Prevention of Secondary Stroke in VA: Role of Occupational Therapists and Physical Therapists

By Schmid, Arlene A.; Butterbaugh, Lisa et al. | Journal of Rehabilitation Research & Development, September 2008 | Go to article overview

Prevention of Secondary Stroke in VA: Role of Occupational Therapists and Physical Therapists


Schmid, Arlene A., Butterbaugh, Lisa, Egolf, Courtney, Richards, Virginia, Williams, Linda, Journal of Rehabilitation Research & Development


INTRODUCTION

Each year, approximately 700,000 people in the United States sustain a stroke [1]; approximately 200,000 of these are recurrent strokes. Stroke risk is increased in those who have had a stroke [2], with more than 12 percent of those with stroke or transient ischemic attack (TIA) experiencing a second stroke event within 1 year [3-4]. This increased risk persists for at least 5 years [5]. Furthermore, 15 percent of strokes are preceded by a TIA [6]. These data suggest that persons who have had a stroke or TIA should be targeted for stroke risk-prevention strategies.

The American Heart Association (AHA) identifies numerous risk factors for stroke [7]. While some of these factors are not modifiable (e.g., age, heredity), numerous modifiable risk factors exist (e.g., atrial fibrillation, obesity, tobacco and alcohol use, hypertension, physical inactivity) [8-9]. Rodgers et al. state that prevention of a first or second stroke is possible through identification and control of stroke risk factors [10]. Modifiable risk factors are most effectively managed through a combination of lifestyle and medication management and, thus, require the combined and collaborative efforts of providers and stroke survivors [11-12].

Hoenig et al. state that stroke survivors are at an increased risk of a second stroke because of continued unhealthy lifestyle choices regarding stroke risk factors [13]. One method of encouraging lifestyle changes in stroke survivors is through health promotion (HP) and disease prevention interventions aimed at known modifiable stroke risk factors. Such factors may include diet, lifestyle and daily routine, degree of social support, amount of exercise, and sense of autonomy [14].

Department of Veterans Affairs (VA)/Department of Defense (DOD) stroke rehabilitation guidelines were published in 2005 [15] (as an executive summary of the AHA clinical practice guidelines for stroke rehabilitation [16]) and specifically identify HP and secondary stroke prevention as integral aspects of stroke rehabilitation. The inclusion of stroke prevention in the rehabilitation guidelines underscores the need for rehabilitation professionals such as occupational therapists (OTs) and physical therapists (PTs) to include prevention-oriented goals to reduce the likelihood of a second stroke.

The American Occupational Therapy Association's "Occupational Therapy Practice Framework: Domain and Process" emphasizes the support of function and occupational performance and mandates the integration of HP activity during therapy [17]. OTs focus on including participation (community integration, return to work, volunteering, social participation), which represents a step toward an integrated view of health and a relationship with HP [18]. OT wellness and HP programs with older adults have successfully demonstrated major improvements in vitality, general health, general mental health, social function, and absence of health-based role limitations [14,19-20].

The "American Physical Therapy Association Guide to Physical Therapy Practice" also emphasizes the use of HP techniques [21] and is concerned with the maximization of movement potential through promotion, prevention, treatment, and rehabilitation. Through qualitative interviews, Rea and colleagues found that while PTs believe they are introducing patients to HP, fewer people than desired are reached [21]. While providers, including therapists, may be knowledgeable about the impact of risk-factor modification, they may not aggressively counsel or engage individuals in behavioral modification to prevent a second stroke [22].

This study assessed whether OTs, PTs, OT assistants (OTAs), and PT assistants (PTAs) in Veterans Health Administration (VHA) Veterans Integrated Service Network 11 (VISN 11) were aware of the VA/DOD stroke rehabilitation guidelines and whether they used HP techniques and concepts during rehabilitation to assist in management of stroke risk factors and secondary stroke prevention. …

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