Rehabilitation and life after stroke
Rehabilitation is an integral part of management. A recent guideline authored by the Agency for Health Care Policy and Research outlines the strategies to maximize recovery.
A key to successful rehabilitation is a coordinated team approach that involves active participation of several rehabilitation specialists. Rehabilitation should begin as soon as the patient is medically stable. Education of the patient and family members about stroke and its consequences is an important step in rehabilitation. For example, the family should be informed about the nature of the neurologic impairments. In particular, they should be appraised of any prominent cognitive or emotional sequelae, such as:
- Language impairments
- Sleep disturbances
Patients with major strokes in the nondominant hemisphere may not exhibit much emotionality and may not be aware of other persons’ emotional status.
Physical therapists concentrate on:
- Major motor and sensory impairments of the limbs.
Speech pathologists address:
- Language or articulation impairments
- Disorders of swallowing.
Occupational therapists focus on:
- Fine motor movements of the hands
- Arm function
- Utilization of tools.
Patients should be assessed by these professionals and a treatment plan be tailored to each patients’ individual impairments and abilities. Rehabilitation plans should respect the wishes of the patients and families and the patients’ neurologic and general medical status. It is also important to enlist the assistance of a:
- Social service specialist
- Discharge planner
While the preliminary steps in rehabilitation begin in the acute care setting, a strategy should be developed for continued outpatient and inpatient rehabilitation. In the United States, patients are eligible for intensive inpatient rehabilitation in an acute-care or stand-alone rehabilitation facility if they need at least two rehabilitation modalities (speech, occupational, physical) and if they can tolerate at least 3 hours of treatment daily.
Skilled nursing facilities can provide inpatient rehabilitation for those who cannot tolerate the more intensive inpatient care. Patients with minimal deficits can be treated as outpatients.
Patients are assessed at regular intervals during their recovery from stroke. The types of and settings for rehabilitation are adjusted in response to the patients’ conditions. The goal will be for the individuals to be as independent as possible. As the patients recover, the following issues should be addressed:
- Returning to work
- Driving an automobile.
The patients’ living quarters may need to be modified to permit a return to home. In order to accommodate the patients’ impairments, alterations should be made to such facilities as:
Depression after stroke
Depression is common following stroke; the mood disorder can be an emotional reaction to the sudden and devastating change in the patients’ lives and independence.
Depression after stroke is also an organic consequence of the brain injury. Severe depression is more common with strokes in the dominant hemisphere. Less commonly, stroke can cause mania. Depression can hamper recovery from the stroke and limit the efficacy of rehabilitation.
Both counseling and the use of antidepressant medications often are needed. Antidepressant medications, either tricyclic drugs or serotonin agonists, in particular, are helpful. While major tranquilizers, such as haloperidol, may slow recovery from a stroke, some reports suggest that amphetamines may potentiate recovery.
In an era of managed care, plans for management after discharge from the acute-care setting should begin as soon as the patients are medically stable. Most institutions have a care manager/discharge planner who can provide assistance in arranging for continued treatment after hospitalization. The goal should be to provide continued long-term medical treatment and rehabilitation that meets the patients’ and families’ wishes and needs.