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Melanie Cole (Host): UAB Medcast is an ongoing medical education podcast. The UAB Division of Continuing education designates that each episode of this enduring material is worth a maximum of 0.25 AMA PRA Category 1 credit. To collect credit, please visit uabmedicine.org/medcast and complete the episode’s posttest.

Approximately 800,000 patients experience a stroke in the US with Alabama having one of the highest rates in the country. Here to tell us about that is Dr. Chen Lin. He’s an Assistant Professor in the Department of Neurology and the Director of the Stroke Recovery Clinic at UAB Medicine. Dr. Lin, tell us about the current state of stroke care today. What’s the prevalence, the societal and global impact of stroke and what is different now about what we know about this disease?

Dr. Chen Lin (Guest): Hi Melanie, thank you for inviting me to talk with you about this very important topic. Stroke is the leading cause of disability in the world. As you mentioned, approximately 800,000 patients a year experience a stroke in the US and there’s 7,000,000 people in the US that live with stroke on a daily basis. Now here in Alabama we have one of the highest rates of stroke and we have the worst stroke mortality rate in the country. Despite all of that, only 30% of stroke survivors receive any outpatient stroke rehabilitation which results in less than optimal recovery. A lot of focus in current stroke treatment is on acute therapy, so getting the patient to the hospital as quick as possible to receive medication or surgical procedures but more and more focus is now on the outpatient side as well and transitions of care.

Host: Dr. Lin, as we’re going to talk about rehabilitation, which can result in this suboptimal recovery and the fact that they’re not getting it – I want to go back to something you said, why do you think that Alabama has such a high mortality, is it because of the rural areas or because awareness of the symptoms, and the acronym FAST and just not getting to the emergency room in time? What do you think are some of those reasons?

Dr. Lin: I think you’ve mentioned two very important factors. There’s a lot of territory in Alabama and it’s something that we face in the entire country really where there’s a shortage of neurologists and a shortage of comprehensive stroke centers and so Alabama has the University of Alabama Birmingham, which is the only comprehensive stroke center in the state, but also one of the reasons for the high mortality rate is genetics as well. So we often think of stroke as both an environmental factor and a genetic factor. So there’s things that we do that we can control and there’s things that we do that we can’t control. So unfortunately, some people do have bad genetics and there is a whole segment of the research world in stroke that is focusing on the genetics of stroke as well.

Host: Tell us about some of the latest advances going on in the treatment of stroke, including anything new that you can discuss with TPA or mechanical thrombectomy with tPA, what do you want to tell us?

Dr. Lin: So there’s a lot of great research going on and really the advent of tPA or IV alteplase in the last two decades has really transformed acute stroke care and so we’re able to – before whereas we were just watching people come in with stroke and weren’t able to do anything about it, well now with both tPA, alteplase, and mechanical thrombectomy, we have a high chance of making these people better. We’re able to change the way that people recovery from stroke just based on their acute intervention, but not just that, the fact that we have to educate patients, educate our own healthcare system, has been transforming how we get people from the community into our hospitals to deliver this care and beyond that care, in the hospital setting itself, we know that people in hospitals that have dedicated stroke units with dedicated nursing care, dedicated therapists, dedicated neurologists who all work together to provide stroke patients with the optimal evidence based research and care, we’re able to improve their outcomes and decrease mortality rates and in the long term we have to think about how we can stop people from having recurrent strokes, so more and more data is also coming out on the correct medications and the correct tests to do to find out why people are having strokes and what we could do to prevent recurrent strokes and what I’m interested in the most is in stroke recovery and rehabilitation. So prior to a lot of the acute care, that was where a lot of the focus and recovery research was focusing on therapy and how much therapy and the intensity of therapy. Unfortunately, we don’t have the correct dose, we don’t know the right dose to give in therapy, but we do know that early therapy can be beneficial in select populations. So we’re starting to see studies and trials that are focusing on patients not after years of stroke but soon after the stroke, several weeks, several months and so I think that is where one major factor will come into play in the next few years where we’ll learn about what we can do besides this therapy and develop new pharmaceuticals and new device interventions that we can implement in the subacute setting, or as I define that, after a few weeks of their stroke.

Host: Tell us a little bit about the Stroke Recovery Clinic at UAB and it’s one of only a handful of similar clinics across the whole country. Tell us a little bit about it.

Dr. Lin: Thank you for asking about the Stroke Recovery Clinic. We hope to improve some of the serious concerns regarding stroke and it’s high incidence and prevalence of disability across the southeast and particularly in Alabama. So the Stroke Recovery Clinic is a multidisciplinary clinic with the mission of improving the continuum of care for patients with stroke. We’ll be able to evaluate the stroke cause, evaluate how to best prevent future stroke, and determine patient rehabilitation needs all in one multidisciplinary clinic. Patients will have the opportunity to see multiple different providers including a neurologist, physiatrist, and therapist, all of whom are experienced providers in stroke care. During the clinic visit, we can tailor the services needed depending on the individual’s needs. This allows patients one convenient opportunity to be evaluated by multiple important services all in one appointment. You had mentioned the Stroke Recovery Clinic is one of only a handful of clinics across the country that are able to offer multidisciplinary care in the outpatient setting for stroke patients and it’s one of its only types like this in the southeast and in Alabama. In addition, our clinics will be focused on improving quality of care and outcomes after stroke. We’ll have unique opportunities for patients to participate in new research studies exclusive to UAB for stroke rehabilitation recovery in addition to some national clinical trials coming down the pipeline. The clinic will be hosted at the Outpatient Clinic at Spain Rehabilitation Center at UAB and it’ll occur every 4^th Thursday of the month.

Host: Can you share with us how the timing and intensity of rehab affects recovery? Do you have some predictors of treatment response and some insights into why recovery plateaus after several months? What might be done to prevent this from occurring?

Dr. Lin: That’s a great question. So every study has proven that rehabilitation is beneficial for stroke patients. Now what we don’t know is the correct timing and the dose of rehabilitation that would benefit each patient from stroke early on in their course and so while there is early therapy after stroke during hospitalization, early and intensive therapy has not been shown to be beneficial. In fact, it could potentially cause more harm in patients. But that being said, early therapy is still something we still try to strive for in at least the acute hospital setting. Now that shouldn’t stop in the acute hospital setting. That’s something that we want to encourage in the Stroke Recovery Clinic because we see patients in clinic that are recently hospitalized. So within a week, a few weeks after their hospital stay and I think that is where we should continue to encourage and motivate patients to participate in therapy, get therapy, exercise, especially since you’re an exercise physiologist, you should – you know the importance of exercise here. So this is a continual lifelong process and that is the same considered for stroke recovery and wide plateaus. So natural recovery does slow down roughly between 6 months to a year after stroke, but we believe that stroke rehabilitation and recovery is a lifelong process. So even though the improvements after this one year are not known to be as large, people do get better. In fact, most stroke rehab and recovery trials in the past have focused on after a year, but that being said, more trials are looking at within a few weeks to several months, particularly in this outpatient period of time, and so I think the community has started to focus on the fact that we can intervene and change this plateau, and so often times it does take the effort of the patient, the family, and friends to help at this point to remain motivated. Sometimes there needs to be extra motivation, which is where our clinic can help and I think that’s why research opportunities in stroke recovery and rehab are so helpful because they provide additional resources and opportunities to improve. In fact, we have a study here with students here at UAB looking at how to improve motivation in stroke rehab and recovery. Again, while we do know of this traditional plateau, we do believe now that this is modifiable.

Host: Dr. Lin, one thing I found interesting in my research, was that with this recognition, that stroke units, thrombolytic therapy, enhanced rehab can improve patient care and outcomes as you said and hopefully reduce that plateau that might happen after 6 months, does this afford you the opportunity to focus on aspects of stroke care with stroke survivors and their families, their caregivers, to help with those transition across care environments whether its in the rehab setting, in the hospital, at home, tell us a little bit about that?

Dr. Lin: I think you’re absolutely correct in that the transitions of care has been becoming more and more important and a major aspect of the transitions are caregivers and so right now with the Stroke Recovery Clinic, we’re going to be working with the caregivers in determining their needs as well as the patients because we know that with the longitudinal care patients, the primary caregiver, their family or friend, are going to be very important in participation of the primary patient’s care because they often have disabilities that wouldn’t allow them to do certain activities and those are the people that are going to be able to help them and so when therapists work with patients, they’re also working with families and so when we’re in this clinic, we’re going to be able to work with the families, talk with the families, and get a sense of what their needs are, and as you had mentioned with the stroke unit in the hospital, well there’s not a model that is consistent across outpatient care, and so that’s something that we’re trying to develop in this recovery clinic, which is develop this unit of care, and so your family is as important as our therapist, our providers are as important as people you see in the community, and so we’re going to be there to help motivate the patient into participating in their recovery as much as they can. Most of our patients are very motivated, that’s why they’re in the clinic in the first place. So talking with you, getting the word out into the community, that this is a resource available I think is also a part of the educational component to allow more people and understanding that there are things we can do after stroke and even before stroke, so there’s lots of things that are done in the stroke world that people need to know about.

Host: Couldn’t agree with you more. So wrap it up for us Dr. Lin, what would you like other providers to know about the stroke recovery model that you’re using there at the stroke recovery clinic at UAB Medicine and when you feel it’s important that they refer?

Dr. Lin: So this Stroke Recovery Clinic is a new endeavor for our UAB community and there aren’t many models in strokes like this. So that leaves us a great opportunity that we get to create our own. All clinic patients will have an opportunity to participate in a dedicated recovery registry where we get to look at several stroke specific outcomes including quality of life and the caregiver concerns. We’ll also be able to identify new studies when they’re available and which patients to participate in the new stroke rehab and recovery studies. Now these are just some of the ways that will be different from a routine clinic and I think for referrals and other providers, understanding that stroke is a transition of care, longitudinal care, it’s not just about what we do in the hospital; it’s about what happens in the clinic setting and there’s lots of other things that we can be looking at including ways to prevent future strokes, what tests we’re doing to look at those stroke etiologies and then all the therapy components, all the research components added on, so at any point after a patient is discharged from the acute hospital, or their inpatient rehab, there’s an opportunity that they would benefit from the stroke recovery clinic. The fact that we have stroke neurologists, we have physiatrists, we have multiple therapists, we have neuropsychologists, social works, all in our clinic means that there’s going to be a chance that the stroke patient would benefit from at least two of our services.

Host: It is such a comprehensive program and Dr. Lin, thank you so much for coming on and for explaining the stroke recovery model and what other providers can take away from that and use and why they should be looking to UAB for that model. Thank you again for joining us. A community physician can refer a patient o UAB Medicine by calling the MIST line at 1-800-UAB-MIST, that’s 1-800-822-6478. You’re listening to UAB Medcast. For more information on resources available at UAB Medicine, you can go to uabmedicine.org/physician, that’s uabmedicine.org/physician. This is Melanie Cole, thanks so much for tuning in.