By the numbers, cerebrovascular accident (CVA) — commonly known as stroke — is staggering. The Centers for Disease Control & Prevention (CDC) says one in every 20 deaths in the United States every year is caused by stroke, and that each year, nearly 800,000 people in the country sustain CVAs.
The CDC adds that the cost of strokes — for healthcare services, medications and missed work and productivity — is an estimated $34 billion per year.
The sheer volume of CVAs means huge numbers of CVA patients get discharged from acute-care settings while still experiencing mobility impairments. The good news is that today’s seating and wheeled mobility technology could greatly support CVA clients as they return to their homes and daily routines.
But do those patients always get the help they need?
Preconceived Notions for Stroke Patients?
The CDC reported that in 2009, 34 percent of stroke patients hospitalized were younger than 65 years old. That means two of three stroke patients are 65 or older — and presumably, members of the stereotypical pool of seniors served by Medicare.
So does the age of a stroke patient impact the typical seating & mobility interventions they are offered? Do other demographics determine the complexity and robustness of function of the equipment they’re provided?
A recent study (see sidebar) by Trisha Sando, DPT, CWS, MSc, a doctoral student in the division of epidemiology, Department of Family Medicine and Population Health, Virginia Commonwealth University School of Medicine, Richmond, Va., noted that though so many stroke patients continue to have mobility deficits that impact their activities of daily living, too many aren’t referred for outpatient physical or occupational therapy.
Similarly — or as part of that same equation — people who have had CVAs are not always provided high-level seating & mobility equipment, said Lauren E. Rosen, PT, MPT, MSMS, ATP/SMS, Motion Analysis Center program coordinator at St. Joseph’s Children’s Hospital in Tampa, Fla.
“Where there’s a gap,” Rosen said, “is that in a lot of cases, people who have strokes don’t get rehab. So you’ve got an inpatient therapist and a DME coordinator for the hospital who are coordinating [the assistive technology]. They may see Mrs. Smith back again because she has a second stroke, but they don’t know the [assistive technology] outcomes, and they aren’t necessarily thinking about those outcomes.”
Even when stroke patients are admitted to rehab centers, “the place where Mrs. Smith does her rehab is not like an acute rehab place that has a seating clinic,” Rosen said. “It’s usually more like a long-term care facility kind of system, and I think that there’s just a lack of education of what [funding sources] pay for.”
Therapists providing outpatient physical or occupational therapy might also fall into patterns when recommending mobility equipment for their stroke patients, many of whom are seniors.
“I don’t know if therapists think that you can’t get that equipment for those kinds of people,” Rosen said. “‘I can’t get a good manual chair or a good power chair because Medicare just doesn’t pay for that stuff.’ I think that’s the thought process that a lot of people have.”
Evaluating CVA Patients for CRT
Sando’s work certainly suggests that something other than clinical need is preventing most stroke patients from fully getting therapy that could improve their mobility. Without that access to a therapist, stroke patients could also have reduced access to seating & mobility equipment, especially the more complex, fully functioned type typically used by other patients with neurological conditions, such as spinal cord injury.
But ideally, would a stroke patient — even one who is older — have access to the same sort of comprehensive seating & mobility evaluation that a spinal cord injury patient traditionally receives?
“Absolutely,” Rosen said. “We would have conversations about what the goals are. Does Mrs. Smith just want to be able to get around her house? Does she want to be able to go out to her garden? And we go from there.”
Among the special considerations for stroke patients, Rosen added, would be if and how the CVA impacted other functions, such as vision.
“There are some things that I have to take into account that I don’t usually have to with, for example, my patients with spinal cord injuries,” Rosen said. “Some people who’ve had strokes have visual field cuts and neglects. Sometimes I can’t do every bit of equipment I want to do because of that. It’s just not totally safe, and I have to, as a PT, refer to some of the other medical professionals to figure out the cuts and the neglects. If I’m going to do a chair for somebody, I want them to be safe, first and foremost.”
But that does not mean Rosen scales down the overall mobility goals she has for her stroke client.
“Safety is at the top of my list, but very close right underneath that is function. I just feel like too many people think, ‘Oh, stroke: hemiheight chair with an armrest.’ And I think it’s just because these therapists don’t see the after-effects [of that sort of equipment].”
When evaluating a CVA client for seating & mobility, Rosen indicated that she considers the usual breadth of technology possibilities, as she would for clients with other diagnoses.
“If you’ve had a completely debilitating stroke where you’ve got no function and no cognition, a lot of times people are best served in, for instance, a [manual] tilt-in-space chair,” she said.
When power mobility is called for, Rosen said that too often, the stroke client is defaulted to a consumer-style model: “Most people get Group 2 chairs, when clearly, positioning-wise because of the weakness and the inability to stand, they should be in Group 3 chairs.”
If she’s specifying a self-propelled manual chair for a stroke client, Rosen said she considers the same criteria she would for any other client.
“If I’m going to have them propelling a chair, I also need to look at are there any other things going on,” she noted. “If we’re talking about an older population — a lot of them have arthritis and may have had a rotator cuff tear — I would consider that with anybody who was going to propel a wheelchair, to make sure that however I design a chair, if they’re propelling, that I can get the wheel where it needs to be so I can maximize their ability to propel. Besides being heavy, you’re more likely to get a rotator cuff tear from pushing those really heavy chairs with the wheels way back. All that research that we have about wheel position and weight of chair says when you’re older and the chair weighs a ton and the wheels are way back, you tear your rotator cuff.”
So would Rosen rule out an optimally configured ultralightweight chair for a senior who’s had a stroke?
“No,” she said. “If anything, that would be where I would look first. I might not look at the same ultralight chairs that I usually do for other people because some [stroke patients] may need hemi height, and they may need something that they can operate with one hand, one leg. So I’d have to go with something with swing-away legrests that I don’t use a lot in the younger populations because I’m not as fond of folding chairs as I am of rigid-framed chairs.”
As for high-end technology such as power-assist systems and advanced electronics on power chairs, Rosen said it’s all about knowing your client’s unique needs and comfort levels.
“That is a real consideration if you’re adding anything technology based to a chair — whether or not that’s something the person is accepting of and capable of operating,” she said. “Some people, regardless of age, are just not computer savvy people. So if you give them more technology, you just make their life more difficult. That’s definitely something you have to consider with older individuals because they did not grow up around computers.”
In the end, Rosen said, clients who’ve had strokes are entitled to the same robust evaluation that other CRT clients get.
“I’m looking at all the same things that I would with anybody in my clinic. That’s the biggest thing — I should do just as extensive an evaluation where I’m looking at strength, I’m looking at range of motion, I’m looking at spasticity. The evaluation should be somewhat similar with every neurologic patient that I have come into my office, whether that be head injury, cerebral palsy, spinal cord injury or stroke. I need to look at all those things because all of those things affect their ability to sit in a chair.”