Amy Fuhs, MDc


Nominated From: University of Washington

Research Site: Peru

Research Area: Neurology; Stroke

Primary Mentor: Dr. Joseph Zunt

Research Project

Post-Stroke Rehabilitation in Lima, Peru

To provide appropriate management of neurological and psychological impairment following stroke, it is important to assess neurological impairment, levels of functional disability, family support, quality of life, and improvement over time. This is best accomplished through the use of standardized assessment tools, such as the NIH Stroke Scale, within the first 24 hours of stroke presentation. Results should be communicated with the patient and caregivers, and patients should be reassessed upon hospital discharge. We propose to prospectively assess current capacity for assessment and treatment of common disabilities in patients with stroke receiving care at the Instituto Nacional de Ciencias Neurologicas (INCN), including: motor function, cognition and communication, swallowing, nutrition and hydration, bowel and bladder function, ability to perform Activities of Daily Living (ADLs), skin breakdown and risk for deep venous thrombosis (DVT), level of pain and mental health.

The American Heart Association (AHA) and American Stroke Association (ASA) have developed guidelines for post-stroke care that aim to assess and improve outcomes in various spheres of daily living, including: gait, locomotion, joint integrity, circulation, posture, range of motion, reflex integrity, sexual activity, balance, and aerobic capacity. In addition, many patients require adaptive equipment, durable medical equipment devices, orthotics, and wheelchairs following stroke. We propose to conduct structured qualitative interviews with neurologists, patients and caregivers – during the initial hospitalization following stroke and during outpatient visits – to identify areas in physical, occupational and speech therapy where guidelines are met and areas where guidelines are not met. We will request details regarding current processes for referral to rehabilitative and adaptive services, availability of services, proximity of services to place of residence, and out-of-pocket costs associated with these services. Using an implementation science approach, we will create process flow charts to identify areas that inhibit access to rehabilitative services.

Using results of the process flow charts, we will work with the directorship of the INCN, as well as physicians directing stroke and rehabilitation services at the INCN, to develop a strategy to improve provision of rehabilitative services during and following hospitalization for stroke. Areas for improvement that have been identified by Peruvian neurologists include: early mobilization of acute stroke patients to reduce DVT, skin breakdown, contractures, constipation, deconditioning, and pneumonia; early therapy initiation with range-of-motion exercises and progressive increase in activity levels to increase likelihood of patient resuming self-care activities; and involvement of patient’s family/caregiver in decision-making surrounding the rehabilitation setting and treatment plan, as well as training to assist the patient with functional activities. Patients should follow up with primary care within one month of discharge and continue with secondary stroke prevention and exercise programs.