Vol. 15 Issue 9
Rethinking Stroke Rehab
PTs look to carry research into the clinic
Life for 85-year-old Anna Rumaks of Wilmington, DE, isn't much unlike that of the other 5 million survivors of stroke in this country. Mrs. Rumaks followed the traditional track of care following her stroke in 2002, making notable gains in both physical and cognitive function while in both acute care and subacute rehab.
But Mrs. Rumaks has not been able to return to the house in Newark, DE, that she's called home for the last 10 years, and now lives with her son in the converted one-story suburban home he purchased so she could leave assisted care. A live-in care worker takes care of her daily essential needs.
If not for the financial resources of her family, and their willingness to stay actively involved in her quality of life, Mrs. Rumaks would probably never have left the nursing home.
A Problem of Resources
Given the number of emerging treatment machines and philosophies that are currently gathering an impressive amount of supporting clinical data in the area of stroke rehab, the unfortunate reality is that these therapies are often too cost- or time-prohibitive to reach those who truly need them.
"To put it bluntly, ideas are a dime a dozen," said Peter Levine, BA, PTA, senior research associate at the PM&R department at the Drake Rehabilitation Center, a research arm of the University of Cincinnati. "There is no shortage of therapies and machines that can help people who are discharged from therapy after a stroke. That's why it's so important to track these folks, to find out where they go next. Many times, they are just sent home, where they sit and do nothing, or are sent to a nursing home to rely on others."
Levine acknowledges that emerging therapies must be scrutinized through research study, which is expensive and time consuming. But because pinpointing which therapy will be most effective varies between individuals, Levine advocates a model in which an array of proven techniques is offered to the stroke patient, performed closely by trained and knowledgeable therapists, and paid for by insurance.
"There are a lot of proven therapies out there, but the residual effects of stroke are unique to each individual," said Levine, who fills a rare role as a full-time rehab researcher, alongside noted neurorehab authority Stephen Page, PhD. "Maybe imagery won't help this person, but constraint therapy could. Maybe e-stim machines won't help, so let's try mirror images, or Botox, or a combination of therapies. This is the way I'd like to see folks handled after they're discharged from therapy."
Modified Constraint Therapy
But what looks great in theory rarely holds up once the numbers are crunched. Levine recognizes that payers aren't likely to pursue this ideal without a struggle.
So in the interest of making exciting new developments available to more people, Levine and Dr. Page are prolifically researching and publishing studies that not only reflect the latest science, but that can be delivered to a wide number of deserving patients who need them.
Constraint-induced therapy (CIT), the brainchild of Edward Taub, PhD, of the University of Alabama at Birmingham, has shown remarkable results in patients who have the finances and fortitude to follow the demanding protocol, which includes restraining the unaffected arm for hours at a time and performing strict supervised motor tasks with the affected limb for a period of several weeks.
Recognizing that this therapy may be too cost- and time-prohibitive for most peoplenot to mention the cry from many PTs and OTs that they simply do not have the staffing resources to handle such therapyDr. Page and Levine wondered whether a modified CIT protocol (mCIT), in which time and intensity are geared down, would also result in improvements.
"This was our attempt at making CIT more closely parallel typical outpatient therapy," said Levine, adding that mCIT participants attend 30-minute therapy sessions three times per week for 10 weeks. During the sessions, patients practice everything with their affected arms, along with using the affected limb for all home activities for five hours per day, five days per week.
"We're hoping that we can prove, through fMRI studies, that there is efficacy here," Levine said. "If so, then it's a matter of opening dialogue with managed care, Medicare and Medicaid about getting this funded and getting it out to people. In talking with therapists, we've found that most of them would love to be doing these things. But it has to be paid for."
"This is a significant discovery that will help stroke victims return to productive, viable lifestyles," added Dr. Page, who came to Drake two years ago specifically to open an entire research lab dedicated to studying neurological impairments. "Many positive things are happening with these patients, the most impressive of which is that we are able to track a notable motor improvement in just a 10-week period."
In addition to researching and publishing many mCIT trials, the pair has just completed an imagery study, in which patients sink into deep relaxation with the aid of an audio CD. Dr. Page and Levine want to know if the power of suggestionin which patients imagine performing a task such as reaching for and grasping a cupcombined with actual therapistaided practice of the task, will result in higher outcomes than traditional therapy alone.
Two other studies that Levine is excited to report involve the use of machines. Patients who have only trace amounts of movement in their wrists are practicing on a muscle stimulation machine with a biofeedback component, in which the machine assists the completion of a wrist movement when patients have met a predetermined threshold. If the threshold cannot be met, the machine brings the threshold down to meet the user.
Also just beginning, under the auspices of a Drake physiatrist, is a study that will challenge the traditional theoretical construct that dictates that therapists often focus on just the hemiparetic side in lower extremity stroke rehab.
In this trial, a bilateral incumbent cycle is being recruited to determine whether performing this repetitive motion, which replicates walking, will result in the same mind-body connective improvements that CIT is believed to, thus leading to better balance, walking speed and ease of transfer in its users.
Other Study Areas
The Drake Center isn't alone in cutting edge stroke research. At Burke Rehabilitation Hospital in White Plains, NY, researchers are hard at work examining the muscle patterns that lead to pusher syndrome, a post-stroke phenomenon in which patients have difficulty orienting to midline, and will compensate by actively pushing to their weaker side. As a result, standing, bed mobility, transfers and walking can be impaired.
"This observance is different from someone who is falling because of balance difficulty," explained Teresa Smith, MS, PT, NCS, supervisor of PT on Burke's stroke unit. "The muscles are weaker on one side. So with help from Suzanne Babyar, PhD, PT, and the faculty of Hunter College, we're testing the balance of people with and without this occurrence. We're trying to find out what's happening on the muscular level by observing firing patterns and other stimuli."
The Burke team has developed a pusher syndrome severity scale to more accurately stage the level of impairment than other tools. It has stood up to reliability studies, and the Burke researchers use this scale as the basis for other clinical trials that examine the effectiveness of treatment interventions such as EMG.
And along with Michael Majsak, EdD, PT, Smith is in the data collection phase of a motor learning study in which patients, along with a therapist, observe themselves performing a sit-to-stand task on videotape. "We're trying to uncover their thought process, to learn whether there is a learning effect from watching themselves perform the task," Smith explained.
Finally, Smith and colleagues are conducting an orthotics study, comparing the designs of articulated vs. semi-rigid polypropylene AFOs for effectiveness following a stroke. "We're specifically eyeing people who don't have a very dynamic gait, and attempting to pinpoint at what level there seems to be a difference in efficacy between the designs, and what the potential carryover may be," she said.
Pre-hab: The Future of Stroke Care?
While PTs in research labs are hoping to reshape the face of stroke treatment in the 21st century, it is on the inpatient wards and the skilled nursing units across the land where that newfound knowledge will ultimately be put to the test.
Diana Rich, PT, rehab supervisor at the Advanced Center for Rehabilitation Medicine (ACRM) in Norwalk, CT, feels strongly that the philosophy currently driving the post-stroke care continuum in our health care systems needs to be rethought.
"We want to do what's best for the individual patient, and abandon the old way of automatically sending patients from acute care, to inpatient rehab, then to subacute care and the skilled nursing facility," said Rich, who oversees the rehab of survivors of stroke and other inpatients of Honey Hill Care Center and Norwalk Hospital.
As one example, Rich feels that many of her patients exiting acute care have difficulty tolerating the three-hour therapy requirement necessary for inpatient rehab. So along with ACRM administration, she hopes to begin sending these patients to her SNF unit for a period of weeks before transferring them back to the inpatient neuro unit.
"The goal is to match each patient's functional status with the rehab level that will benefit them most," Rich explained. "If the patient can't tolerate the three hours per day of inpatient rehab therapy, you're essentially wasting the patient's time staying at that level. Why not send the patient to subacute first, to build up to the point that inpatient rehab will have maximum benefit?"
Rich is attempting to back up this idea with hard data. In 1998, ACRM began a tracking mechanism to analyze the FIM scores of its stroke patients throughout the care continuum, and goals were set and pursued at each respective level–from acute care, to inpatient rehab, subacute, home care and outpatient. This philosophy has attracted the attention of Uniform Data System, the developers of the FIM documentation tool, and Rich said her patients display better FIM scores in a shorter time as a result.
Once again, it's a theory that works well on paper, but even Rich acknowledges that this can be difficult for health systems that don't operate all rehab levels, as ACRM does. "There's no question that you need close collaboration with the case manager, nurses, the inpatient therapist and others, and we're lucky to have all those components in one place," she said.
But it can be done. ACRM, for example, does not have a home care component, but with an outcome measures initiative, Rich invited area home care agencies into the ACRM continuum. "We invite them to inservices regarding stroke care, they attend all monthly care plan meetings, we taught them how to be FIM certified, and all outcomes measures are shared," she said.
So while working between health systems will unquestionably require additional planning, Rich said she feels patients will ultimately thank their health care providers. "When this is running smoothly, and information flows between representatives from all levels of service, we really get the sense that we're truly individualizing the care for each patient."
Jonathan Bassett is on staff at ADVANCE, and can be reached at firstname.lastname@example.org