Skip to main content

Creating a blueprint for the future of stroke rehabilitation

UT Southwestern’s Chief of Stroke Rehabilitation discusses progress made in clinical care, research, and education

The field of stroke rehabilitation has made rapid advances in recent decades, propelled by innovations in early, coordinated, and multidisciplinary care. Still, the greatest era of innovation lies ahead with the advent of precision rehabilitation, biomarkers, and related technologies. 

Nneka Ifejika, M.D., M.P.H., a Professor of Physical Medicine and Rehabilitation and Neurology at UT Southwestern Medical Center, is a leading rehabilitation expert with a clinical and research focus in acute stroke rehabilitation, including transitions of care, outcomes, and health disparities.  

Dr. Ifejika has played an active leadership role in conducting and disseminating practice-changing research internationally and is the only female Physical Medicine and Rehabilitation (PM&R) physician who is a Fellow of the American Heart Association’s Stroke Council. In addition, she has been recognized by the National Institutes of Health for teaching and mentorship of underrepresented medical students, residents, and fellows. 

“The field of stroke rehabilitation is advancing at a rapid pace – especially around novel approaches to stroke care and treatment,” Dr. Ifejika says. “While most individuals with stroke survive, they do typically live with chronic impairments in body function and activity limitations that impact their quality of life.” 

Rehabilitation From the Time of Stroke Onset 

While there is debate regarding the precise timing and intensity of early rehabilitation after an acute stroke, experts generally accept rehabilitation’s beneficial effect on functional disability. Consequently, initiation of stroke recovery efforts from the time of symptom onset can help guide care and improve outcomes.

“Our goal is to bridge the gap between the hospitalization for acute stroke and the initiation of the ensuing rehabilitation process,” Dr. Ifejika says. 

She notes that the stroke rehabilitation program at UT Southwestern – which incorporates evidence-based rehabilitation paradigms through all levels of stroke care – is highly innovative compared to other programs nationally.  

Dr. Ifejika believes that a successful stroke rehabilitation program requires a multidisciplinary, team-based approach, one that involves neurologists, nurses, physical therapists, occupational therapists, speech therapists, social workers, and other professionals trained specifically in stroke rehabilitation and recovery. 

 “UT Southwestern has a highly collaborative environment, and in our program, we implement stroke recovery efforts from the time of symptom onset,” she says. 

A New Model for Transitions of Care 

The typical stroke patient follows a complex path from the onset of symptoms to the years following the event. Along this journey, transitions take place between the respective spheres of care. 

“Transitions of care for stroke patients are complex,” Dr. Ifejika explains. “Major transitions of care include from the place of stroke onset to acute care hospital and from there to other medical care facilities and then home.” 

To simplify these transitions, Dr. Ifejika and her team at UT Southwestern developed and tested a new transition of care model that facilitates process flow from acute stroke hospitalization to post-acute rehabilitation.  

Implementation of the team’s multistep care model resulted in multiple improved outcomes, including a reduced length of time from acute stroke admission to inpatient rehabilitation care admission, an increase in referrals to the inpatient rehabilitation facility, and a decrease in referrals to skilled nursing facilities.

“The identification of biomarkers, combined with data on disease, patient characteristics, and functional assessment, will accelerate the application of precision medicine in rehabilitation therapy.” Nneka Ifejika, M.D., M.P.H., Professor of Physical Medicine and Rehabilitation and Neurology

Dr. Ifejika and her colleagues recently published these findings in Archives of Physical Medicine and Rehabilitation. “Our model includes weekday interdisciplinary huddle rounds, which create a pathway to ensure stroke patients receive comprehensive rehabilitation care,” Dr. Ifejika explains. “We’ve also incorporated a virtual rounding tool, allowing clinicians to evaluate plan-of-care facilitation using the electronic medical record (EMR).”

Based on their findings, the researchers plan to further validate the model, with the long-term goal of implementing it in stroke centers across the country. 

Moving Toward ‘Precision Rehabilitation’ 

Precision rehabilitation involves applying the optimal type and dose of treatment at the ideal time to maximize return of function for individual patients. Currently, this strategy is of considerable interest to providers and has the potential to substantially reduce long-term disability. 

“While precision rehabilitation is conceptually appealing, building a robust research base for the approach has remained challenging,” Dr. Ifejika notes. “The identification of biomarkers, combined with data on disease, patient characteristics, and functional assessment, will accelerate the application of precision medicine in rehabilitation therapy.” 

She adds that there are many potential use cases of blood-based biomarkers in stroke care, including earlier diagnosis, aiding in triage, risk stratification for acute management, prognostication of functional recovery, and others.

In an ongoing pilot study, Dr. Ifejika and her team are identifying biomarker signals at specific time intervals during the acute stroke hospitalization period. With their findings, they hope to define a “golden window” phase during which use of a multimodal treatment intervention can boost stroke recovery. 

“We’re assessing for relevant biomarker signals within the early acute stroke interval,” Dr. Ifejika explains. “In the angiography suite, we draw blood samples before the clot is even removed from the brain – and following this intervention, we recheck to see if the biomarker levels have changed.” 

As data analysis continues, the researchers eagerly await forthcoming results, which they expect could inform the development of larger-scale biomarker studies. 

Addressing Health Disparities  

Dr. Ifejika is also working to address racial disparities in stroke care and outcomes.

“Racial differences in the treatment of post-stroke sequelae may contribute to known disparities in post-stroke function,” she says. “Improving our understanding of racial differences in functional outcomes may help home in on the underlying causes.” 

According to Dr. Ifejika, significant racial disparities exist in the treatment of common post-stroke sequelae within large hospitals across the United States. 

In a recent study, Dr. Ifejika and her team analyzed EMR data from 65 large health care organizations to identify a cohort of non-Hispanic white, Black, and Hispanic hospitalized acute stroke patients. The researchers’ goal was to quantify the magnitude and timing of racial differences in the treatment of common post-stroke complications. After analyzing the data, they found that compared to non-Hispanic white patients, Black patients were significantly less likely to receive treatment for every condition at nearly every timepoint measured (14-, 90-, and 365-days post-stroke). 

Overall, the team found the differences were greatest at 14 days, indicating that acute hospitalization and rehabilitation are crucial to identify and treat complications to reduce disparities in post-stroke function. These findings were presented at the 2023 International Stroke Conference in Dallas, where Dr. Ifejika’s group received the Stroke Rehabilitation Award and the Paul Dudley White International Scholar Award for the highest-scored abstract in the U.S. 

A ‘One-of-a-Kind’ Residency Program 

While physiatry residency training provides a variety of multidisciplinary clinical experiences, research might not be pursued by residents due to several factors, including limited research exposure and uncertainty of how to begin a project. 

“Limited resident participation in clinical research negatively affects the growth of physiatry as a field and medicine as a whole,” Dr. Ifejika says. “Resident research trainees are uniquely positioned to become future leaders of multidisciplinary and multispecialty collaborative teams.” 

To combat the shortfall, leaders within the Department of PM&R and the Peter O’Donnell Jr. Brain Institute have taken steps to create resident research programs. The research team within the Department of PM&R at UT Southwestern consists of residents, each of whom is assigned a primary mentor, a sponsor, secondary mentors, and collaborators. 

“As a resident, you get to develop your own research question and design the project with guidance from the primary mentor,” notes Audrie A. Chavez, M.D., M.P.H., a former resident in the Department of PM&R, who recently completed a brain injury medicine fellowship at Harvard University. “Residents in the team synergistically lead their own projects and collaborate on their co-residents’ projects.” 

Dr. Chavez adds that this dynamic is important because team members learn to work cohesively to implement the project and collect data despite variations in individual workload. 

“We call it a ‘research family,’” Dr. Ifejika says. “By instilling a sense of community in the work environment, accountability rises amongst our group members, and research productivity increases as a result.” 

Future Directions 

Dr. Ifejika is excited about the future of stroke rehabilitation and hopes that an improved understanding of transitions of care, outcomes, and health disparities will continue to aid efforts in recovery and reduction of long-term disability. 

“We hope our work will lead to more investigation, as the unmet medical need for stroke patients remains high,” she says.