Each year approximately 550,000 people in the United States suffer a stroke. Of these individuals, 150,000 die and 300,000 are left disabled. Due to better medical control of risk factors, improved treatment and changes in health-related behavior, the mortality rate for stroke has decreased considerably over the past 30 years. However, the incidence of new cases of stroke has not decreased at the same rate. The net result is an increased number of stoke survivors with chronic disabilities.
About 3 million Americans are currently living with varying degrees of disability from strokes. The annual cost of stroke in the United States is estimated to exceed $30 billion, with much of the economic burden attributed to disabilities that prevent stroke survivors from returning to their previous level of function. Rehabilitation is believed to decrease the long-term economic cost of stroke.[5,6]
Stroke Rehabilitation and Survival
It has been argued that if a stroke patient is discharged home after rehabilitation and survives 22 months or longer, then stroke rehabilitation is cost-effective and beneficial. Seventy-five percent of stroke patients are able to return home after completing a comprehensive rehabilitation program, and their mean duration of survival after the stroke is 7.5 years.
Goals of Stroke Rehabilitation
and Patient Selection
The goals of stroke rehabilitation are to restore lost abilities as much as possible, to prevent stroke-related complications, to improve the patient's quality of life and to educate the patient and family about how to prevent recurrent stroke.
Approximately 10 percent of stroke survivors are without disability and are able to function independently. These patients do not require rehabilitation. Another 10 percent of patients are institutionalized because of markedly severe disability and are unable to achieve functional independence in a home setting regardless of how many rehabilitation services are provided. The remaining 80 percent of stroke survivors have mild to moderately severe disability and benefit from intense rehabilitation.
Rehabilitation efforts should be initiated 24 to 48 hours after the onset of a stroke. The family physician works closely with a rehabilitation specialist during the acute care, rehabilitation and community reintegration of a stroke patient (Table 1).
Predictors of Functional Outcome
Factors that negatively or positively affect stroke recovery are listed in Table 4. Younger patients generally do better than older patients, who often have multiple medical problems. The longer the interval between the onset of stroke and the initiation of active rehabilitation, the less favorable the functional outcome. The earlier the neurologic recovery, the better the prognosis. The functional prognosis is poor in patients with recurrent stroke.
If seizures do occur, phenytoin Dilantin) is the drug of choice. However, phenytoin levels should be monitored carefully, since overmedication may cause lethargy and balance problems.
When a temporary increase in neurologic deficits (Todd's paralysis) occurs due to a seizure, the event may be misdiagnosed as another stroke.
CENTRAL PAIN SYNDROME
Central pain syndrome rarely occurs following a stroke, but when it does, it is difficult to manage. The syndrome is most likely caused by the brain lesion. Therefore, the pain is described as central in origin. The pain is usually diffuse and intense. It has a burning, tingling, stinging, shooting or, at times, aching quality.
The management of central pain syndrome includes avoiding situations that may stimulate the pain. Thus, it is important to prevent and treat infections, spasticity, contractures, bowel or bladder complications, and pressure sores. Psychotherapy, relaxation training and biofeedback may be helpful. Neurotropic medications such as amitriptyline (Elavil, Endep, Triavil) and anticonvulsant medications such as phenytoinmay be useful.
Significant clinical depression occurs in 30 to 60 percent of stroke patients. The rate of depression is considerably higher in elderly stroke patients than in the healthy elderly population.
Initial depression is related to the location of the stroke in the cortex. Social dysfunction and the level of functional impairment appear to be responsible for the reactive depression that can occur six months to one year after a stroke. Depression occurs more frequently and is more severe in patients who have had a left hemisphere stroke, particularly when the stroke occurred close to the frontal lobe.
Regardless of whether the cause is organic or psychosocial, stroke-related depression responds fairly well to a combination of antidepressant medications and psychotherapy.
Measures to Prevent Recurrent Stroke
Patients who have had one stroke are at five times greater risk of having another stroke. Thus, the prevention of recurrent stroke is an important part of the stroke rehabilitation program.
Preventive measures include the identification and control of risk factors, especially hypertension, cigarette smoking and a sedentary lifestyle. Oral anticoagulants help prevent embolic strokes in patients with atrial fibrillation or prosthetic cardiac valves. Aspirin and ticlopidine (Ticlid) have been found to be effective in preventing recurrent stroke.(29)
Surgical measures to prevent recurrent stroke include carotid endarterectomy in patients with carotid artery stenosis of greater than 70 percent and procedures to clip an intracranial aneurysm or to resect an arteriovenous malformation.
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M. PRABHAKAR REDDY, M.D. is in private rehabilitation medicine practice in Reno, Nev., where he also serves as medical director of the comprehensive medical rehabilitation unit at Saint Mary's Regional Medical Center. Dr. Reddy graduated from the Kakatiya Medical College of Osmania University, India, and completed a residency in physical medicine and rehabilitation at New York Medical College, New York City.
VINAY REDDY, M.D. is a resident in internal medicine at the University of Nevada School of Medicine, Reno, where he also earned his medical degree.
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