Even Years after a Stroke, It’s Never Too Late to START

Man poses for photo

Brett Kissela, MD, Professor of Neurology and Co-Director of the Stroke Recovery Center, in his office on the UC Academic Health Center campus.

Known around the world for its pioneering work in the area of treatment and research into acute stroke, the UC Stroke Team is now making strides in what comes next: the emerging and enormously hopeful field of long-term recovery, rehabilitation and renewal. Nearly 200 stroke survivors from 10 states have benefited from sustained and intensive rehabilitation efforts through the Stroke Team Assessment and Recovery Treatment (START) Program, which celebrates its fourth birthday July 1 at UC Health’s Drake Center.

“There’s a long-held conception that, following a stroke, a patient will improve spontaneously for about six months and then hit a plateau, beyond which further recovery is minimal or impossible,” says Brett Kissela, MD, Co-Director of Drake’s Stroke Recovery Center and a specialist at the Comprehensive Stroke Center at the UC Gardner Neuroscience Institute. “We now know that this is totally wrong. The easy phase may stop at six months, and there is a likelihood that a survivor will plateau a little bit at that time. But what we now know is that you can recover for years — maybe even decades — after your stroke. It’s just harder, and it’s not going to happen spontaneously.”

The new realm of long-term recovery, Dr. Kissela says, “is the next great frontier in stroke.”

Treatments for acute ischemic stroke (one caused by a blockage) involve rapid-fire diagnosis and the delivery of clot-busting medication within 3 to 4 ½ hours of the stroke’s onset. The UC Comprehensive Stroke Center also excels in surgical and endovascular treatments of ischemic and bleeding stroke, which can be used to open stubbornly clogged arteries, remove persistent clots or shut down bleeding aneurysms.

Still, not all patients are helped by these acute treatments. Some never make it to the hospital in time for clot-dissolving medication to be an option. “The American Heart Association’s goal is to have 20 percent of (ischemic) stroke patients treated with acute stroke therapy by 2020,” Dr. Kissela says. “We’re not there, and the general consensus is that we’re not going to make it. Optimistically, we’re pushing 10 percent at this time. Published data says we’re closer to 5 percent, historically.”

This means that 95 percent of people who have suffered a stroke fail to benefit from acute stroke therapy and, if they survive, are left to cope with the often-disabling after-effects of their stroke.

These patients, Dr. Kissela says, experience a whirlwind of activity early in their recovery process: a three-day stay in the hospital, followed by a standard course of treatment at a rehabilitation center. After that, patients may receive therapy at home or in a nursing home. Or, as is often the case, they receive no additional therapy.

Bringing survivors back into the fold
This is where START kicks in: a life-affirming option for patients who have already completed standard treatments. “We have a lot of work to do in helping people who don’t get a reversal of their symptoms. And that’s what the stroke recovery clinic is about,” Dr. Kissela says. “When the six-month spontaneous recovery ends, people can feel abandoned or lost. So the idea is to bring them back into the fold and help them.”

A new patient at START begins with a four-hour visit in which he or she sees a physical therapist, occupational therapist, speech therapist, neurologist and physiatrist (a specialist in physical medicine & rehabilitation). The patient also meets the research team and is screened for all ongoing post-stroke research studies, which often provide therapy at no cost. The patient’s caregiver, meanwhile, has an opportunity to see a neuro-psychologist, who can help the caregiver develop strategies for coping with day-to-day demands.

After the visit, the team sits down as a group and develops a cohesive plan. “It’s the power of collaboration that we so often lack in healthcare,” says Dr. Kissela, who pioneered daily collaborative rounds on the neuro floor at University Hospital in 2008.

Developing a one-year plan
Privately insured patients who want long-term therapy following stroke are typically allotted a limited number of therapy visits a year, a resource that can be exhausted within a few months. The START program differs by spreading out formal therapeutic sessions over the course of an entire year and mixing in periods of at-home exercises and goal-setting, group therapy classes, exercise/wellness programs, and participation in clinical trials that include therapy.

Some research studies include functional MRI, which is used to examine neuro-plasticity, a process in which healthy parts of the brain take over jobs once performed by areas that have been injured by stroke or trauma.

“We take it in one-year blocks because of insurance,” Dr. Kissela says. “Some Medicare plans don’t have a limit, but even so, people need a variety of activities. Therapy is an intensive, interpersonal interaction, and sometimes patients need to have a break, see something new, do something new. We can facilitate that. By looking at it from 10,000 feet, we design a program that keeps the participants fresh.”

Dr. Kissela’s co-director at the Stroke Recovery Program at Drake Center is Mark Goddard, MD, Professor and Chair of the Department of Physical Medicine & Rehabilitation at UC.

Candidates for the START program include those who suffered a stroke years ago and are seeking a fuller recovery. For more information, contact Lucretia White, MBA, BSN, RN, at (513) 418-2549 or Lucretia.White@UCHealth.com.

— Cindy Starr

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