January 1, 2013
““How intense should stroke rehab be?” asks expert Richard Zorowitz. “Knowing if repeating an action three hours a day is as effective as six might make it available for our frailer patients,” he says.”
As a longtime researcher/clinician and key member of national committees that shape where PM&R is going, physiatrist Richard Zorowitz helps the field bypass medical hand-wringing—a common downside when the need for outcomes research is so great. Instead, Zorowitz pushes goals, clinical and otherwise, that stand the best chance of maximizing patient recovery after stroke.
Here the chief of Physical Medicine and Rehabilitation at Johns Hopkins Bayview Medical Center tells, among other things, why Prozac figures into stroke rehab under his watch.
What do we ultimately need to know to change life as we know it for stroke survivors?
On the broadest scale, we need to know how to initiate movement or speech when a survivor has none. What neuroprotective agents can effectively prevent further brain damage? What medications and physical therapies do we combine to the greatest advantage for survivors of stroke in specific brain areas? And how to combine them? We still don’t know that.
What’s considered lower-hanging fruit?
The spotlight that’s been on acute care for stroke is at last shining on patients’ later stages, when it’s critical that they move into the right postacute environment. Patients need the most intensive therapy they can tolerate. Inpatient rehabilitation facilities may provide the best environment for stroke rehabilitation, but if a patient cannot tolerate this intensity, some skilled nursing facilities are ideal. So we set functional goals and make sure they travel with patients. And we use those and other quality benchmarks to evaluate where they’re going, to track patients and make sure they get what they need.
A real problem is what’s driving patient placement. It should be need rather than economy. It’s not uncommon to see patients denied a place they could benefit from because of insurance issues.
What else seems straightforward?
Johns Hopkins has taken a leap of faith and brought stroke-based medical issues to the forefront in rehab. Working on a CARF* consensus panel to update standards of care, I saw that lowering hospital readmissions means being medically proactive during inpatient rehab—rigorously treat hypertension, for example, and care for diabetes, hyperlipidemia and artery disease.
You don’t deny that there’s a major shortage in evidence-based research. A recent overview of stroke rehab—you were part of AHA/ASA** work—documented that, right?
Yes. The overview showed us, as little before, exactly what needs studying and how much. For example, research confirms that constraint-induced movement therapy, with its varied repeating of a motor task, helps outpatients in chronic care. But in an inpatient setting, say, with its built-in discipline, can we get the same results without such variety? There’s no good study to tell. It might even be risky for patients.
So why isn’t there more?
Some reasons have to do with funding and focus. But mostly the problem is: The research is difficult! Stroke populations are amazingly heterogeneous. Patients have varying motor, sensory or cognitive deficits, or all three. To overcome that, we’d have to have incredibly large trials. Plus, outcome measures aren’t always accurate. It’s not like giving a group blood pressure pills and measuring a pressure drop.
And the Prozac?
That shows how fast research can translate. Prozac was the topic of the first clinical trial for a neurostimulant and showed its value in rehab, letting patients stay alert. We’ve worked it into our patient pharmacy.
*the Commission for Accreditation of Rehabilitation Facilities
**the American Heart Association/American Stroke Association Science Advisory and Coordinating Committee