Decreasing Stroke Deficits

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April/May 2000

By Patricia S. Pohl, PhD, PT, and Lorie G. Richards, PhD, OTR

Developing intervention programs and assessing outcomes.

From left: Particia S. Pohl, PhD, PT and Lorie G. Richards PhD, OTR

Each year in the United States more than 730,000 individuals suffer a stroke. Many of those who survive are left with stroke-related limitations in activity and life participation.1 There is an increasing amount of evidence that rehabilitation can make a difference for individuals poststroke by improving neurologic and functional recovery beyond what occurs spontaneously. Ironically, even as the evidence increases, the duration of rehabilitation allotted for stroke patients is decreasing.

Compensation vs Restoration

Each day clinicians are faced with a decision: whether to focus their rehabilitative efforts on compensation or restoration. Compensating is a substitution—a new and different behavior to accomplish some functional goal or the environment and tasks are adapted to attain our goal. Restoration, on the other hand, is a reinstatement of previous behaviors.

Some guidance regarding intervention is available by assessing stroke severity. Severe disability on admission is one of the primary predictors of poor functional outcome. The Orpington Prognostic Scale is a screening tool to assess stroke severity. It screens for sensory-motor, mobility, and cognitive impairments. Because the cognitive section is given verbally and requires verbal responding, language is also screened. It takes only 5-10 minutes to complete, compared to more detailed measures of stroke severity such as the NIH Stroke Scale. The Orpington Prognostic Scale, given within 14 days after stroke, is a better predictor of disability for those with mild and moderate stroke than the NIH Stroke Scale as measured by the Barthel Activities of Daily Living Index and self-reported physical functioning as measured by the SF-36 Physical Functioning Index.2 Those with mild and moderate stroke can be expected to show the most rapid improvements in functional abilities within the first 30 days poststroke. Those with severe stroke have slower and more limited recovery. Compensation techniques may be particularly helpful to individuals with severe stroke who may not be able to regain adequate sensory-motor function to perform daily activities.

Should we attempt to restore previous motor skills or teach adaptations? There is no simple formula that dictates the correct approach. We now know that those who have some voluntary movement after stroke have the best chance of recovering motor control of that extremity. Learned nonuse is certainly a risk for those individuals with stroke who are taught only compensatory techniques.3 Failure to incorporate the hemiparetic limb into functional activities early may make subsequent restoration of motor skills particularly difficult because individuals establish the habit of always using their unaffected upper extremity to the exclusion of the affected but often capable upper extremity.

When the restorative approach is indicated, which therapeutic techniques are the best? While this continues to be an unknown, there is increasing evidence that the technique the clinician uses to facilitate sensory-motor restoration is not important. What is important is practice. The sensory-motor skills that patients must learn, such as moving from a bed to a chair or walking, present the same challenges as athletic skills that we try to learn, such as acing a tennis serve or driving a golf ball onto the green. Skills are obtained by active repetition, active in the sense that the learner is participating cognitively and physically.

Effective Interventions

A comparison of the studies that have shown effective interventions for those with stroke reveal two common themes. One is the intensity of the intervention. For example, individuals with chronic stroke who participated in an intensive 12-week outpatient therapy program showed improvements in motor ability, socialization, and self-esteem.4

The second theme is task specificity. The skills that are practiced are those that improve; little transfer may be found to other skills, even if they are related to the practiced task.5 Thus, interventions should include functional skills that stroke survivors will use in their daily life. Strengthening. Weakness is a hallmark of stroke. Strength training of the hemiparetic side in stroke survivors used to be paramount to heresy, primarily due to fears of increasing spasticity. We now know that these fears are largely unfounded. A progressive resistive strength training program can promote functional recovery after stroke.

Although a unilateral stroke can result in hemiparesis, there is some degree of weakness bilaterally in the lower extremity and the upper extremity.6 Thus, strength training of the less-affected extremities should be incorporated into a comprehensive intervention.

Aerobic fitness. Adults with stroke are deconditioned and may have been so for quite some time before their stroke. Even as sensory motor skills are regained post-stroke, individuals are limited in their community participation by their decreased cardiovascular endurance. Every effort must be made to increase cardiovascular fitness in stroke survivors. Improvements in fitness after stroke are related to functional gains.7 In addition, individuals poststroke are at high risk for subsequent stroke. Improving their fitness may contribute to a lower risk of recurrent stroke. It has been shown that individuals with chronic stroke can improve their fitness level by increasing their daily activities (primarily walking) without a formal supervised conditioning program.8

Vision. It is not uncommon for individuals poststroke to experience impairments in basic visual functions that are associated with functional disability and impairments in higher-level cognitive skills. Can basic visual skills be restored or should individuals with basic visual impairments be taught compensatory skills? There is some evidence that vision might be at least partially recoverable in blind areas of the visual fields through repeated stimulation.9 People with hemianopsia can also learn to compensate for their visual field deficits through techniques and training to influence scanning into a blind field.10 Although it seems likely given what we know about the ability to restore motor skill in the limbs, we know of no studies with individuals who have had strokes that have investigated the ability of exercises to restore oculomotor skills. Cognitive/perceptual. Cognitive and perceptual impairment, if present following stroke, can severely limit activity and life participation.11 Except for attentional deficits, cognitive and perceptual deficits are not restorable or gains on therapy tasks do not usually generalize into daily life activities.12 Compensatory approaches, such as teaching new strategies or modifying environments and tasks, should be adopted. For example, individuals with unilateral neglect successfully learn to consciously scan the left side of their environment with a variety of techniques.13 Although most interventions have failed to result in a permanent restoration of automatic leftward orienting, there are some data to suggest that interventions that consist of practicing orienting to stimuli that appear in the peripheral visual fields may improve such orienting.14

Language/speech. The two most common language and speech deficits following stroke are aphasia and dysarthria. Two recent meta-analyses of aphasia intervention studies have demonstrated that the speech/language of those with aphasia in the acute period following stroke improves nearly twice as much with intervention compared to spontaneous recovery.15 There is also evidence that individuals with dysarthria due to stroke can improve their speech and communicability by learning new strategies to improve their articulation and the understandability of their messages.

Psychosocial aspects. Between 25% and 79% of stroke survivors are depressed after stroke.16 Left untreated, depression may interfere with functional recovery.17 Even more important, depression in the acute stage of stroke is predictive of an increased risk of death.18 Recognition of depression in stroke survivors is the responsibility of every member of the rehabilitation team. Treatment with antidepressants, psychotherapy, and patient and family education should be considered a part of any comprehensive rehabilitation.

Assessing Outcomes

Assessing a person after intervention is important for at least two reasons: determining the amount of change that has occurred during the period of intervention, and determining the current level of function so the appropriate discharge plans are implemented that will maximize the stroke survivor’s ability to participate in desired activities.

What should we measure as outcomes? The World Health Organization (WHO) (1999) describes a model of health in which there are three dimensions that contribute to good health: body function and structure, activity, and participation. A comprehensive battery of outcome measures should include instruments that are directed at each of these levels. “The Post-Stroke Rehabilitation Clinical Practice Guidelines” (US Agency for Health Care Policy and Research, 1995) include recommendations for assessment instruments to use in determining outcomes that span impairment to participation. There are numerous tests at the body function and structure level. There are also well-developed assessments of basic activities of daily living (ADLs) at the activity level. It is important to remember, however, that individuals with stroke may reach ceiling levels on these daily activity assessments. Good measures of instrumental ADLs that actually capture a given individual’s ability to perform are somewhat difficult to find and because the activities that individuals choose to participate in vary a great deal, and no single measure can include all the possibilities.

Duncan and colleagues have recently developed the Stroke Impact Scale (SIS), an assessment measure for individuals with mild and moderate stroke that addresses all three levels of the WHO model.19 The SIS contains items that measure physical functioning of the arm and hand, cognitive ability, functional language ability, emotional function, basic and instrumental ADLs, and social participation. Items were generated from focus groups of individuals with stroke and their caregivers. The resultant assessment uses self-report to quantify not only the ability of someone to perform an activity, but also the difficulty involved.

The SIS is reliable, valid, and sensitive to change for those with mild or moderate stroke. It takes only 20 minutes to administer. A study is presently under way to see if the scale can be administered by mail, which may be appropriate for those in home health settings. A current limitation of the SIS is that it can be administered only to individuals with minimal language and cognitive impairments because it relies on self-report.

Interventions for adults poststroke must maximize the individual’s active participation. Practice of functional activities that the individual will carry over to home life should be combined with general strength and aerobic fitness training. N Patricia S. Pohl, PhD, PT, is an assistant professor in physical therapy education at the University of Kansas Medical Center (UKMC), Kansas City, and an assistant scientist for UKMC’s Center on Aging. Lorie G. Richards, PhD, OTR, is a teaching associate in occupational therapy education at UKMC, an associate scientist for the Center on Aging, and a courtesy assistant professor in the Psychology Department at UKMC, Lawrence.

References

1. Grimby G, Andrén E, Daving Y, Wright B. Dependence and perceived difficulty in daily activities in community-living stroke survivors 2 years after stroke. Stroke. 1998;29:1843-1849.
2. Lai SM, Duncan PW, Keighley J. Prediction of functional outcome after stroke: comparison of the Orpington Prognostic Scale and the NIH Stroke Scale. Stroke. 1998;29:1838-1842.
3. Wolf S, Taub E. Constraint induced movement techniques to facilitate upper extremity use in stroke patients. Topics in Stroke Rehabilitation. 1997;3:38-61.
4. Werner RA, Kessler S. Effectiveness of an intensive outpatient rehabilitation program for postacute stroke patients. Arch Phys Med Rehab. 1996;75:114-120.
5. Wagenaar RC, Meijer OG. Effects of stroke rehabilitation. J Rehab Sci. 1991;4:61-109.
6. Bohannon RW, Andrews AW. Limb muscle strength is impaired bilaterally after stroke. J Phys Ther Sci. 1995;7:17.
7. Potempa K, Lopez M, Braun LT, Szidon JP, Fogg L, Tincknell T. Physiological outcomes of aerobic exercise training in hemiparetic stroke patients. Stroke. 1995;26:101-105.
8. Fujitani J, Ishikawa T, Akai M, Kakurai S. Influence of daily activity on changes in physical fitness for people with post-stroke hemiplegia. Arch Phys Med Rehab. 1999;78:540-544.
9. Corbetta M, Marzi C, Tassinari G, Aglioti S. Effectiveness of different task paradigms in revealing blindsight. Brain. 1990;113:603-616.
10. Rossi P, Solomon K, Reding M. Fresnel prisms improve visual perception in stroke patients with homonymous hemianopsia and unilateral neglect. Neurology. 1990;40:1594-1597.
11. Suhr J, Grace J. Brief cognitive screening of right hemisphere stroke: relation to functional outcome. Arch Phys Med Rehab. 1999;80:773-776.
12. Hajek V, Kates M, Donnelly R, McGree S. The effect of visuo-spatial training in patients with right hemisphere stroke. Canadian J Rehab. 1993;6:175-186.
13. Paul S. The effects of video assisted feedback on a scanning kitchen task in individuals with left visual neglect. Canadian J Occup Ther. 1997:64;63-69.
14. Vallar G, Rusconi M, Bernardini B. Modulation of neglect hemianesthesia by transcutaneous electrical stimulation. Journal of the International Neuropsychological Society. 1996;2:452.
15. Robey R. The efficacy of treatment for aphasic persons: a meta-analysis. Brain and Language. 1994;47:585-608.
16. Gordon WA., Hibbard MR. Poststroke depression: an examination of the literature. Arch Phys Med Rehab. 1997;78:658-663.
17. Hermann N, Black SE, Lawrence J, et al. The Sunnybrook stroke study: a prospective study of depressive symp- toms and functional outcome. Stroke. 1998;29:618-624.
18. Morris PLP, Robinson RG, Andrzejewski P, et al. Associations

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April/May 2000