Focused Stroke Rehabilitation Programs

  • Published on
    05-Mar-2017

  • View
    217

  • Download
    5

Embed Size (px)

Transcript

  • This article was downloaded by: [Case Western Reserve University]On: 29 October 2014, At: 10:59Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH,UK

    Loss, Grief & CarePublication details, including instructions forauthors and subscription information:http://www.tandfonline.com/loi/wzlg20

    Focused Stroke RehabilitationProgramsMichael J. Reding MD a ba Cornell University Medical College , USAb Burke Rehabilitation Hospital , White Plains, NY,USAPublished online: 22 Oct 2008.

    To cite this article: Michael J. Reding MD (1998) Focused Stroke RehabilitationPrograms, Loss, Grief & Care, 8:1-2, 23-36, DOI: 10.1300/J132v08n01_04

    To link to this article: http://dx.doi.org/10.1300/J132v08n01_04

    PLEASE SCROLL DOWN FOR ARTICLE

    Taylor & Francis makes every effort to ensure the accuracy of all theinformation (the Content) contained in the publications on our platform.However, Taylor & Francis, our agents, and our licensors make norepresentations or warranties whatsoever as to the accuracy, completeness,or suitability for any purpose of the Content. Any opinions and viewsexpressed in this publication are the opinions and views of the authors, andare not the views of or endorsed by Taylor & Francis. The accuracy of theContent should not be relied upon and should be independently verified withprimary sources of information. Taylor and Francis shall not be liable for anylosses, actions, claims, proceedings, demands, costs, expenses, damages,and other liabilities whatsoever or howsoever caused arising directly orindirectly in connection with, in relation to or arising out of the use of theContent.

    This article may be used for research, teaching, and private study purposes.Any substantial or systematic reproduction, redistribution, reselling, loan,sub-licensing, systematic supply, or distribution in any form to anyone is

    http://www.tandfonline.com/loi/wzlg20http://www.tandfonline.com/action/showCitFormats?doi=10.1300/J132v08n01_04http://dx.doi.org/10.1300/J132v08n01_04

  • expressly forbidden. Terms & Conditions of access and use can be found athttp://www.tandfonline.com/page/terms-and-conditions

    Dow

    nloa

    ded

    by [

    Cas

    e W

    este

    rn R

    eser

    ve U

    nive

    rsity

    ] at

    10:

    59 2

    9 O

    ctob

    er 2

    014

    http://www.tandfonline.com/page/terms-and-conditions

  • Focused Stroke Rehabilitation Programs:A Review of Prospective Controlled Trials

    Michael J. Reding

    Major advances have been made in the medical and surgical manage-ment of stroke. Through carefully designed controlled studies we nowhave firm data to support the use of aspirin for prevention of further TIAor stroke due to platelet thromboemboli, the use of CoumadinR to preventcardiac embolic strokes due to atrial fibrillation, and the use of carotidendarterectomy for treatment of symptomatic carotid artery stenosis.Equally compelling data support the role of focused stroke rehabilitationteams in the management of functional disabilities following stroke.Prospective randomized studies currently available in the world litera-

    ture allow us to make several affirmations concerning the value of strokerehabilitation. They will be discussed in turn as follows: (1) Rehabilitationhas a differential effect on self-care functional deficits as opposed toneurologic impairments. (2) The more focused the rehabilitation programthe better the outcome. (3) No one rehabilitation approach has been shownto be better than any other. (4) Cost effective use of rehabilitation re-sources requires selection of patients most likely to benefit.

    REHABILITATION AFFECTS DISABILITYMORE THAN IMPAIRMENT

    The value of stroke rehabilitation is usually discussed in terms of itseffect on recovery of ambulation and self-care function. It is important to

    Michael J. Reding, MD, is Associate Professor of Neurology, Cornell Univer-sity Medical College, and Director of Stroke Rehabilitation at Burke Rehabilita-tion Hospital in White Plains, NY. Dr. Reding is Board certified in internalmedicine and neurology.

    [Haworth co-indexing entry note]: Focused Stroke Rehabilitation Programs: AReview of Prospec-tive Controlled Trials. Reding, Michael J. Co-published simultaneously in Loss, Grief & Care (TheHaworth Press, Inc.) Vol. 8, No. 1/2, 1998, pp. 23-36; and: After Stroke: Enhancing Quality of Life (ed:Wallace Sife) The Haworth Press, Inc., 1998, pp. 23-36. Single or multiple copies of this article areavailable for a fee from The Haworth Document Delivery Service [1-800-342-9678, 9:00 a.m. - 5:00 p.m.(EST). E-mail address: getinfo@haworth.com].

    E 1998 by The Haworth Press, Inc. All rights reserved. 23

    Dow

    nloa

    ded

    by [

    Cas

    e W

    este

    rn R

    eser

    ve U

    nive

    rsity

    ] at

    10:

    59 2

    9 O

    ctob

    er 2

    014

  • AFTER STROKE: ENHANCING QUALITY OF LIFE24

    review our use of the term function as opposed to impairment. TheWorld Health Organization has emphasized that neurologic injury is mani-fested at different levels as: pathology, neurologic impairment, functionaldisability and handicap.1 Pathology is expressed as a structural abnormal-ity at the tissue level. The effect of stroke on brain function produces aneurologic impairment: hemiparesis, hemihypesthesia, ataxia. Stroke atthe level of the organism as a whole produces a disability, interfering withthe way individuals walk, dress, and care for themselves. The next level ofeffect of a stroke on the individual is called handicap. Handicap is theeffect of stroke on the individuals ability to function within the family,socially, and at work.One does not expect rehabilitation to affect pathology, the encephalo-

    malacic area within the brain. It is uncertain whether rehabilitation affectsthe neurologic impairments: weakness, sensory loss, hemianoptic visualdeficit, etc.Rehabilitation has been shown to minimize disability by enhancing

    self-care function. If a patient is weak and has trouble walking then a caneand brace may be helpful. If a patient is hemiparetic and has troubledressing then adapted clothing, changing clothing styles, or using hemi-plegic dressing techniques may be helpful. Rehabilitation after stroketeaches patients to use devices and techniques which improve their abilityto perform self-care functional activities appropriate for their spectrumand severity of neurologic impairments.Rehabilitation devices and training are also helpful in minimizing the

    effects of stroke on the patients handicap interacting with others sociallyand in the workplace. Home and work modifications, for example, allowwheelchair accessibility to bathroom, recreational, and work facilities andenable patients to remain productive family and community members.

    VALUE OF REHABILITATION: RANDOMIZED TRIALS

    It is important to realize that rehabilitation is provided in differentsettings and at different intensities. The inpatient rehabilitation experienceis most intense with 24 hour medical and nursing rehabilitation care, plusrehabilitation therapy sessions 5 days per week. It implies that the patienthas more need for assistance with ADL function, has perhaps more inten-sive nursing care needs, feeding tubes, bladder care, catheterization andneed for medical supervision. Outpatient rehabilitation is usually recom-mended if the patient can be easily mobilized in the community and getfrom home to the outpatient clinic with reasonable effort. The next level ofrehabilitation care is homecare with the therapist treating the patient at

    Dow

    nloa

    ded

    by [

    Cas

    e W

    este

    rn R

    eser

    ve U

    nive

    rsity

    ] at

    10:

    59 2

    9 O

    ctob

    er 2

    014

  • Clinical Perspectives 25

    home. This is the rehabilitation option of choice if the patient is functional-ly able to be discharged home but is not able to be brought into theoutpatient clinic for logistical reasons.Rehabilitation is a process which occurs over time. The acute phase of

    rehabilitation is usually described as the first two weeks after stroke. Thesubacute phase is from two weeks to six months. The chronic phase begins6 months after stroke. There is an exponential recovery curve during theacute and subacute phase. Progress is still seen during the chronic phasebut the rate of change is much slower.With the above issues in mind, it is apparent that there are a number of

    factors to be considered in studying the value of rehabilitation followingstroke. Studies should be designed using a prospective randomizationtechnique with use of a control group to evaluate the effects of sponta-neous recovery on rehabilitation outcome. To be relevant, studies shouldassess the effects of rehabilitation on disability, not neurologic impair-ment. The intensity of rehabilitation, the setting in which it was delivered,and the time interval following stroke at which patients were treatedshould all be specified.A literature review shows that there are no prospective studies which

    compare patients not receiving rehabilitation therapy with those enrolledin a rehabilitation program. Such a study is usually considered unethical asit would deprive patients of treatment which is considered usual and cus-tomary. There are 5 studies which randomize patients to alternate rehabil-itation care on a general medical unit versus rehabilitation on a focusedstroke rehabilitation unit (see Table 1). Patients on the medical ward re-ceived physical, occupational, and speech therapy, but the process was notpart of a focused team approach to the patients functional, and socialsupport needs. The randomization process in these studies is usually basedupon which service had a bed available.The first such study was in 1979 by Feigenson et al.2 Patients were

    randomized on admission to a rehabilitation hospital to go either to ageneral rehabilitation ward or to a focused stroke rehabilitation ward. Theauthors looked at functional outcome for the two patient groups. Bothgroups received rehabilitation services. On the general rehabilitation wardthe therapists and nursing staff dealt with the full gamut of rehabilitationproblems: stroke, head injury, multiple sclerosis, Guillian Barr Syn-drome, orthopedic rehabilitation, amputation, etc. The stroke unit admittedonly patients with stroke. Over 600 patients were studied. There wassignificant benefit in favor of the stroke unit with better ambulation scoresand fewer patients requiring nursing home placement.The next study was published in 1980 by Gaff et al. from Edinburgh,

    Dow

    nloa

    ded

    by [

    Cas

    e W

    este

    rn R

    eser

    ve U

    nive

    rsity

    ] at

    10:

    59 2

    9 O

    ctob

    er 2

    014

  • AFTER STROKE: ENHANCING QUALITY OF LIFE26

    TABLE 1. Focused Stroke Rehabilitation Improves Function(Randomized Controlled Trials)

    REFERENCE SIZE BENEFIT

    FEIGENSON, Stroke n = 667 Ambulation1979; 10:5-8 Home Discharge

    GARRAWAY, Br. Med. J. n = 307 Ambulation1980; 280:1040-1043 Self-Care

    SMITH,* Br. Med. J. n = 133* Ambulation1981; 282:517-520 Self-Care

    STRAND, Stroke,1985; 16:29-34 n = 293 Ambulation

    Self-CareLength of Stay

    KASTE, World Stroke Cong. n = 243 Self-Care1992; S27 Length of Stay

    Home Discharge

    *Outpatient Program4days/week at 6 hrs/day vs. 3 days/week for 3 hrs/day vs. home care,no rehabilitation

    Scotland.3 This again was a situationally randomized study. Patients wererandomized from the emergency room to go either to a stroke unit or to ageneral medical ward. On the stroke unit the physician, physical therapy,occupational therapy, speech therapy, social work, and nursing staff allworked as a team. They met regularly to discuss patient goals, progress,and problems. They had protocols in place to assess and treat the medicaland rehabilitation problems frequently encountered in patients followingstroke. On the general medical ward every patient received rehabilitationservices but they were not part of a coordinated team approach. The studyconsisted of 370 patients. There were statistically significant improve-ments noted in favor of the stroke unit in ambulation scores and also inself-care scores.Smith et al. from Northwick Hospital outside of London randomized

    133 patients in the emergency room to be admitted either to a generalmedical ward or to a stroke unit.4 They found significantly greater im-provements in ambulation and self-care scores in favor of the stroke unit.Strand et al. in a study from Sweden randomized 293 patients seen in

    the emergency room to be admitted to a general medical ward or to astroke ward based upon bed availability.5 They found significant benefits

    Dow

    nloa

    ded

    by [

    Cas

    e W

    este

    rn R

    eser

    ve U

    nive

    rsity

    ] at

    10:

    59 2

    9 O

    ctob

    er 2

    014

  • Clinical Perspectives 27

    in favor of the stroke unit for ambulation scores, self-care scores, andlength-of-stay.Another study by Kaste et al. from Finland with a similar design and a

    sample size of 243 found benefit in favor of the stroke unit for self-carescores, length-of-stay and need for nursing home placements.These studies are best summarized by saying that there is now an

    international consensus that focused stroke rehabilitation units improveambulation scores, self-care scores and need for nursing home placementfor patients with stroke.There was a study by Wade et al. in 1985 that studied the effects of

    patient randomization to stroke rehabilitation at home versus nursing visitsto the home with appropriate health and hygiene recommendations.7 Theystudied 800 patients. Those randomized to receive home rehabilitationcare were seen by a physical therapist, an occupational therapist, and aspeech therapist. The therapists were working a half-day schedule andevaluated and treated 400 patients over two years. Working five half-daysper week each therapist had to evaluate four new patients a week, inaddition to treating those receiving ongoing therapy. They found no bene-ficial effects of the home rehabilitation program. Their study design hasbeen criticized for its lack of intensity. There are many other possiblereasons why they failed to demonstrate a treatment effect. Such negativestudies are of limited value, especially when positive effects have beendemonstrated by five different research groups as cited above.

    NO ONE REHABILITATION PHILOSOPHY HAS BEEN SHOWNTO BE SUPERIOR TO OTHERS

    It is not clear what is the optimal rehabilitation treatment approach.There are two divergent philosophical approaches; one tries to restorenormal or near normal movement, and the other tries to substitute for theloss of movement by using preserved muscle groups. The following au-thors have written therapy texts which aim to restore normal movement. In1956 Knott and Voss published the Proprioceptive Neuromuscular Facil-itation (PNF).8 In 1972 the Bobaths published the NeurodevelopmentalTechnique (NDT)9. Karr and Shepherd developed the Motor RelearningProgram (MRP) which was published in 1985.10 The traditional approachallows--even encourages--the substitution of preserved functions for thosewhich have been lost.11 The main treatment goal is functional movement.Quality of movement is of secondary importance. The Brunnstrom ap-proach uses spinal cord segmental and supra segmental reflexes to facili-tate mo...

Recommended

View more >