Stroke Rehabilitation: A Function-Based Approach PDF
Preview Stroke Rehabilitation: A Function-Based Approach
DRUG USE DOSAGE ROUTE SIDE EFFECTS OTHER MEDICAL ISSUES Antispasmodics/Spasmolytics Carisoprodol (Soma) Skeletal muscle relaxant 350 mg tid and qhs PO Drowsiness, ataxia, tremor, nausea/ vomiting (N/V), tachycardia Chlorzoxazone (Parafon Forte) Skeletal muscle relaxant 250 to 500 mg tid-qid PO Drowsiness, dizziness, N/V, angioedema Cyclobenzaprine (Flexeril) Decrease muscle spasm via brainstem 10 mg tid PO Drowsiness, dry mouth, dizziness, N/V, angioedema Diazepam (Valium) Central nervous system (CNS) depressant 2 to 10 mg bid- qid PO Drowsiness, ataxia, urinary retention, anxiety Avoid in fi rst trimester Methocarbamol (Robaxin) Skeletal muscle relaxant 1 to 1.5 g qid PO Drowsiness, dizziness, N/V, headache (HA) Orphenadrine (Norfl ex/Norgesic) Skeletal muscle relaxant 100 mg bid 60 mg every 12 hours IV PO, IV Drowsiness, dry mouth, dizziness, HA, weakness Antispastics Baclofen (Lioresal) Skeletal muscle relaxant 5 to 20 mg tid-qid PO Drowsiness, dizziness, weakness, N/V, confusion Dantrolene sodium (Dantrium) Skeletal muscle relaxant 25 mg qd to 100 mg qid PO, IV Drug-induced hepatitis Diazepam (Valium) CNS depressant, skeletal muscle relaxant 2 to 10 mg bid-qid PO Drowsiness, ataxia, urinary retention, anxiety Avoid in fi rst trimester Tizanidine (Zanafl ex) Central alpha 2 adrenergic agonist; central skeletal muscle relaxant 4 to 8 mg tid-qid PO Asthenia, drowsiness, ataxia, abnormal liver function tests, dry mouth Rare cardiac events Anticonvulsants Beclamide (Beclase) Grand mal, psychomotor seizures 990 to 1980 mg/ day PO Drowsiness, ataxia, aphonia, agitation, leukopenia Carbamazepine (Tegretol) Grand mal, partial complex, mixed seizures; neuropathic pain 300 to 600 mg bid PO N/V, dizziness, complete blood count (CBC) changes, drowsiness, unsteadiness Therapeutic level 6 to 12 mcg/ml Clonazepam (Klonopin) CNS depressant, a benzodiazepine; neuropathic pain 0.5 mg tid to 5 mg qid PO Drowsiness, ataxia, aphonia, agitation, confusion, anemia Diazepam (Valium) CNS depressant, for status epilepticus 5 to 10 mg IV push IV Respiratory arrest, hypotension, bradycardia Total dose IV up to 30 mg Ethosuximide (Zarontin) Suppresses 3 cycle/sec spike, petit mal seizures 500 mg up to 1000 mg/day PO Anorexia, N/V, lethargy, incoordination, CBC changes Not in pregnancy/ nursing Ethotoin (Peganone) Grand mal, partial complex seizures 2 to 3 g/day in 4 to 6 doses PO Ataxia, sedation, HA, N/V, cardiac dysrhythmias Monitor blood counts, blood level 15 to 50 mcg/ml Felbamate (Felbatol) Partial seizures Up to 2400 to 3600 mg/day in divided doses PO Anorexia, gastrointestinal (GI) discomfort, fever, acute liver failure, bone marrow suppression Monitor liver function Gabapentin (Neurontin) Partial seizures, social phobia 900 to 1800 mg total in tid divided doses PO Ataxia, sedation, mania, lability, mood alterations, rare edema and hypertension (HTN) Medications Commonly Used to Treat Stroke and its Comorbidities Continued on back endsheets DRUG USE DOSAGE ROUTE SIDE EFFECTS OTHER MEDICAL ISSUES Lamotrigine (Lamictal) Partial seizures 200 to 500 mg/ day PO Leukopenia, anemia, disseminated intravascular coagulation, hepatitis, Stevens-Johnson syndrome Must stop immediately in presence of rash Levetiracetam (Keppra) Grand mal, partial, psychomotor seizures Maximum daily dose of 3000 ng PO Somnolence, asthenia, infection, dizziness Phenobarbital (Luminal) CNS depressant 50 to 100 mg tid serum 15-40 mcg/ml PO, IV HA, vertigo, confusion, N/V, respiratory depression; respiratory arrest with IV 15 mg/kg IV in status epilepticus Phenytoin (Dilantin) Grand mal, psychomotor seizures; neuropathic pain 100 mg tid PO, IV Ataxia, sedation, HA, N/V, cardiac dysrhythmias Level: 10 to 20 mcg/ml Primidone (Mysoline) Barbiturate; grand mal, focal, psychomotor seizures 250 mg tid to 500 mg qid PO Ataxia, sedation, HA, N/V, irritability Level: 5 to 12 mcg/ml Valproic acid (Depakote/ Depakene) Absence seizures; neuropathic pain 1000 to 3000 mg/day PO Ataxia, sedation, HA, N/V, aggression Avoid in pregnancy Antihypertensives ACE inhibitors Antihypertensive PO, IV Nephrotic syndrome Alpha-blockers (Minipress, etc.) Antihypertensive, control of sympathetic dystrophy PO, IV Syncope, sedation, HA, urinary retention Beta-blockers Antihypertensive PO, IV Congestive heart failure, bradycardia, hypotension, peripheral vascular disease (PVD) Calcium channel blockers Antihypertensive PO, IV Dizziness, HA, hypotension Direct vasodilators Antihypertensive PO, IV Tachycardia, hypotension, HA Diuretics Antihypertensive PO, IV Metabolic/electrolytes, cramps, hypotension, renal failure Postganglionic neuron inhibitors Antihypertensive PO, IV Diarrhea, hypotension, depression Antidepressants Fluoxetine (Prozac) Antidepressant 20 to 80 mg qd-bid PO Anxiety, tremor, insomnia, nausea, diarrhea MAO inhibitors Antidepressant PO Dizziness, vertigo, HA, constipation, HTN Patient must avoid tyramine/ tryptophan Sertraline (Zoloft) Antidepressant 50 to 200 mg qd-bid PO Anxiety, tremor, insomnia, nausea, diarrhea Tricyclics (e.g., amitriptyline) Antidepressant, pain control adjuvant PO Myocardial infarction (MI), hypotension, seizures, confusion, leukopenia, parathesias, N/V, coma, constipation, hepatitis Best for continuous neuropathic pain Anticonvulsants—cont’d REGISTER TODAY! Evolve Student Learning Resources for Gillen: Stroke Rehabilitation, 3E, offers the following features: Activities for students to test their application and clinical thinking skills References linked to PubMed Glossary To access your free Evolve Resources, visit: http://evolve.elsevier.com/Gillen/stroke Glen Gillen, EdD, OTR, FAOTA Associate Professor of Clinical Occupational Therapy Programs in Occupational Therapy Columbia University College of Physicians and Surgeons; Honorary Adjunct Associate Professor of Movement Sciences and Education Teachers College New York, New York 3251 Riverport Lane St. Louis, Missouri 63043 STROKE REHABILITATION: A FUNCTION-BASED APPROACH, THIRD EDITION ISBN: 978-0-323-05911-4 Copyright © 2011, 2004, 1998 by Mosby, Inc., an affiliate of Elsevier Inc. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/ permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Notices Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Library of Congress Cataloging-in-Publication Data Stroke rehabilitation : a function-based approach / Glen Gillen. -- 3rd ed. p. cm. Includes bibliographical references and index. ISBN 978-0-323-05911-4 (hardcover : alk. paper) 1. Cerebrovascular disease--Patients--Rehabilitation. I. Gillen, Glen. RC388.5.S85625 2011 616.8’1--dc22 2010026437 Vice President and Publisher: Linda Duncan Executive Editor: Kathy Falk Managing Editor: Jolynn Gower Publishing Services Manager: Anitha Rajarathnam Project Manager: Mahalakshmi Nithyanand Book Designer: Maggie Reid Printed in the United States of America Last digit is the print number: 9 8 7 6 5 4 3 2 Contributors Guðrún Árnadóttir, PhD, MA, BOT Private Practitioner, Associate Professor Division of Occupational Therapy, Faculty of Health University of Akureyri, Iceland; Coordinator of Occupational Therapy Research and Development Projects, Occupational Therapy Grensás, Landspítali, University Hospital Reykjavík, Iceland Sandra M. Artzberger, MS, OTR, CHT, CLT Lecturer, Consultant, Hand Therapist Rocky Mountain Physical Therapy Pagosa Springs, Colorado Wendy Avery, MS, OTR/L Occupational Therapist Amedisys Home Health Bluffton, South Carolina Matthew N. Bartels, MD, MPH Assistant Professor of Clinical Rehabilitation Medicine Columbia University New York, New York Clare C. Bassile, EdD, PT Assistant Professor of Clinical Physical Therapy Physical Therapy Program Columbia University New York, New York Carolyn M. Baum, PhD, OTR, FAOTA Associate Professor of Occupational Therapy and Neurology Washington University School of Medicine St. Louis, Missouri Heather Edgar Beland, MS, OTR/L Staff Therapist Englewood Hospital and Medical Center Englewood, New Jersey Birgitta Bernspång, PhD, OT Professor of Occupational Therapy Department of Community Medicine and Rehabilitation Umeå University Umeå, Sweden Karen A. Buckley, MA, OT/L Clinical Assistant Professor Department of Occupational Therapy New York University New York, New York Helen S. Cohen, EdD, OTR, FAOTA Associate Professor Bobby R. Alford Department of Otorhinolaryngology and Communicative Sciences Baylor College of Medicine Houston, Texas Salvatore DiMauro, MD Lucy G. Moses Professor of Neurology College of Physicians and Surgeons Columbia University New York, New York Susan M. Donato, OTR/L Occupational Therapist Merrimack Special Education Collaborative Chelmsford, Massachusetts Catherine A. Duffy, OTR/L Advanced Clinician, Occupational Therapy Department New York-Presbyterian Hospital Columbia University Medical Center; Instructor in Clinical Occupational Therapy, Programs in Occupational Therapy Columbia University New York, New York Janet Falk-Kessler, EdD, OTR, FAOTA Associate Professor of Clinical Occupational Therapy Director, Programs in Occupational Therapy Columbia University New York, New York Jessica Farman, MS, OTR/L Director of Rehabilitation Belmont Manor Nursing Center Belmont, Massachusetts iii Susan E. Fasoli, ScD, OTR/L Clinical Instructor Physical Medicine and Rehabilitation Harvard Medical School Cambridge, Massachusetts; Rehabilitation Manager Rehabilitation Services Newton Wellesley Hospital Newton, Massachusetts Glen Gillen, EdD, OTR, FAOTA Associate Professor of Clinical Occupational Therapy Programs in Occupational Therapy Columbia University College of Physicians and Surgeons; Honorary Adjunct Associate Professor of Movement Sciences and Education Teachers College New York, New York Sheila M. Hayes, BSN, MS, PT Convent of Mary the Queen Yonkers, New York Leslie A. Kane, MA, OTR/L Manager of Occupational Therapy New York-Presbyterian Hospital and Columbia University Medical Center; Instructor in Clinical Occupational Therapy Programs in Occupational Therapy Columbia University New York, New York Megan Kirshbaum, PhD Founder and Executive Director Through the Looking Glass; Co-Director The National Center for Parents with Disabilities and their Families Berkeley, California Josefi ne Lampinen, MSc Council Certifi ed Specialist in Occupational Therapy Norrlands University Hosptial Umeå, Sweden Virgil Mathiowetz, PhD, OTR, FAOTA Associate Professor Program in Occupational Therapy University of Minnesota Minneapolis, Minnesota Stephanie Milazzo, MA, OTR, CHT Director of Rehabilitation Rehab Resources Unlimited Ossining, New York Barbara E. Neuhaus, EdD, OTR Adjunct Associate Professor (Retired) Programs in Occupational Therapy Columbia University New York, New York Susan L. Pierce, OTR, CDRS Certifi ed Driver Rehabilitation Specialist Adaptive Mobility Services, Inc. Orlando, Florida Karen Halliday Pulaski, MS, OTR/L Trauma Team Supervisor Inpatient Rehabilitation Moses Cone Health Systems Greensboro, North Carolina Ashwini K. Rao, EdD, OTR/L Assistant Professor of Clinical Physical Therapy Physical Therapy Program Department of Rehabilitation Medicine Columbia University New York, New York Karen Riedel, PhD, CCC-SLP Director Speech-Language Pathology Department Rusk Institute of Rehabilitation Medicine New York University Medical Centers New York, New York Judith Rogers, OTR/L Pregnancy and Birthing Specialist Parenting Equipment Specialist Through the Looking Glass Berkeley, California Kerry Brockmann Rubio, MHS, OTR/L Lead Occupational Therapist Maria Parham Hospital Henderson, North Carolina Patricia A. Ryan, MA, OTR/L Senior Occupational Therapist Department of Occupational Therapy New York-Presbyterian Hospital Columbia University Medical Center; Instructor in Clinical Occupational Therapy Programs in Occupational Therapy Columbia University New York, New York iv Contributors Joyce S. Sabari, PhD, OTR, FAOTA Associate Professor and Chair Occupational Therapy Program State University of New York—Downstate Medical Center Brooklyn, New York Mary Shea, MA, OTR, ATP Clinical Manager, Wheelchair Clinic Kessler Institute for Rehabilitation West Orange, New Jersey Celia Stewart, PhD, MS, CCC-SLP Department Chair Associate Professor Communicative Sciences and Disorders Steinhardt School of Culture, Education, and Human Development New York University New York, New York Jennie W. Sullivan, OTR/L Occupational Therapist East Tennessee Children’s Hospital Knoxville, Tennessee Carolyn A. Unsworth, PhD, BAppSc (OccTher), AccOT, OTR Associate Professor School of Occupational Therapy La Trobe University Bundoora, Victoria, Australia Jocelyn White, BSc (OT) Senior Occupational Therapist Royal Perth Hospital Shenton Park Campus Perth, Western Australia Timothy J. Wolf, OTD, MSCI, OTR/L Instructor in Occupational Therapy and Neurology Program in Occupational Therapy Washingon University St. Louis, Missouri CONTRIBUTORS TO PREVIOUS EDITIONS Lorraine Aloisio Beverly K. Bain Ann Burkhardt Judith Dicker Friedman Michele G. Hahn Lauren Joachim Christine M. Johann Steve Park Denise A. Supon Jeffery L. Tomlinson Nancy C. Whyte Contributors v To: Peg & Ed � � Preface The third edition of Stroke Rehabiliation: A Function-Based Approach strives to be the most up-to-date text on this topic, incorporating state of the art tools and techniques to maximize function and quality of life for those living with stroke. This edition’s contributors include expert clinicians, researchers, and scientists from across the United States of America, Australia, Iceland, and Sweden. Contibutors are experts in various disciplines, including neurology, occupational therapy, physiatry, physical ther- apy, psychology, and speech and language pathology. The current text combines aspects of background medical information, a comprehensive review of stan- dardized and nonstandardized evaluation procedures and assessments, treatment techniques, and evidence-based interventions. It contains the most up-to-date research on stroke rehabilitation from a variety of rehabilitation set- tings and professions without losing its holistic perspec- tive on the overall care of the people whose lives we as clinicians touch. This text has overarching themes. First and foremost, clinicians are provided with specifi c suggestions to main- tain a client-centered approach when working with stroke survivors. Furthermore, clinicians are challenged to use the most up-to-date treatment approaches (including both remediation and adaptation approaches) to decrease impairments, prevent secondary complications, improve the client’s ability to perform meaningful activities, and, most important, decrease participation restrictions and improve quality of life. Although this book is written primarily by occupational therapists, it is an appropriate reference for a variety of rehabilitation professionals, including physiatrists, physi- cal therapists, speech and language pathologists, rehabili- tation nurses, social workers, vocational counselors, and therapeutic recreation specialists. The immense value of an interdisciplinary team approach when working with the stroke survivor population cannot be overestimated. This text may also be benefi cial to therapists who practice virtu- ally alone in the community or as a case manager because its research on the specifi c topic of stroke rehabilitation is comprehensive. The terms patient and client have been used interchangeably; it is recognized that stroke rehabili- tation can take place in multiple settings. Educators and students can use this text in the classroom setting. Key terms, chapter objectives, review questions, and case studies have been provided as learning tools. A text that can appeal to the basic learner and the specialist alike, this book is a good investment for any clinician who plans to work with neurologically impaired persons—specifi cally, adults who have had a stroke. This text spans the conti n- uum of care—from acute to long-term management—in a variety of roles and settings. The fi rst fi ve chapters provide the necessary medical and therapeutic foundations that should be the basis of any intervention plan. Chapter 1 has been expanded to not only include medical management but also a compre- hensive approach to acute stroke rehabilitation because current practice dictates that rehabilitation services begin within 24 hours of stroke in many cases. Acute care evalu- ations and interventions are clearly delineated for those working in intensive care units, step down units, and the acute hospital settings. The information in Chapter 2 , Psychological Aspects of Stroke Rehabilitation, as well as in Chapter 3 , Improving Participation and Quality of Life Through Occupation, should be implicit in any therapeutic interaction with this population. Chapters 4 , Task-Oriented Approach to Stroke Rehabilitation, and 5 , Activity-Based Intervention in Stroke Rehabilitation, pro- vide readers with an overall view of current therapeutic approaches and should be understood before the chapters on specialized topics are read. Chapters 6 through 15 focus on the motor control aspects of stroke rehabilitation. Chapter 6 , Approaches to Motor Control Dysfunction: An Evidence-Based Review, provides the reader with critical information to evaluate traditional and current practice approaches. Specifi c top- ics related to motor control that are covered include trunk control ( Chapter 7 ), balance ( Chapter 8 ), vestibular dys- function ( Chapter 9 ), comprehensive approaches to upper extremity function and management ( Chapter 10 ), use of cutting-edge technology to improve limb function after stroke ( Chapter 11 ), acute and subacute edema con- trol ( Chapter 12 ), splinting of the neurological upper extremity ( Chapter 13 ), functional mobility ( Chapter 14 ), and gait ( Chapter 15 ). The following fi ve chapters provide readers with insight into managing simple and complex visual, percep- tual, cognitive, and speech/language impairments that interfere with daily function. Chapters focus on assess- ment and interventions related to visual and spatial skills vii ( Chapter 16 ), clinical reasoning during assessment and treatment planning for those with cognitive and percep- tual defi cits ( Chapter 17 ), standardized assessment of the impact of cognitive-perceptual impairments on meaning- ful tasks ( Chapter 18 ), function-based approaches to man- aging and evaluating cognitive and perceptual defi cits ( Chapter 19 ), and management of speech and language defi cits ( Chapter 20 ). This text contains comprehensive chapters on specifi c aspects of daily living after a stroke, such as driving, sexu- ality, leisure, instrumental activities of daily living, re- sumption of parenting roles after stroke, mobility, and self-care. Specifi c interventions highlighted include dys- phagia management, home adaptation, and wheeled mo- bility and seating prescription. Finally, two stroke survi- vors who share their thoughts, frustrations, and experiences provide readers with invaluable insights to the stroke recovery process. It is my hope that this text will challenge practicing clinicians to consider their present approaches to stroke rehabilitation and serve as a foundation on which students can build their philosophies for intervention with the stroke population. ACKNOWLEDGMENTS I am grateful for all I have learned from the hundreds of stroke survivors I have interacted with over the past 21 years. It is my hope that this text will make a positive impact on improving the quality of life of those living with stroke. I am grateful to all of the professionals from my own community, across the country, and internationally for their contributions to this book. They accepted my challenge to put their knowledge and skill base into words. Their dedication to this project will inspire future generations of clinicians and researchers I continue to appreciate the dedication and persistence of the staff at Elsevier for supporting my work for over a decade, specifi cally Kathy Falk, Megan Fennell, Jolynn Gower, and Melissa Kuster. Glen Gillen viii Preface Contents 1 Pathophysiology, Medical Management, and Acute Rehabilitation of Stroke Survivors, 1 Matthew N. Bartels, Catherine A. Duffy, and Heather Edgar Beland 2 Psychological Aspects of Stroke Rehabilitation, 49 Janet Falk-Kessler 3 Improving Participation and Quality of Life through Occupation, 66 Timothy J. Wolf and Carolyn M. Baum 4 Task-Oriented Approach to Stroke Rehabilitation, 80 Virgil Mathiowetz 5 Activity-Based Intervention in Stroke Rehabilitation, 100 Joyce S. Sabari 6 Approaches to Motor Control Dysfunction: An Evidence-Based Review, 117 Ashwini K. Rao 7 Trunk Control: Supporting Functional Independence, 156 Glen Gillen 8 Overview of Balance Impairments: Functional Implications, 189 Susan M. Donato and Karen Halliday Pulaski 9 Vestibular Rehabilitation and Stroke, 210 Helen S. Cohen 10 Upper Extremity Function and Management, 218 Glen Gillen 11 Rehabilitation Technologies to Promote Upper Limb Recovery after Stroke, 280 Susan E. Fasoli 12 Edema Control, 307 Sandra M. Artzberger and Jocelyn White 13 Splinting Applications, 326 Stephanie Milazzo and Glen Gillen 14 Functional Mobility, 350 Leslie A. Kane and Karen A. Buckley 15 Gait Awareness, 389 Clare C. Bassile and Sheila M. Hayes 16 Managing Visual and Visuospatial Impairments to Optimize Function, 417 Glen Gillen 17 How Therapists Think: Exploring Therapists’ Reasoning When Working with Patients Who Have Cognitive and Perceptual Problems Following Stroke, 438 Carolyn A. Unsworth 18 Impact of Neurobehavioral Deficits on Activities of Daily Living, 456 Guðrún Árnadóttir 19 Treatment of Cognitive-Perceptual Deficits: A Function-Based Approach, 501 Glen Gillen and Kerry Brockmann Rubio 20 Managing Speech and Language Deficits after Stroke, 534 Celia Stewart and Karen Riedel 21 Enhancing Performance of Activities of Daily Living, 553 Birgitta Bernspång and Josefine Lampinen 22 Parenting after Stroke, 583 Judith Rogers and Megan Kirshbaum 23 Driving and Community Mobility as an Instrumental Activity of Daily Living, 598 Susan L. Pierce 24 Dysphagia Management, 629 Wendy Avery 25 Sexual Function and Intimacy, 648 Jessica Farman and Judith Dicker Friedman 26 Seating and Wheeled Mobility Prescription, 665 Mary Shea and Christine M. Johann 27 Home Evaluation and Modifications, 693 Catherine A. Duffy ix 28 Activities of Daily Living Adaptations: Managing the Environment with One-Handed Techniques, 716 Patricia A. Ryan and Jennie W. Sullivan 29 Leisure Participation after Stroke, 735 Glen Gillen 30 A Survivor’s Perspective, 748 Salvatore DiMauro 31 A Survivor’s Perspective II: Stroke, 752 Barbara E. Neuhaus x Contents 1 Pathophysiology, Medical Management, and Acute Rehabilitation of Stroke Survivors chapte r 1 k ey t er m s acute management decubitus ulcer early mobilization hemorrhagic stroke intensive care unit (ICU) ischemic stroke stroke diagnosis stroke management stroke prevention c h a p t er ob j ec t i v es After completing this chapter, the reader will be able to accomplish the following: 1. Describe the pathophysiology of stroke. 2. Explain the diagnostic workup of stroke survivors. 3. Understand the medical management of various stroke syndromes. 4. Describe interventions to prevent the recurrence of stroke and its complications. 5. Understand normal and abnormal responses to acute stroke rehabilitation. 6. Be familiar with standardized assessments used during acute stroke rehabilitation. 7. Implement a comprehensive treatment that is safe for the acute and ICU settings. 8. Write appropriate goals for the acute and ICU settings. 9. Be able to prevent secondary complications such as skin breakdown and contracture after stroke. Pathophysiology and Medical Management of Stroke Matthew N. Bartels PREVALENCE AND IMPACT OF STROKE Stroke remains the third leading cause of mortality in the United States after cardiovascular disease and cancer, accounting for 10% to 12% of all deaths. 15 , 127 Globally, stroke is the second leading cause of mortality in developed nations with 4.5 million deaths every year. 109 An estimated 550,000 strokes occur each year, resulting in 150,000 deaths and more than 300,000 individuals with signifi cant disability. 119 The United States has an estimated 3 million stroke survivors today, which is double the number of survivors 25 years ago. 54 The economic impact of stroke in 2007 was estimated at $62.7 billion, markedly increased from the estimate in 2001 of $30 billion, of which $17 billion
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