So why aren’t we prescribing it and reimbursing it well?
Studies show survivors of stroke benefit from aerobic programs with similar dosing to cardiac rehabilitation and why doing so pays dividends.
Movement is medicine and at the same time vital to optimal stroke recovery. So why don’t we prescribe it and reimburse it this same way (like cardiac rehab) after stroke?David Dansereau of Know-Stroke.org | Enable4Us.com
Survivors of stroke may face both movement disability and increased cardiovascular risks which possibly lead to further complications and a second stroke risk. Most treatment for stroke includes rehabilitation focused on restoring functional movement to complete basic ADLs with less emphasis on restoring aerobic capacity. Lack of structure and a formal recovery pathway essentially leads to a recovery dead end once movement is stopped. This contributes to further sedentary behavior and often mistakingly categorizes the patient as having reached a recovery “plateau”.
In some of our early research at EnableUs we asked care providers what were the most common reasons for their patient hospital re-admissions post stroke. This is what we learned. Medication adherence, poor blood pressure control and lifestyle choices, along with lack of access to rehab leading to falls all contributed to poor outcomes and return visits to the hospital.
So why wouldn’t a comprehensive behavior change and aerobic program similar in design to cardiac rehabilitation enable better outcomes, lower hospital re-admissions and be beneficial for survivors of stroke?
Well, turns out it does!
A study we covered on our Know Stroke podcast highlights how this comprehensive model works to enable better care. The encouraging Stroke-HEART Trials at JFK Johnson Rehabilitation Institute (Edison, NJ) findings were also reported in American Journal of Physical Medicine & Rehabilitation.
Quickly summarize findings:
Stroke Recovery Program Design
The JFK Johnson Stroke Recovery Program (SRP) provided 36 sessions of medically monitored interval cardiovascular training — as well as follow-up visits with a Physical Medicine and Rehabilitation physician along with psychological, nutritional and educational support and risk factor (such as smoking, diet and exercise) management. This was in addition to standard physical, occupational and speech therapy.
- Stroke Rehab + Cardiac Rehab = Lower Re-hospitalizations (22% lower rate) compare to those not completing program
- The cost to CMS of conventional care for stroke patients (traditional outpatient therapy and average hospital readmissions) is estimated at $9.67 billion annually. But using the Stroke Recovery Program and, as a result, reducing hospital readmissions, the study projected this would reduce overall costs to $8.55 billion. Study conclusion-estimated: over 1 Billion dollars in saving!
- The first study of the Stroke-HEART Trials looked at overall mortality. It found that those who did not complete the Stroke Recovery Program were nine times more likely to die than those who did complete the program. The study also found people in the program significantly improved their cardiovascular performance over 36 sessions and had improved function in measures of daily activities.
Takaway quotes from the primary investigators on the study-
In the United States, we’re not doing enough to prevent disability and death among stroke patients. We’re not doing enough to help them lead healthier lives. We can and must do better. The Stroke Recovery Program provides the structure to help our stroke patients adopt behavioral and lifestyle changes to lead healthier lives.Talya Fleming, MD, director, Aftercare and Stroke Recovery Program at JFK Johnson and Co-Principal Investigator of the study
Time to Think Outside the Box!
There was this thinking that you could not get stroke patients to perform cardiovascular rehabilitation due to their hemiplegia, or one sided weakness. But as physical medicine physicians, we know how to get people with serious impairment moving. Our study found that, with some modifications, stroke survivors, even those with serious neurologic injury and paralysis, could exercise safely. And we found the benefits in overall survival and health to be substantial.Sara J. Cuccurullo, MD
There’s Work to Do to Enable Better Care for Stroke!
Why? (CMS Currently Doesn’t Pay!)
CMS currently pays for 36 sessions of cardiovascular rehabilitation for patients who experience heart attacks, but does not pay for cardiovascular rehabilitation for those who experience stroke — even though both events involve the vascular system.
Be sure to join in on our next podcast as we continue this discussion about the heart and the brain and along the way work to build solutions to enable better stroke recovery.
Am J Phys Med Rehabil 2019;98:953–963
J Am Heart Assoc. 2019;e012761