Surprising stroke rehab advice

It’s widely known that patients who experience a stroke need physical rehabilitation afterwards to help restore some of the functions that may have been lost. But a new study, published in the scholarly journal PNAS, indicates that the timing of rehab matters for recovery of strength and coordination.

Researchers uncovered a critical period where the brain had the greatest capacity to rewire its circuits – and the news has upended the traditional thinking on the subject.

While in the past, stroke patients were advised that they would see the most benefits from rehabilitation immediately after the stroke, the new study suggests that they will actually see the most benefits if they start rehab two or three months after the event.

The study was done at a rehabilitation facility near Washington, D.C. Most of the patients were in their 50s or 60s. Stroke patients were assigned to an extra 20 hours of intensive training that started during one of three time blocks:

• Within 30 days of their stroke
• Between 60 and 90 days afterwards
• Six months or more later.

“The precise therapy regimen was tailored to each patient and what the study found was that the best recovery was for the people who received this intensive training at about two or three months after their stroke,” explained Neurologist Michael Markowski, DO, FAAN at Neurologists of Cape Cod in Hyannis. “Basically, it questions some of the current practices of beginning rehabilitation right away.”

Currently, as soon as people are medically cleared and safe to leave the hospital, they either go home with physical therapy there, or they are transferred for inpatient rehab at one of the local rehabilitation centers, he said.

Doctors have known for years that the majority of recovery of neurological deficits after a stroke occurs within the first six months. Common stroke deficits include weakness, numbness, clumsiness, speech difficulties, balance, and walking difficulties. After six months, there is unlikely to be significant improvement. The only exception is aphasia with an expressive speech problem or comprehension difficulties. Dr. Markowski has seen those patients continue to improve to a smaller extent one to two years down the road.

“We know most recovery is seen within the first six months and this study really pointed to a more critical window at the two- or three-month mark,” he said. He offered a possible explanation of why the timing of the new window makes sense.

“With a stroke you literally have death of brain cells. That’s what a stroke is – a blockage of a blood vessel or bleeding in the brain, if it is a hemorrhagic stroke, that causes permanent damage to brain cells. But we know in addition to the brain cell death, there is also this release of inflammatory chemicals and it takes a few weeks for that inflammatory chemical cascade to quiet down and, as that happens, there can be greater return of brain function.”

In addition to that, there is also edema or swelling in the brain that peaks around two to three days. This is usually alarming to the patient and family members who worry that the patient is getting worse or having another stroke, but doctors reassure them that the swelling will slowly resolve over two to three weeks.

The biggest problem with the study is that the advice it promotes would be nearly impossible to implement in the real world of medicine, Dr. Markowski said. The bottom line is that insurance companies, not doctors, decide the treatment the patient will receive.

“It would be ideal if patients could have continued inpatient services for three months, due to the critical window they mention in the study, but that’s not realistic because insurances would never pay for someone to remain as an inpatient for three months after a stroke,” he said. “It is also not realistic to discharge really sick people home and then have them admitted to a rehabilitation facility at the two-month mark. That’s just not how the current medical system works. A patient cannot be directly admitted to a rehab facility from home, rather they would be transferred from a hospital.”

Take-Away Message

That said, there is a take-away message from the study that can be implemented. Sometimes people who go to an inpatient treatment facility improve enough that they are reluctant to spend the extra money on co-pays for additional physical therapy, occupational therapy and speech therapy as an outpatient.

“If patients question whether it’s worth the money to continue rehabilitation as an outpatient, the answer is a resounding yes, based on this study, because you still want to continue therapy through that three-month critical window,” Dr. Markowski said.

This is helpful information for a lot of local people because Cape Cod Hospital is a very busy stroke center. The Emergency Department at Cape Cod Hospital has more than 150 stroke presentations a month and that number increases to 170 to 180 in the summer months.

The good news is that stroke patients can count on getting excellent care. For the past three years in a row, Cape Cod Hospital and Falmouth Hospital have been awarded the American Heart Association Get With the Guidelines Gold Plus Award with Honor Roll, which is the highest award they give out. That means the hospital adheres to the most up-to-date, evidence-based treatment guidelines to improve patient care and outcomes in the community it serves.

“We are designated as an extra-high-volume stroke center in Massachusetts,” Dr. Markowski said. “We have seven neurologists and fortunately we have an award-winning stroke center and excellent rehabilitation services to provide the care our patients need.”