Recovery after a stroke can feel like a journey with an unclear path. Often patients are not aware of the services available to them that can maximize their recovery throughout the continuum of care.
This is unfortunate, since evidence in the literature demonstrates that recovery after a neurologic event is lifelong. The results of the Locomotor Experience Applied Post Stroke (LEAPS) Trial, the largest stroke rehabilitation study conducted in the United States, funded by the National Institutes of Health, were announced at the American Stroke Association’s International Stroke Conference in 2011, in Los Angeles. The study found that patients continued to demonstrate improvement in gait up to 1 year after stroke. The LEAPS Trial provides evidence that recovery does not stop after 6 months post-stroke.
The current continuum of care after a person experiences a stroke allows a patient on average to spend 2 to 3 weeks in an inpatient rehabilitation facility, discharge to home with home care for 2 to 3 months, and transition to outpatient for an additional 2 to 3 months, thus providing formal rehabilitation services for a total of 3 to 6 months despite the fact that poststroke recovery is still occurring. Throughout this continuum, the patient often works with various clinicians, relying on them to communicate and coordinate the rehabilitation plan. Timely assessments and appropriate interventions may be delayed or even missed in a fragmented continuum. Certainly, there are many patients who move through the process smoothly and swiftly with positive outcomes. However, there are many patients who become lost and do not reach maximum functional recovery. After rehabilitation services end, patients often experience complications or secondary issues related to their event, such as increased tone, abnormal gait, urinary and bowel difficulties, depression, or pain, all of which can lead to a significant change in function, independence, and quality of life.
The Neurorehabilitation Clinic at Braintree Rehabilitation Hospital, Braintree, Mass, was established to focus on the continuum of care as it relates to a person’s function, enabling patients to participate in a comprehensive rehabilitation program instead of one that is fragmented and of varying quality. The clinical team consists of a board-certified physician specializing in physical medicine and rehabilitation, and a physical therapist. Both of these clinicians specialize in neurologic disorders and understand their complexity and subsequent complications. In collaboration with the patient’s primary care physician and/or community neurologist, the clinicians work with patients to create a road map for a comprehensive rehabilitation plan that emphasizes functional independence.
The most common neurological diagnoses that patients are evaluated for in the clinic are: stroke, acquired brain injury, spinal cord injury, multiple sclerosis, and Parkinson’s disease. The neurorehabilitation assessment uses objective impairment level and performance-related outcome measures to identify potential complications related to function after a neurologic event. Complications such as spasticity, shoulder pain, complex regional pain syndrome, gait dysfunction, issues with orthotic devices, dysarthria, dysphagia, depression, bladder dysfunction, positioning, decreased mobility, and decreased ability to perform activities of daily living are all potential concerns and barriers to independence, recovery, and quality of life.
There is evidence in the literature to support the importance of an outpatient clinic focused on impairments and how they directly affect functional independence. In order to determine the timeline of neurologic recovery after a stroke, Jorgensen et al1 looked at 1,197 patients who experienced an acute stroke and were admitted to an inpatient stroke unit. In the study, the Scandinavian Neurologic Stroke Scale was used to measure neurologic recovery on admission, weekly, at the end of rehabilitation, and finally 6 months post-stroke. The stroke scale examines level of consciousness; eye movement; power in the arms, hands, and legs; orientation; aphasia; facial paresis; and gait. The study also assessed recovery of function with activities of daily living (ADLs) on admission, weekly, at the end of rehabilitation, and finally 6 months post-stroke using the Barthel Index.
The results of the study support the importance of a follow-up assessment related to function in patients who have suffered a stroke. Moreover, the study demonstrates that optimal recovery takes place well after patients have been discharged from an acute inpatient rehabilitation setting. For instance, the current national average length of stay in an inpatient rehabilitation hospital is 15 days (2 weeks). However, after 6 months following a stroke, 95% of the patients who experienced a moderate stroke obtained their best ADL function within 13 weeks. What’s more, 95% of the patients who experienced a severe stroke obtained their best ADL function within 17 weeks.
In a separate study, Wolf et al2 identified that up to 85% of stroke survivors experience hemiparesis in an upper extremity. That same study found between 55% and 75% of survivors continue to experience upper extremity functional limitations 3 to 6 months after their stroke.2 Wolf observed 222 patients who experienced a stroke within the previous 3 to 9 months. The patients participated in a 2-week program of constraint induced movement therapy of the hemiparetic upper extremity. The participants realized statistically significant improvements in motor arm function, demonstrating that recovery after stroke is to be expected over a continuum.
Based in part on this revealing research, we established the Neurorehabilitation Clinic at Braintree Rehabilitation Hospital in order to help patients maximize their overall level of function by providing them with appropriate resources or services at optimal times throughout their recovery. In addition to occupational and physical therapies (which include wheelchair and seating/positioning specialists), the clinic offers bracing and orthotics, return to driving sessions, and speech-language pathology (which includes swallow evaluations).
The clinic also houses an array of cutting-edge technologies and treatments to assist individuals suffering from stroke or neurological conditions, including ultrasound diagnostics, electromyography (EMG), ultrasound-guided steroid and Botox injections, functional electrical stimulation (FES) devices, FES bikes, neurorobotic solutions, low-level electrical stimulation for foot drop and hand paralysis, and body weight-supported treadmill training.
A case management program covers transportation, vocational rehab, and insurance/benefits issues, and also makes arrangements for psychological and neuropsychological services.
The clinic has successfully collaborated with community neurologists, primary care physicians, therapists, and other health care providers to optimize neurologic recovery and functional independence. The clinic acts as a checkpoint along the road to recovery to evaluate the treatment plan as it relates to function, and assists patients in achieving maximum functional independence throughout recovery. RM
Daniel Parkinson, PT, MBA, is director of Rehabilitation Services at Braintree Rehabilitation Hospital in Braintree, Mass. Zachary Bohart, MD, MS, is board certified in physical medicine and rehabilitation and is director of Braintree Rehabilitation Hospital’s Neurorehabilitation Clinic. For more information contact .
- Jorgensen HS, Nakayama H, Raaschou HO, Vive-Larsen J, Stoier M, Olsen TS. Outcome and time course of recovery in stroke. Part II: Time course of recovery. The Copenhagen Stroke Study. Arch Phys Med Rehabil. 1995;76:406-412.
- Wolf SL, Winstein CJ, Miller JP, et al; EXCITE investigators. Effect of constraint-induced movement therapy on upper extremity function 3 to 9 months after stroke: the EXCITE randomized clinical trial. JAMA. 2006;296:2095-2104.