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Ahead of their time
Monday January 21, 2013
PTs work with stroke patients at the Rehabilitation Institute of Chicago

(Photo courtesy of RIC)


I Frankie Muniz, a 27-year-old actor best known for his role on the television series "Malcolm in the Middle," revealed on his Twitter account that he had recently had a transient ischemic attack, otherwise known as a mini-stroke.

Muniz told People magazine he had most of the classic symptoms of stroke: The vision in his right eye began to blur, his hands went numb, he was dizzy and unbalanced, he had difficulty speaking, and he felt like he was being "stabbed in the head."

The celebrity has recovered, but represents a growing trend in the U.S., according to a report released in 2011 by the U.S. Centers for Disease Control and Prevention. The report showed the rate of hospitalization for ischemic strokes among those ages 15-44 rose by up to 37% from 1995 to 2008.

A more recent study in the October 2012 journal Neurology supports the CDCs findings. It showed that in the estimated 1.3 million population of the Cincinnati/Northern Kentucky region the proportion of all strokes in people younger than 55 increased from 12.9% in 1993-94 to 18.6% in 2005.

Among whites ages 20-54, the rate rose from 26 strokes for every 100,000 people, to 48 per 100,000. Among African Americans in the same age group, the rate climbed from 83 to 128 per 100,000.

"This is of great public health significance because strokes in younger patients carry the potential for greater lifetime burden of disability and because some potential contributors identified for this trend are modifiable," the Cincinnati researchers wrote.

The increase may be attributed to an increase among younger people in risk factors, including obesity, diabetes and high blood pressure, researchers suggested. At the same time, more patients presenting stroke symptoms are receiving MRIs and other tests that better identify stroke once hospitalized.

"Why it’s happening is a tough question," said Ryan Pelo, PT, DPT, staff physical therapist at the patient recovery unit at the Rehabilitation Institute of Chicago, a national leader in stroke rehabilitation. "There is conflicting evidence on why strokes are occurring in the younger population."

PTs work with stroke patients at the Rehabilitation Institute of Chicago
(Photo courtesy of RIC)
Intense therapy showing results

PTs working with younger stroke patients are finding success with more intense therapy than generally is given older stroke patients. At RIC, where almost half of stroke patients are younger than 55, therapy includes using overhead safety harnesses, treadmill systems and other equipment with safety provisions that allow for more intense therapy. Patients move over a variety of surfaces and navigate stairs in therapy, which aims for dramatic increases in steps taken each session, Pelo said. "There’s a lot of data that suggests high repetition and high intensity can have positive results on stroke patients," he said.

For example, early results for one gait trial over variable environments at RIC show promise, with patients taking an average 3,000-4,000 steps per session — up to 10 times more than a typical stroke rehab session.

Pelo said the physical therapy sessions for young stroke patients are generally an hour a day, which is not any longer than usual, but the sessions are much more productive. "We try to do the entire hour walking," he said. "Before, we would work on transfers to stand and bed mobility in that hour — walking was the final goal. But now with only walking we’re seeing good results. Improved walking leads to improved transfers and improved bed mobility."

PTs work with stroke patients at the Rehabilitation Institute of Chicago
(Photo courtesy of RIC)
Fewer comorbidities

In 1984, the New England Rehabilitation Hospital in Woburn, Mass., began a stroke program specifically for younger patients that was one of the first such programs of its kind, said Mary Fiorentino, PT, therapy supervisor in the stroke and brain injury unit there. The 210-bed acute facility has seen a steady increase in strokes among its younger patients.

In 2012, approximately 12% of the hospital’s admits were 55 and younger for the young stroke program with the youngest being age 31, Fiorentino said. For patients 65 and younger, the rate was 24%, she said.

Physical therapy often is different for this patient group, she said. "Most of these younger patients are employed and may have children still at home," Fiorentino said. "Their goals are completely different than an elderly patient who may be home and more sedentary."

Therapy can be more intense because younger stroke patients generally have fewer comorbidities, said Kate Martel, MPT, CKTP, staff PT at New England Rehab. "You can push them harder," she said. "If they are elderly and have arthritis or incontinence, they might not be able to use our therapy pool. Or if they have a cardiac condition or a pacemaker, they can’t tolerate intense therapy."

Also, health insurance for the younger population often covers more therapy sessions than Medicare does, Fiorentino said. "These patients typically have managed care insurance and can stay longer," she said. Typical therapy sessions, including physical, occupational and speech, at the hospital are three hours a day, five days a week and can last for more than a month, she said. Under Medicare, a stroke patient typically will receive only two or three weeks of therapy.

Another approach used for young stroke patients at the hospital is Neuro-Integrative Functional Rehabilitation and Habilitation, said Danielle Dreyfus, MPT, CKTP, a staff PT trained in the technique. "The approach is to only assist with what the patients are lacking," she said. "It focuses on normal movement versus settling for compensation."

Because younger patients often are able to respond to therapy better and make full recoveries, working with them can be rewarding, Fiorentino said. "Some of the young stroke patients come in with no movement on one side of their body," she said. "They [leave] here, and you would never know there was a problem." •

Teresa McUsic is a freelance writer.

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Monday January 21, 2013
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