004): physical activity remains a cornerstone in the current armamentarium of risk-reduction therapies for the prevention and treatment of stroke, and the fervour of the physician’s recommendation appears to be the single most powerful predictor of participation in an exercise-based risk reduction programme. The referral for this is physiotherapy.

Key points from the AHA recommendations table:

  • Stroke survivors: improved short-term survival has produced a large survivor population (>4,700,000 in the US); recurrent stroke and cardiovascular disease are leading causes of mortality; physical activity is a cornerstone of risk factor management; activity intolerance is common, especially in the elderly; stroke patients achieve lower maximal workloads, heart rate and blood pressure responses than controls; energy expenditure during walking in hemiplegic patients is often up to twice that of able-bodied people at the same submaximal speed.
  • Benefits of aerobic conditioning: survivors benefit from counselling on activity and exercise training; aggressive rehabilitation beyond the usual 6-month period increases aerobic capacity and sensorimotor function; aerobic exercise programmes can improve cardiovascular risk factors; stroke risk can be reduced with regular leisure-time physical activity; exercise trainability may be comparable to age-matched healthy counterparts.
  • Pre-exercise evaluation: recommended for all stroke survivors, comprising history, physical examination and usually graded exercise testing with ECG, with the testing mode adapted to the survivor’s needs (handrails, arm cycle, arm-leg or leg cycle ergometry).
  • Exercise programming: treadmill walking combined with resistance, flexibility and neuromuscular training is advantageous; an individual approach is needed given comorbidities, neurological deficits and emotional barriers; light-to-moderate exercise with greater frequency and duration for those unable to perform graded testing; subsets of survivors (depression, fatigue syndrome, poor family support, communication, cognitive or motor deficits) need further evaluation and specialised programming; family support and social isolation should be addressed; exercise recommendations should form one component of a comprehensive stroke and cardiovascular risk reduction programme.

Life after stroke and supported self-management

The long-term aim is supporting and enhancing the person and their whanau’s self-efficacy (confidence) and skills to self-manage their recovery.

The challenge for rehabilitation runs as a sequence: rehabilitation involves less time in hospital, then early discharge and community services, but rehabilitation services are finite, producing a sense of abandonment after discharge, so stroke survivors need to be supported to optimise their continued recovery.

Supported self-management means not leaving people to “get on with it” on their own, but supporting them to build the skills and behaviours needed to live with their long-term condition.

Continuum of self-management interventions (Health Foundation 2011), plotted on two axes, focus on self-efficacy versus focus on technical skills, and information provision versus behaviour change. The interventions plotted are motivational interviewing, telephone coaching, goal setting, care plans, active group education, patient-held records, online courses, group education, electronic information, self-monitoring and written information.

Bridges Stroke Self-Management Programme: helps individuals with stroke take control of their rehabilitation and daily lives. It works through multidisciplinary/interdisciplinary team training and a stroke workbook, both feeding into integrating self-management support into daily practice.

Take Charge (Harwood et al. 2012; Fu et al. 2020): a simple, low-cost intervention in the community phase of stroke recovery aiming to promote self-directed rehabilitation, which improved outcomes in a randomised controlled trial. The Take Charge Session is an 80-minute individualised assessment with a structured risk factor and activities of daily living assessment, designed to engage the patient and their family in the process of recovery and facilitate a process where they identify for themselves areas where they can make progress and set personal goals.

Back home: issues to anticipate are carer stress, isolation, depression, driving (or alternatives), employment and hobbies. Considering these before discharge helps develop strategies to manage them. Support comes from the inter-professional team, the Stroke Foundation, the Carer’s Society, stroke clubs, the community and whanau.

Important

The case of Mrs AC frames the lecture: 72 years old, with type II diabetes and treated hypertension, collapsed in her kitchen and was found by her husband with right-sided paralysis and incomprehensible speech; emergency services arrived within 10 minutes. FAST is the stroke-recognition tool referenced.

Self-test

  1. Define restitution, substitution and compensation as components of stroke recovery.
  2. List the four outcomes that stroke rehabilitation aims to optimise.
  3. State the approximate proportions of ischaemic, haemorrhagic (with its subtypes) and not-otherwise-specified stroke.
  4. Describe the OCSP definition of a TACI and give its 6-month mortality and functional outcome.
  5. Distinguish TACI from LACI in terms of recurrence risk and functional outcome.
  6. What proportion of lost movement, at an impairment level, do patients recover post-stroke, and within what period does most spontaneous recovery occur?
  7. List four good and two poor outcome predictors after stroke.
  8. Explain the “rule of thumb” relating presentation to discharge, and why this matters for planning.
  9. Describe the three delivery settings that count as organised stroke unit care, and state the main outcome benefit found by the Cochrane review.
  10. For whom is early supported discharge best suited, and what does it provide?
  11. Describe the structure and scoring range of the FIM instrument.
  12. What FIM level corresponds to a score of 4, and what does a score of 1 mean?
  13. Distinguish Modified Rankin Scale scores 3 and 4.
  14. Describe the steps of the PREP algorithm from 72 hours to 14 days, with the SAFE score cut-offs.
  15. Predict the rehabilitation focus for a patient with a SAFE score of 2, no MEPs on TMS, and an MRI asymmetry index of 0.2.
  16. Describe the steps of the TWIST algorithm and the timing of its assessments.
  17. What is the stated limitation of TWIST’s accuracy relative to physiotherapists?
  18. List the motor and sensory challenges to recovery, and name the two therapy disciplines they are referred to.
  19. What proportion of stroke survivors experience depression, and to whom are emotional barriers referred?
  20. What proportion of strokes impair swallow, how quickly do most recover, and what feeding options are given for an unsafe swallow?
  21. Distinguish dysarthria, dysphasia and dysphonia, and state the risk of failing to recognise language problems.
  22. Define agnosia and list its forms as given.
  23. According to the AHA statement, what is the single most powerful predictor of participation in an exercise-based risk reduction programme?
  24. Explain why energy expenditure during walking is a particular problem for hemiplegic patients.
  25. Describe what the Take Charge Session involves.
  26. Explain the sequence of challenges that leads to the conclusion that stroke survivors need continued support after discharge.
  27. Integrative: a 72-year-old presents with right-sided paralysis and incomprehensible speech. Explain how you would classify the stroke, what tools you would use to predict upper limb and walking recovery, and which team members you would involve as she moves from ward to home.

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