REVIEW PAPER

Stroke Issues in Recovery and Rehabilitation

M Jane Riddoch Glyn W Humphreys Andrew Batemun

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Key Words Attention deficits, stroke, stroke rehabilitation. e f f icy studies for stroke, proprioceptive loss. Summary The rehabilitation of survivors of stroke places heavy demands on NHS resources. Studies investigating the efficacy of stroke rehabilitation have produced equivocal results. We argue that the research methods used may be inappropriate, the research ques- tion may be too general or there may be a failure to take account of factors other than the physical problems following stroke.

General Factors Associated with Stroke Pathology Stroke is the third most common cause of death and a major cause of hospital resource consump- tion, not only in acute-care hospitals but also in institutional long-term care (Kaste et al, 1995). The incidence in the UK has been given as 1.7-2.0 per 1,000 population per year (ie 450 cases per year in an ‘average’ UK health district of 250,000 people (Wade et al, 1985). Cifu and Lorish (1994) state that, of acute stroke survivors, 10% are not disabled, 40% are mildly disabled, 40% have moderate to severe disability requiring special services, and 10% require long-term care; in addi- tion, 70% live for one to three years after stroke, and 30% live 11 years or more. The nature of the disability will vary: 50430% will have some form of motor deficit, 25% a sensory deficit, and 30% will have speech disturbances (Wade et al, 1985). These figures demonstrate that the treatment of stroke accounts for considerable amounts of NHS budgets. Most stroke patients show considerable recovery of function over the first few months, some argue that little further functional recovery will occur after the first three months (Andrews et al, 1981; Olsen, 1990) and the exact extent and duration of this recovery is variable (Wade et al, 1985).

Prognostic Indicators for Recovery FoLlgwing Stroke Different studies identify various factors as prognostic for recovery following stroke. The asso- ciation of increasing age with poor outcomes hae been noted in a number of studies (see Jeffery and Good, 1995, for a review). Cognitive impairment as a result of a stroke has also been found to result in poorer rehabilitation outcomes (see Jeffery and Good, 1995, for a review). For instance, Wade et a2 (1985) propose that the most important adverse prognostic factor both for survival and recovery of function is urinary incon- tinence (if present a t 7 to 10 days after stroke). Wade et al claim that the degree of weakness of the limbs was not found to be a prognostic factor (in their study at least) and suggest that therapy should be directed at improving cognitive function rather than poor motor function. A number of studies have reported that acquisi- tion of independence takes longer and is more difficult for patients with right as opposed to left brain damage (eg Denes et al, 1982; Miller, 1985); although other studies have shown that perfor- mance in activities of daily living (ADL) to be unrelated to lesion side (eg Wade et al, 1984). Right hemisphere pathology is often associated with attentional deficits (in particular, unilat- eral neglect), and it is of interest to note that at least five studies have shown that patients with attentional deficits are significantly more impaired in ADL than patients with no attentional deficits (Denes et al, 1982; Fullerton et al, 1986; Henley et ~2,1985; Kinsella and Ford, 1980; Wade et al, 1983). More recently, Blanc-Garin (1994) has also argued that motor recovery following stroke may not be a straightforward indicator of outcome; her conclusions were based on the results of multi- component analysis of the data obtained from a group of 90 patients with hemiplegia. Data were collected from three main sources: sensorimotor (including motor ability and somatic sensitivity of both upper and lower limbs), hc t iona l (walking and hand utilisation abilities), and ADL. In addi- tion, a number of different measures of attention were taken; these included visuo-spatial explo- ration both ipsi- and contralesionally, and the effect of an additional cognitive load on visuo- spatial exploration (these effects were assessed by

letter cancellation tasks). From these data it was poeeible to determine the severity of impairment at the time of admission relative to discharge, the time taken to attain the discharge level, and the extent of change. On the bases of subsequent statistical analyses, Blanc-Garin stressed the dangers of over generalisation and global interpretations, arguing that inter-individual variability was a significant factor and that recovery was a multi-dimensional progress. A preliminary statistical analysis allowed identi6- cation of two main sub-groups of patients: the consistent recovery group (in this group functional improvement was correlated with motor improve- ment) and the functional lag group (the walking and ADL skills of patients in this group seemed lower than expected from their motor abilities, and functional recovery appeared delayed). The consistent recovery group formed the major part of the sample (62.2%), and consisted of approxi- mately equal numbers of right and left brain damaged patients. "here was a greater proportion of patients with right brain damage in the func- tional lag group (78% of the patients within this group). The effect of various variables on recovery was explored: thew variables included age, lesion aide and attentional variables. BlancGarin (1955) concluded that severity of initial paralysis was an 'ambiguous' predictor of discharge level; recovery followed M e r e n t patterns across the sample of patients - there was nu homogeneous pattern. Similarly, neither age nor lesion side could be viewed as simple predictors of outcome; however, a signi6cant correlation between ADL and general attentional processes was demonstrated for the sample as a whole.

Others have implicated proprioceptive loss as significant in eventual functional outcomes. For instance, Smith et ul(1983) documented a signif- icant loss of proprioceptioa in 44% of sample of patients with stroke (N = 218). In 20 patients (W), proprioceptive loss was the dominant cause of disability and major neurological deficiQ all had a right cerebrovascular accident (CVA). Of the proportion of the total sample with significant proprioceptive loss, 60% had been discharged home by a lbweek c u t 4 point (25% were inde- pendent in self-care). This contrasts with 92% of the sample that had shown no significant pmprio- ceptive loss (78% were independent in self-care). The significance of proprioceptive impairment in the eventual functional outcome has been further demonstrated by Nakayama et al (1994) who charted the time course and degree of recovery of upper extremity function in a population of 421 stroke patients. The extent of recovery was shown to be related to the degree of paresis on admission, and most recovery was shown to occur in the first

two months after stroke. Patients with well preserved sensation achieve greater improvement in motor functions than patients with gross sensory deficits (Kusoffsky et al, 1982). Interest- ingly, a relationship has been shown between somatosensory function (as assessed by somatosensory evoked potentials) and motor recovery in the upper but not the lower extremity (Kusoffsky et al, 1982). This may be because (1) the leg is used for weight bearing in locomotion whereby sensory pathways other than proprio- ception are activated, or (2) gait control is based to a large extent on centrally generated activation patterns which function relatively independently of peripheral sensory mechanisms: in contrast co- ordinated movements of the arm and hand require an intact cortical proprioceptive sensory feedback for fine control (Kusoffsky et al, 1982). In summary, it appears that patients with right hemisphere damage have a poorer prognosis; in particular, when the damage is associated with attentiod dysfunction and/or pmprioceptive loss.

Consequences of Stroke The World Health Organisation (1980) provided a classification system by which the consequences of disease may be identified at three different conceptual levels. The three levels are that of impairment (defined as loss at the level of an organ), disability (reflecting the consequences of impairment in terms of functional performance and activity by the individual), and handicap (the social consequence of disability related to cost, disadvantage and stigma, etc). On the whole, rehabilitation professionals focus assessment and intervention on the impairments resulting from stroke, and relatively little attention is paid to aapecta of disability and handicap (Condie, 1992; Wood-Dauphinee et al, 1994). The impairments resulting from the stroke include impairments of consciousness, physical impairments (eg including sensation, strength, range of movement, tone and co-ordination), cognitive impairments (eg perception, language, memory), visual impair- ments (eg field defects), emotional problems, and Urinary impairments (eg incontinence). However, as far as patients are concerned, intermediate and long-term outcomes have equal (if not greater priority) than short-term outcomes and it is important that rehabilitation professionals look to the global results of a stroke in addition to short-term goals and expectations in therapy (Wood-Dauphinee et al , 1994).

For stroke survivors, rehabiliktion, advice and/or counselling may come from a number of different professional sources. For instance, physical prob kms are usually considered to be the mncern of physiotherapists and occupational therapists;

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cognitive problems are seen to fall within the domain of neuropsychologisb, occupational andlor speech therapists. Psychological and social prob- lems are seen to be the remit of psychologists and social workers respectively. However, it is prob- ably not in the best interests of patients to compartmentalise the different problems in this way; principally because they may all signifi- cantly influence treatment outcome (Stachura, 19941, but also because not every rehabilitation department has access to all the different specialisms. Generally speaking, rehabilitation tends to focus on the physical problems resulting from stroke; relatively little time and/or few resources are spent on the assessment (and possible rehabilitation) of any cognitive, psycho- logical andlor social difficulties. It is clear, however, that cognitive, social or psychological problems may have significant effects on the outcome of the rehabilitation process. For instance, consider some of the Merent cognitive impairments that may result from a stroke; these may include impairments of comprehension, memory, visual recognition, attention, etc. Such deficits can have profound effects on physical functioning. For instance, the patient must be able to understand the therapist’s commands; remember the therapist’s instructions; recognise physical objects in the environment; attend equally to both sides of space; maintain arousal levels sufficiently to co-operate throughout a treatment session and continue to implement what the therapist has taught throughout the remainder of the day, etc. If one of the aims of rehabilitation is to optimise treatment outcomes, consideration should be paid to all factors that may have influence on those outcomes.

Efficacy of Stroke Rehabilitation Trials investigating the efficacy of rehabilitation for stroke in general (rather than the specific treatment methods) have had equivocal results. Dobkin (1989) argues that focused stroke rehabil- itation programmes do not improve outcome. A similar conclusion is reached by Dombovy et al (1986) on the basis of a review of clinical trials. Ottenbacher and Jannell(1993) examined the effectiveness of programmes of stroke rehabilita- tion on functional outcomes by means of the methods of meta-analysis. The results of 36 trials (from a total of 124 clinical trials conducted between 1960 and 1990) met selection criteria and were evaluated. The number of patients in total waa 3,717. The results indicated that the average patient receiving a programme of focused stroke rehabilitation performed better than approxi- mately 65.5% of those patients in comparison groups.

Despite the inconclusive results of maearth triale, practitioners and doctore remain convinced that, without specific physiotherapy intervention, stroke patients would suffer a greater degree of impairment and dependence. The dearth of clear evidence regarding cost effectiveness and cost benefits of rehabilitation must be a cause for concern. It was estimated in 1985 that an un- rehabilitated stroke patient cost society about 8100,OOO (about €64,000) more over the course of his or her life than did a rehabilitated stroke survivor (Scharfenberger and Ill, 1989). It is also the case that stroke rehabilitation must be evalu- ated in terms of the quality of life of the ~urvivor, not just the cost to the NHS; and in both instances, it is crucial to demonstrate that stroke rehabilitation is effective. However, as we have indicated above, research trials investigating the efficacy of rehabilitation have resulted in equiv- ocal results. We suggest that this may be the result of a number of M e r e n t factors including (1) the use of an inappropriate methodology, (2) the generation of research questions which are too general, given the current state of knowledge of the role of physiotherapy in stroke rehabilitation, and (3) failure to consider different outcome levels.

Use of Inappropriate Methodology The standard research method used to inv-te efficacy involves some form of randomieed controlled trial. In theory, statistical comparisons should be made between a treatment and a no- treatment group; in practice, however, in recent years, it has become difficult to perform such studies because of ethical considerations and the expectations of patients and families. As a result the majority of the clinical trials included in the Ottenbacher and Jannell(1993) review consisted of comparisons being made between one group receiving some standard treatment (the compar- ison group) and another group receiving more intensive or specialised rehabilitation (the treat- ment group). The use of randomised controlled trials is problematic because the population under investigation - stroke patients - is very heteroge- neous. Individuals will differ not only according to site, size and location of lesion, but also (in the context of this paper) sseociated cognitive deficits. In addition, they wil l also differ according to sex, age, pre-morbid health, social circumstances, etc.

In a randomised controlled trial, interpretation of results rests entirely on the exact comparison of the two groups prior to treatment, and this is so whether a comparieon is between a no-treatment and treatment group, or between atan- treat- ment and intensive/specialised treatment. Assignment of patients to the two different groups

can be done either by matching or by randomisa- tiom Matdung ia the more rigomus procedure and consists of deliberately assigning patients based on patient characteristics. However, even if all the variables on which such matching should be done are known, adequate .matching is problematic because there are too many variables likely to be correlated with recovery (age, sex, time since onset, severity, intellectual level, social circum- stances, etc). The problems for the group study approach should certainly not be underestimated. Robertson (1994) uses the example of research into the effectiveness of AZT in the treatment of AIDS to point out that contradictory results are produced even with well controlled and method- ologically sound group studies using very large numbers of patients. Group studies require multiple replications before a particular treat- ment strategy may be accepted with confidence (Robertson, 1994). This is costly, time consuming and probably premature for physiotherapy prac- tice where it remains unclear which treatments should be applied to whom and when in the course of the disorder.

An alternative methodology is the single-subject design. This form of methodology is used in many fields by different professional groups (eg applied behaviour analysis, clinical psychology, social work, special education, communication disor- ders, etc (see Kratochwill, 1992); its use has also been demonstrated in therapeutic settings (Campbell, 1988; Lennon, 1992; Ottenbacher, 1986; Riddoch, 1991; Riddoch and Lennon, 1991, 1994). Riddoch and Lennon (1994) have argued that the problems identified with the group study approach may be overcome by the use of single- subject experimental designs, and that a series of well controlled single cases (in which similar treatment procedures are used to address similar physical problems in a number of different indi- viduals) may produce consistent patterns of results which can be seen to be supportive of a particular intervention for a particular physical problem.

The Research Question A different problem with many studies evaluating the efficacy of stroke rehabilitation is that they have taken a wide perspective, investigating factors such as intensive wmus normal treatment (Sivenius et al, 19851, treatment on a specialist stroke unit versus treatment in the general ward (Kaira, 19941, comparison of the neuro-develop- mental (Bobath) and Brunnstrom methods (Wagenaar et al, 1990) etc. As yet, no specific therapy has been shown to be better than any other (Johansson, 1993). Before attempting to address larger questions such as those above we

believe that it is crucial to establish that physio- therapy is effective in stroke rehabilitation over and above factors such as spontaneous recovery. Following stroke, most surviving stroke victims improve over time, particularly over the first three months. This improvement may be related to rehabilitation procedures (although as we have indicated, the efficacy of these procedures remains unproven). In addition it has been argued that there is a degree of plasticity of the adult brain and it is possible that undamaged brain tissue may take over some of the functions of the area of infarction (Bach-y-Rita, 1990). Both experi- mental studies with animals (Dietrich et al, 1987) and positron emission tomography (PET) studies in humans (Chollet et al, 1991) suggest that ipsi- lateral motor pathways may play a role in the recovery of motor function aRer ischaemic stroke. The relative contributions of rehabilitation proce- dures and neural plasticity in the recovery of the stroke patient have not been assessed.

Studies that have had a narrower perspective have produced some interesting results. As an illustration, consider some of the recent reports on rehabilitation of proprioception. For instance, Carey et a1 (1993) were able to show effective training of tactile discrimination in a case series, and effective training of both tactile and proprio- ceptive discrimination in a series of four multiple baseline designs. Magnusson et al(1994) demon- strated that a group of patients who received sensory stimulation - in the form of acupuncture both manual (bi-lateral) and electrical (uni- lateral) on the affected side - showed significant differences in balance, mobility and ADL. These differences were maintained two years after stroke. In addition, Taub et a1 (1993) have argued that poor functional use of the upper limb may not be the result of sensory and/or motor impairment, but may reflect learned disuse. They explored the effects of restraining the unaffected upper extremity in a sling for 14 days. All subjects were at least one year after stroke, and the treated group showed extensive improvement which was maintained during a two-year follow-up period. The control group showed only small to moderate improvement which was not maintained.

Levels of Outcome Outcome measures may be taken at a number of different levels. For instance, evaluation may be relatively specific and focus at the level of impair- ment (eg range of motion, strength, sensory status). At a more general level it may focus at the level of function which may be relatively specific (eg the ability to get in and out of bed, dress, eat, etc) or may evaluate the more complex aspects of human functioning (eg the ability to work, run a

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household, participate in leisure activities, etc). The clinician is likely to be concerned with more specific measures which enable patient progress to be monitored (and allow for change in treat- ment programmes if the patient fails to improve at a desired rate); however, while treatment may result in improvement of a specific impairment, the effects may not be seen to be important if changes at the level of impairment do not contribute to changes at the more complex levels of human functioning (ie at a level at which there are likely to be major financial implications both for the patient and for the community). Wood- Dauphinee (1994) have indicated that there are numerous measures of impairment which are well developed, reliable and valid. There are also a number of scales for assessing ADL. However, there are relatively few measures available for the assessment of handicap, health status or health related quality of.life. In order to answer ques- tions about the efficacy of treatment following stroke, it is essential to consider all levels of human functioning.

Treatment of Stroke by Physiotherapists Rehabilitation of stroke patients may be approached in a number of distinct ways; for example, the Brunnstom, Rood, &bat and Knott, and Bobath methods (see Swenson, 1983, for a review). In general, in the UK, the treatment for neurological patients has largely been based on Bobath principles (Bobath, 1977,1978) although elements of the other methods may also be incor- porated. This approach was originally developed for use with children with cerebral palsy. The essence of the treatment is the attempt to replace pathological motor function with normal move- ment patterns which follow a definite develop- mental sequence. The same principles are applied to adult patien@ with motor dysfunction. Recently the Bobath approach has been ques- tioned (Anderson and Lough, 1986; Carr and Shepherd, 1980,1989; Stachura, 1994), and argu- ments have been made for a systems approach (ie psychological systems haye a natural tendency to compensate for component limitations and therefore have an important role to play in reha- bilitation (Anderson and Lough, 1986), a motor learning model, the basic assumption of which is that training a motor-disabled person should be both task- and context-specific (Carr and Shep- herd, 1980, 1989) and a multifaceted approach, focusing on physical, social and pey~hdogical factors (Staehura, 1994). Unfortunately, there have been a few attempts to validate the different approaches to stroke rehabilitation and those that have do not demonstrate differences between

the different methods (Dickstein et aZ, 1986; Johansson, 1993; Wagenaar et d, 1990).

Conclusiope In the UK there is a high incidence of stroke, and moderate to severe disability is the expected outcome for up to 50% of the survivors. Poor outcomes appear to be particularly associated with right hemisphere damage (particularly when this is associated with attentional andlor proprio- ceptive deficits). The efficacy of etroke rehab- ilitation in general, and by physiotherapists in particular, appears largely unproven. At the level of individual patients it seems essential to perform theoretically motivated assessments (including assessments at the level of disability and handicap, not just at the level of impairment). Such assessments should include measures of arousal, attentional orienting and proprioception; if patients show impairments in these abilities, they should be seen as primary in importance for targeted interventions. At a global level, it is crucial that properly designed, methodologically sound studies are undertaken. Given the prob- lems outlined above, studies should perhaps consist of a series of experimental single case studies. In the future it may prove possible to reduce the effects of or eliminate stroke incidence by pharmacological means; until then, both for the individual stroke victim and for society (since it is at this level that costs are born) it is essential to demonstrate that treatment has the effect of reducing both impairment and disability.

Acknowkdgments This work was supported by a Stroke Association Grant to all three authors and by a Medical Research Council Grant to the first two authors.

Authors M Jane Riddoch PhD CPsychol MCSP is a senior lecturer in psychology, Glyn W Humphreys PhD CPsychol FBPS Is a professor in psychology, and Andrew Bateman BSc MCSP is a research d a t e in psychology at the University of Birmingham. This article was received on April 28.1995. and accepted on July 19, 1995.

Address for Correspondence Dr M J Riddoch, Cognitive Science Research Centre, School of Psychology. University of Birmingham, Birmingham 815 2lT.

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