FRAMEWORK FOR

REHABILITATION
• Rehabilitation has an important role in
reducing disability and promoting
independence.
• Complications of stroke can be reduced or
prevented while quality of life is promoted
• Optimal management involves a coordinated
interdisciplinary team to oversee a
comprehensive plan of care (POC).
• physician,
• nurse,
• physical therapist,
• Occupational therapist,
• pathologist
• social worker
• neuropsychologist,
• nutritionist,
• recreational therapist
• vocational counselor
• The patient/client, family,
• caregivers are also important members of the
team and should be involved in all decision
making regarding the POC.
• Interdisciplinary communication is critical for
effective team function and occurs through
case conferences, informal interactions,
patient care rounds, and patient/client family
meetings.
• Effective case management also includes a
coordinated education plan and accurate and
effective documentation.
• It is critical for the team to provide a
supportive environment to assist patients and
their family members in their adjustment to
this life-altering event.
• The National Stroke Association has instituted a
process to certify stroke rehabilitation specialists.
The designation of clinical stroke rehabilitation
specialist (CSRS) ensures that therapists are expert
stroke clinicians.
• The rehabilitation POC considers the patient’s
history, course, and symptoms, together with
impairments, activity limitations, and participation
restrictions. Of equal importance are the patient’s
abilities (assets), priorities, and resources,
including family, home, and community resources.
• Interventions are restorative (aimed at improving
impairments, activity limitations, and participation
restrictions), preventive (aimed at mini -mizing
potential complications and indirect impairments),
and compensatory (aimed at modifying the task,
activity, or environment to improve function).
• The overall focus for patients with moderate to
severe stroke is on long-range planning, with
consideration of anticipated episodes of care that
typically include hospital based care (acute care,
inpatient rehabilitation), outpatient rehabilitation,
and home/community-based care.
• A therapeutic care continuum refers to the
complete range of care, services, and/or programs
provided for a patient. For patients with stroke, the
care continuum is based on two important factors:
(1) stage of recovery; and (2) degree of disability
resulting from stroke.
 Acute Phase
• Low-intensity rehabilitation is begun in the
acute care facility as soon as the patient is
medically stabilized, typically within 72 hours.
• The patient may be first seen in a neurological
intensive care unit (ICU) or specialized stroke
care unit in a facility that also provides
comprehensive rehabilitation services.
• Evidence supports the benefits of specialized
stroke units in improving functional outcomes
when compared to patients not receiving
specialized care. Individuals who received this
care were more likely to be alive,
independent, and living at home 1 year after
stroke.
• The therapist needs to be aware of the patient’s
current status by reviewing the medical record
and communicating with the medical team.
During acute care, the therapist assists in ongoing
monitoring of the patient’s recovery and is alert
for significant changes in the patient’s status
(e.g., changes in vital signs [heart rate (HR), blood
pressure (BP, or respiratory rate (RR)], drop in O2
saturation levels, skin changes, alterations in
mental status and consciousness, and so forth).
• Early mobilization prevents or minimizes the
harmful effects of bed rest and
deconditioning. It may also increase the
patient’s level of consciousness and foster
return to independence. Functional
reorganization is promoted through early
stimulation and use of the hemiparetic side.
• Learned nonuse of the hemiparetic extremities
and maladaptive patterns of movement are
minimized. Mental deterioration, depression,
and apathy can be reduced through the
fostering of a positive outlook toward the
rehabilitation process.
• Interventions include but are not limited to
positioning, functional mobility training (e.g.,
bed mobility, sitting, transfers, locomotion),
ADL training, range of motion (ROM),
splinting, and positioning.
• Instruction, education, and training of patients
and their families/caregivers is initiated early
regarding current condition (pathophysiology,
impairments, activity limitations) and risk
factors for disability
• It includes an overview of the recovery
process, the rehabilitation POC, and expected
transitions across care settings. It is important
to remember that this is a highly stressful time
for patients and families and information
needs to be graded in appropriate amounts
and repeated and reinforced throughout the
course of treatment.
• The therapist needs to establish effective
communication. This includes speaking to the
patient in a normal tone and volume, speaking
slowly and giving the patient enough time to
respond, using simple yes/no questions,and
using gesture and tactile cues whenever
appropriate.
• Current trends are toward shorter acute care
hospital stays (average stay is about 5 days).1
However, early discharge has resulted in an
increase in the number of serious medical
complications seen during subacute
rehabilitation or at home.
• These complications may result in delays
during active rehabilitation and, for some,
temporary cessation of therapy or transfer
back to the acute hospital until medical
complications are resolved. Therapists need to
be vigilant in monitoring patients for potential
risk of complications and medical emergencies
(e.g., cardiac arrhythmias, DVT, uncontrolled
BP, recurrent stroke, and so forth).
 Subacute Phase
• Patients with moderate or severe residual
impairments or activity limitations may
benefit from intensive inpatient rehabilitation
provided in a freestanding rehabilitation
facility or in a rehabilitation unit within the
acute care hospital
• Evidence supports the value of physical therapy in
producing improved functional outcomes for patients
with stroke.
• Patients are referred to inpatient rehabilitation if they
can tolerate an intensity of services consisting of two
or more rehabilitation disciplines, 6 days a week for a
minimum of 3 hours of active rehabilitation per day. If
the patient requires less intensive services, transfer to
a transitional care unit (TCU) within a skilled nursing
facility is instituted. Here rehabilitation services are
less intense, ranging from 60 to 90 minutes of therapy
services 5 days per week.
• The timing of rehabilitation services is a
important factor in predicting outcome.
• A shorter onset-to-admission interval, within
the first 20 days, has been shown to
significantly improve functional outcomes
when compared to longer intervals.
 Chronic Phase
• Rehabilitation services during the chronic phase,
generally defined to be more than 6 months post-
stroke, are typically delivered in an outpatient
rehabilitation facility, in a community setting, or
at home.
• Outpatient services are prescribed for the patient
who is discharged from inpatient rehabilitation, is
in need of continuing rehabilitation, and can
enter and exit the home with ease.
• Many of the interventions begun during
inpatient rehabilitation are continued and
progressed in order to sustain the gains made
and improve functional performance.
• Other interventions, including constraint-
induced movement therapy (CIMT), bilateral
training, virtual reality training, an
electromechanical-assisted walking, may be
implemented.
• Some patients with mild involvement who did
not require intense inpatient rehabilitation
also benefit from outpatient rehabilitation
services.
• The intensity of services provided varies but is
generally less than that of inpatient
rehabilitation (e.g., 60 to 90 minutes per visit,
two to three times per week).
• Outpatient intervention programs that target
progressive improvements in flexibility, strength,
balance, locomotion, endurance, and UE function
have been shown to be effective in producing
meaningful outcomes.
• The patient and family are instructed in a home
exercise program (HEP) and educated about the
importance of maintaining exercise levels, health
promotion, fall prevention, and safety.
• The patient may receive home care rehabilitation
services, typically for the patient who is unable to
exit the home independently.
• Finally, the patient should be assisted in resuming
participation in community and recreational
activities. With increasing activity levels, it is
important to monitor the patient’s endurance
levels carefully and provide instruction in activity
pacing and energy conservation techniques as
needed.
• Community fitness programs51 and water-based
activities have been shown to improve function
after stroke. A small number of stroke survivors
can be evaluated and assisted in return to work.
• As the patient becomes successful in the home
and community environments, services should be
gradually phased out. Follow-up visits at periodic
intervals are recommended to identify problems
as they develop and to ensure long-term
maintenance of function.
• Additional research is also needed to
investigate the effect of rehabilitation
interventions on quality of life, participation,
and overall cost-benefit ratios, and the
differential effects of stroke severity, latency,
and age.