Shannon Scott, OTR/L
Thursday, December 19th, 2013
According to the American Heart Association (AHA, 2013) stroke can occur at any age however recent studies indicate that over the past 15 years there has been an increase in the incidence of ischemic stroke occurring in young adults (George, Tong, Kuklina, & Labarthe, 2011). Risks associated with increased obesity, hypertension, diabetes, and tobacco and alcohol use have been proposed factors contributing to this rise (George et al., 2011). With increased rates of survival, younger individuals are living longer with disability and the direct and indirect costs associated with healthcare and lost productivity can be significant (George et al., 2011; Wolf, Baum, & Connor, 2009). According to AHA (2013), loss of earnings is projected to be the highest costs associated with stroke.
Most healthcare costs in the United States (US) are paid for through employer based health insurance and federal programs, such as Social Security and Medicare, are financed through payroll taxes (Shi & Singh, 2012). Even if employed, many individuals do not have any, or have variable, employer based health insurance coverage, with women being more disadvantaged than men (Shi & Singh, 2012). A large percentage of young stroke survivors are unable to return to work (Wolf et al., 2009) with the rate of unemployment for those with stroke significantly higher than the rate of unemployment in the general population (O’Brien & Wolf, 2010). Recent reports indicate there has been a significant rise in the number of working age individuals claiming early disability and income replacement benefits (Hackett, Glozier, Jan, & Lindley, 2012).
With the age of the general population increasing, further financial strains on federal programs will occur when these individuals retire and there is an additional decrease in working taxpayers (Shi & Singh, 2012). It is therefore even more critical to retain people in the workforce (Hackett et al., 2012). In addition, after stroke, the inability to return to work (RTW) can contribute to “occupational deprivation, social isolation, and…physical and psychological consequences” (Fowler, 2013, p. 3) and RTW has been associated with significantly higher levels of self-worth, well-being, socialization, and life satisfaction (Wolf et al., 2009).
In the US, 795,000 new or recurrent strokes occur every year (AHA, 2013). Women have a higher incidence of stroke with 55,000 more women than men experiencing stroke each year (AHA, 2013). A recent study indicates that almost 45% of strokes occur in individuals less than 65 years of age with 27% occurring in those less than 55 years of age (Wolf et al., 2009). The estimated direct and indirect cost associated with stroke in 2010 was $73.7 billion (AHA, 2013) and it is estimated that 25% of all costs and 58% of indirect costs are associated with lost productivity (Wolf et al., 2009).
In 2012, 86% of social security insurance benefits paid were due to disability or blindness; the annual rate of increase in disabled beneficiaries was 2.2% compared to 1.6% retirees; the average age of individuals receiving disability benefits decreased to 53.2 years; and the proportion of women receiving disability benefits rose to 48% compared to 49% of women retirees (Social Security Administration, 2013). Stroke is the leading cause of disability in the US and it is projected that by 2030, an additional 4 million individuals will experience stroke (AHA, 2013) and according to some studies, only 53% of stroke survivors return to paid employment (Glozier, Hackett, Parag, & Anderson, 2008). In addition, by 2030, 19% of the general population will reach retirement age (Shi & Singh, 2012) with 86% of retirees relying on Social Security benefits as their major source of income (Administration on Aging, 2012).
In a cohort of young stroke survivors, 82% experienced mild to moderate stroke (Wolf et al., 2009). Those with moderate stroke typically demonstrate motor impairments which result in the provision of rehabilitation services (O’Brien & Wolf, 2010). Upper extremity (UE) function has been determined to be the main contributing factor to independence in ADL’s (Harris & Eng, 2007) which is a strong predictor of ability to RTW after stroke (Hackett et al., 2012). It is reported that 80% of stroke survivors have some level of impaired UE function during the acute and subacute stages of stroke (Brauer, Hayward, Carson, Cresswell, & Barker, 2013) and 45% of stroke survivors have impaired UE function at 18 months post stroke (Welmer, Holmqvist, & Sommerfeld, 2008). Research on UE recovery after stroke recommends early, intensive, and task oriented treatment approaches (Brauer et al., 2013).
Implications for Rehabilitation
The rehabilitation and recovery of young stroke survivors differs from those who are older secondary to the greater incidence of mild to moderate stroke; the likelihood of a better neurological recovery with less need for institutionalization; and their unique psychosocial, supportive, and social needs (Mahon et al., 2012). Current therapy services utilize outcome measures and interventions that tend to focus more on body functions and independence in basic and instrumental ADL’s (O’Brien & Wolf, 2010) and the vocational needs and issues of young stroke survivors are often neglected (Mahon et al., 2012). Discharge recommendations are typically based on measures of impairment and predominantly rely on outcomes measures that focus on motor impairment and ADL’s and less on activity participation and life satisfaction (Edwards et al., 2006; Wolf et al., 2009). Even for those who do receive therapy services, those with mild to moderate stroke are not successful in reintegrating back into everyday living (Wolf et al., 2009) and many clinicians report still utilizing neurorehabilitation treatment interventions that are not supported by the research (Natarajan et al., 2008).
Clinicians need to be current with the literature and aware of the distinct needs and issues associated with a younger stroke population. They need to utilize assessment tools that not only address motor impairments and ADL’s, but that are sensitive to all aspects of participation, to include work, family, and community integration, to identify impairments that might otherwise go unseen and make accurate discharge recommendations (Wolf et al., 2009).
Clinicians need to learn, embrace, utilize, and advocate for access to, and reimbursement of, evidence based interventions and technologies to ensure provision of the most effective and meaningful interventions during the limited clinical time they have available (Doucet, 2012). The US healthcare system does not currently support the level of treatment intensity that the literature documents as being needed to facilitate optimal recovery due to limited visits and therapy caps and therefore clinicians must also develop and advocate for alternative models of service delivery (Mahon et al., 2012).
With increased legislative interest in better understanding the brain and RTW initiatives for young stroke survivors, along with increased resources for research funding, clinicians can play a critical role by engaging in research to better understand the RTW issues for young stroke survivors, create new assessment tools, and develop and determine effective vocational and community based rehabilitation services (Wolf et al., 2009).
Clinicians can also advocate on behalf of their clients on issues that help them receive needed RTW services (Fowler, 2013) such as permanently repealing the Medicare therapy cap and supporting the RTW Act introduced to congress on May 22, 2013 by Senator Mark Kirk (R-IL) and Representative Joyce Beatty (D-OH), both stroke survivors, which was created to promote increased awareness and assistance among employers and employees through the Job Accommodation Network, US Department of Labor’s Office of Disability Employment, to enable stroke survivors to RTW (NSA, 2013).
In order to meet societal needs for health and well-being, clinicians must and can help by optimally addressing the unique needs of a growing population of young stroke survivors (Wolf et al., 2009).
Shannon Scott, OTR/L, is the Clinical Assistant Professor at Stony Brook University Southampton. She is a graduate of the University of British Columbia in Vancouver, Canada and is currently pursuing her doctorate in OT through Quinnipiac University. She has over 23 years of clinical experience, specializing in Neurorehabilitation. She is Level One Brain Injury Certified and is NDT trained. Shannon was one of the first 10 therapists trained in the use of Saebo. Prior to teaching at Stony Brook, Shannon was the Director of Clinical Services at Saebo.
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Wolf, T. J., Baum, C., & Connor, L. T. (2009). Changing face of stroke: Implications for occupational therapy practice. American Journal of Occupational Therapy, 63, 621-625.
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