Stroke is now the leading cause of serious long-term disability in the world. According to the National Stroke Association, 40% of stroke survivors experience moderate to severe impairments, 25% die shortly after the stroke or experience such severe impairment that they require care in a long-term-care facility, and 25% recover with minor sequelae. Only 10% experience a near-complete recovery.

But at the dawn of the new millennium, the outlook for patients who experience stroke is improving. Mortality continues to decline. And preliminary data from studies of new therapies for the acute treatment of stroke suggest that more patients will survive and that those who do will have less severe residual deficits.

Acute Rehabilitation Advances

Evidence of improved outcomes for patients admitted to specialized stroke units for acute treatment continues to accrue. Other recent studies show that stroke unit care, when compared with hospitalization on a general medical ward, improves long-term survival, functional state, and quality of life, and increases the number of patients who are able to live at home 5 years after stroke.

 Stroke experts believe that improved outcomes are the result of emphasis on early mobilization and rehabilitation and aggressive measures to prevent, identify, and treat medical and psychological complications. Comprehensive, coordinated, interdisciplinary care provided by a well-trained, knowledgeable staff is also believed to be a key factor in improved outcomes.

Areas of Assessment

All stroke patients require thorough clinical assessments performed on admission and throughout the acute hospitalization. These provide critical information about the course of recovery. Initially, a complete clinical evaluation is required to confirm the diagnosis and determine the cause of stroke, as well as its location and extent. The acute assessment should also determine if the patient has coexisting medical conditions that could affect participation in therapy or increase the risk of further complications. Changes in clinical status should also be documented.

Another component of the evaluation is an assessment of basic health functions. While these problems and their sequelae are well-known individually, close attention to the particular constellation of problems experienced by a stroke patient can help pinpoint problems early, before a cascade of deterioration begins. Examinations should include an assessment of these areas:

Dysphagia

This occurs frequently in stroke patients. If the problem remains undetected, however, it could result in aspiration and pneumonia. Swallowing problems can be identified by conducting a careful pharyngeal and laryngeal nerve examination and performing barium videofluoroscopy. Researchers are also looking at the blink reflex as a potential early neurophysiologic marker for determining whether a patient will be able to swallow after a stroke.

Skin Breakdown

Incontinent patients are at greatest risk for this problem. Other factors, such as sensory deficits and poor nutrition, compound the risk. Daily examination of the patient's skin, with close attention to pressure points, can help identify problems early on, before the development of decubitus ulcers.

Nutrition Status

Adequate nutrition reduces the risk of infection, pressure sores, and mental status changes, but a number of factors can reduce a patient's ability and desire to eat after a stroke. Swallowing disorders, perceptual deficits, and reduced mobility are just a few of the potential troublesome areas. Careful attention to caloric intake, body weight, and urinary and fecal output can help ensure that the patient is receiving sufficient vitamins, nutrients, and micronutrients.

Physical Activity Endurance

A key factor in the choice of a rehabilitation setting is the patient's physical stamina. Identifying and treating potential causes of limited endurance can help ensure that a patient is not unnecessarily denied access to an intensive rehabilitation program. The best way to identify limited endurance is by direct observation during exercise. Respiration, blood pressure, and heart rate also provide important clues.

Preventing Complications

Stroke patients are at increased risk for recurrent stroke and venous thromboembolism. Efforts to prevent recurrent stroke should focus on modifiable risk factors. For example, aspirin and ticlopidine (Ticlid) have been shown to reduce the likelihood of stroke in patients with transient ischemic attacks (TIAs) or a minor stroke. According to one recent study, although aspirin is associated with a significant increase in the risk of hemorrhagic stroke, its overall benefit almost certainly overcomes this potential risk in patients who have already experienced a stroke.⁹

Anticoagulation with warfarin has been shown to reduce future cardioembolic events and mortality in patients with nonvalvular atrial fibrillation (AF). Interestingly, recent findings from the Copenhagen Stroke Study, which show that stroke recurrence is more frequently associated with a history of TIA, AF, male gender, and hypertension, also show that only 12% of patients with AF receive anticoagulant treatment before recurrence.¹⁰ Other means of reducing the risk of recurrent stroke include surgical treatment of cerebral aneurysms after subarachnoid hemorrhage and carotid endarterectomy in patients with minor acute ischemic stroke or TIA.

Management strategies to reduce the risk of venous thromboembolism include early mobilization, elastic stockings, intermittent pneumatic compression, and if there are no contraindications, prophylaxis with low-dose heparin, low molecular weight heparin, or warfarin.