Identification and Management of Cognitive and Perceptual Deficits in the Rehabilitation Patient

The rehabilitation nurse frequently encounters patients who display cognitive/perceptual impairments as a result of a head injury or cerebrovascular accident. Deficits in attention, perception, memory, sequencing, and initiation may prevent the patient from reaching goals set by nurses or other rehabilitation professionals. When nurses recognize cognitive or perceptual impairments and have techniques available that will compensate for such deficits, they can more readily help patients meet rehabilitation goals.     

Determinants of mobility and self-care in older people with stroke: importance of somatosensory and perceptual functions

BACKGROUND AND PURPOSE: Somatosensory as well as mental impairments are easily overlooked after acute stroke. Furthermore, their associations with activity limitations are not fully understood. The purpose of this study was to examine this association and whether the assessment of somatosensory functions will provide information on perceptual functions after acute stroke. SUBJECTS AND METHODS: In 115 subjects who were > or =65 years of age, the following parameters were assessed 5 days after stroke: somatosensory (touch and proprioceptive), perceptual, and cognitive functions; depressive symptoms; mobility; and self-care. RESULTS: Multivariate analyses showed that normal proprioceptive function was significantly associated with better mobility. Normal perceptual and touch functions were significantly associated with better self-care. Subjects with normal proprioceptive function were 8.6 times as likely to have normal perceptual function as subjects with proprioceptive impairment. DISCUSSION AND CONCLUSION: Somatosensory and perceptual functions were significantly associated with subjects' activity levels. Normal proprioceptive function also might indicate normal perceptual function.     

Predictors of daily mobility skills 6 months post-discharge from acute care or rehabilitation in older adults with stroke living at home

Purpose. To determine the evolution of daily mobility skills from the timed up-and-go (TUG) upto 6 months after home return in older adults with stroke discharged from acute care or rehabilitation; and to identify the best predictive factors of the TUG at 6 months post-discharge.

Methods. In this longitudinal prospective study, people with stroke aged 65 years or more and discharged home from an acute care hospital (n = 82) or a rehabilitation service (n = 109) were included. The TUG was measured at discharge (T1), and at 3 and 6 months post-discharge (T2 and T3). Correlations between the TUG at T3 and sociodemographic and clinical variables, as well as physical, cognitive, perceptual and psychological measures at T1, were used in a multiple regression model to identify the best predictors of TUG at T3.

Results. TUG did not change between T1, T2 and T3 in the two groups of participants. The best predictors of TUG at T3 in participants from acute care were the use of a walking aid in daily life, age, deficits in oral expression and the presence of depressive symptoms. In participants from rehabilitation, predictors were the stage of motor recovery of the foot, the use of a walking aid in daily life, number of schooling years and memory impairments.

Conclusion. Daily mobility skills, as assessed with the TUG, did not deteriorate upto 6 months after home return in older adults with stroke. The best predictor of the TUG at T3 is the use of a walking aid during daily life in participants from acute care, and motor recovery of the foot in participants from rehabilitation.     

Predictors of handicap situations following post-stroke rehabilitation

Purpose : Many stroke survivors have to cope with impairments and disabilities that may result in the occurrence of handicap situations. The purpose of the study was to explore bio-psycho-social predictors of handicap situations six months after discharge from an intensive rehabilitation programme.

Methods : At discharge from a rehabilitation programme, participants were evaluated with instruments measuring motor, sensory, cognitive, perceptual, affective and psychosocial impairments and disabilities that may play a role in the development of handicap. Some other demographic and clinical variables, and those related to rehabilitation, were also collected. Six months later, they were re-assessed in their own environment in order to document their handicap level with the Assessment of Life Habits (LIFE-H).

Results : One hundred and thirty-two stroke patients participated in the discharge evaluation and 102 of them also participated in the handicap measurement. Relationships between handicap level and impairments and disabilities were all statistically significant. Multiple regression analyses indicated that affect, lower extremity co-ordination, length of stay in rehabilitation, balance, age and comorbidity at the end of an intensive rehabilitation programme are the best predictors of handicap situations six months later (adjusted R 2 : 68.1%).

Conclusions : In spite of its exploratory nature, this study revealed that, among a substantial number of personal characteristics, some were more related to a handicap measure and have greater predictive value. Other studies should be carried out to validate these findings and to consider more environmental factors in order to better understand factors related to the development of handicap situations.     

针灸配合康复训练对脑卒中偏瘫患者的康复作用

目的探究针灸配合康复训练对脑卒中偏瘫患者的康复作用。方法将100例脑卒中偏瘫患者随机分为观察组(针灸+康复训练)与对照组(常规康复训练),各50例。比较两组的康复治疗效果。结果康复治疗后,观察组的NIHSS、FMA、GQOLI-74及BI评分优于对照组(P<0.05)。随访1年后,观察组的正常患者占比高于对照组(P<0.05)。结论针灸配合康复训练对脑卒中偏瘫患者的康复有积极促进作用,是提升患者运动功能和生活质量的有效途径。     

Mobility status during inpatient rehabilitation: a comparison of patients with stroke and traumatic brain injury

OBJECTIVES: To compare the mobility status (admission and discharge status, change in status) between patients with stroke and traumatic brain injury (TBI) during inpatient rehabilitation and to determine the relationship between mobility status and outcome variables including length of stay (LOS). DESIGN: Prospective study. SETTING: Free-standing tertiary rehabilitation center. PARTICIPANTS: A total of 210 patients with stroke (n = 136) and TBI (n = 74) consecutively admitted for inpatient rehabilitation. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Clinical Outcome Variable Scale (COVS), a 13-item scale of mobility status (measured on admission and discharge from inpatient rehabilitation), and rehabilitation LOS. RESULTS: With age and time since injury controlled in the model, the TBI group showed a significantly higher mobility status on admission and discharge over the stroke group, but the change (improvement) in mobility status did not differ. The admission mobility status accounted for 61% and 60% of variability of the discharge mobility status for the stroke and TBI groups, respectively. The admission mobility status accounted for 40% and 50% of the variability in rehabilitation LOS for the stroke and TBI groups, respectively. Either the admission mobility status or the physical therapist's prediction of the discharge status could be used to determine the actual discharge mobility status, although the physical therapist's predictions were more accurate than using a statistical model. CONCLUSIONS: The TBI group showed a higher mobility status at admission and discharge from inpatient rehabilitation than the stroke group; however, the rate of improvement (improvement in mobility status per day) did not differ between groups. Admission mobility status using the COVS was an excellent predictor of discharge mobility status and rehabilitation LOS in stroke and TBI patients.     

3. Rehabilitation interventions: Cognitive,behavioral, and community reentry

Miller MA, Burnett DM, McElligott JM. Congenital and acquired brain injury. 3. Rehabilitation interventions: cognitive, behavioral, and community reentry. Arch Phys Med Rehabil 2003;84 Suppl 1:S12-7. This self-directed learning module highlights the cognitive and psychosocial adjustment aspects of brain injury. It is part of the chapter on congenital and acquired brain injury in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article focuses specifically on evaluation and treatment of mood and behavioral impairments after brain injury, treatment of cognitive impairments, efficacy of cognitive rehabilitation, psychosocial impact of a traumatic brain injury on families, and resources available for community reintegration. Overall Article Objective: To summarize the psychosocial and cognitive impact of brain injury in children and adults.     

针刺治疗脑卒中偏瘫进展

近10年来,针刺治疗脑卒中偏瘫的临床研究取得了较大进展,基础和临床研究均证实,针刺治疗脑卒中偏瘫疗效肯定,但这些相关研究还存在着某些不足,如疗效判定标准缺乏客观指标、临床随访时间短、随机方案不明确等,需要在今后的研究中加以改进。     

Controlling patient participation during robot-assisted gait training

Background  

The overall goal of this paper was to investigate approaches to controlling active participation in stroke patients during robot-assisted gait therapy. Although active physical participation during gait rehabilitation after stroke was shown to improve therapy outcome, some patients can behave passively during rehabilitation, not maximally benefiting from the gait training. Up to now, there has not been an effective method for forcing patient activity to the desired level that would most benefit stroke patients with a broad variety of cognitive and biomechanical impairments.     

31例脑卒中偏瘫患者康复疗效观察

目的观察现代康复综合治疗对脑卒中偏瘫患者功能恢复的影响。方法 6 1例脑卒中偏瘫患者根据是否接受康复治疗分为两组 :治疗组 31例 ,接受 1— 2个月的康复治疗 ,并辅以理疗 ;对照组 30例 ,未接受康复治疗。根据患者入院和出院时Fugl Meyer偏瘫功能评分进行比较。结果两组出院时功能评分比入院时均有增加 ,康复治疗组功能评分明显高于对照组 ,两组比较有非常显著性差异 (P <0 .0 1)。结论现代康复综合治疗对脑卒中偏瘫的功能恢复有明显的促进作用     

Spastic hemiplegia in a quadriplegic patient: treatment with phenol nerve block

A quadriplegic patient with a C6 lesion had a stroke with aphasia and right hemiplegia 20 years after his cervical cord injury. The combination of hemiplegia and quadriplegia created unusual rehabilitation problems, the most disabling of which was a painful flexion contracture of the right elbow that prevented any useful right arm function. A sequence of phenol nerve blocks produced almost complete resolution of this contracture and was a key factor in his successful return to independent living. Although phenol block is much less commonly performed in the upper than lower extremities, its judicious use in carefully selected cases may be beneficial to the patient's functional outcome.     

Rehabilitation needs of community stroke patients

Purpose: The aim was to identify stroke patients not admitted to hospital, to assess their disabilities and the rehabilitation provided.

Method: Stroke patients were notified by General Practitioners, assessed a month after stroke on measures of impairment and disability and the rehabilitation received was recorded. There were 124 patients notified and 93 assessed.

Results: Patients showed an average decline of 1.7 on the Barthel Index and 3.6 on the Extended Activities of Daily Living scale from before to after stroke. There were 27 % with severe mobility problems and 47 % with clinically relevant arm impairment. Many patients had cognitive impairment with only 9% having no deficit. Mood problems were less common with 26% anxious and 13% depressed. Significant stress occured in 15% of carers. The provision of rehabilitation was low and there was poor correspondence between impairments and services provided.

Conclusion: There is an unmet potential for rehabilitation in stroke patients not admitted to hospital.     

Cognitive rehabilitation: a pilot survey of therapeutic modalities used by Canadian occupational therapists with survivors of traumatic brain injury

This pilot study used survey methodology to gather initial information from Canadian occupational therapists on 1) the delivery of cognitive rehabilitation services for survivors of traumatic brain injury and 2) the therapeutic approaches and modalities used currently to manage residual cognitive impairments. A questionnaire was developed, field-tested and mailed to 27 sample sites across Canada, selected non-randomly. Twenty returned questionnaires (74%) were included in the data pool. The findings revealed that a wide range of cognitive impairments were seen very often, with impairments in memory being most common. Respondents used both a cognitive remediation and compensatory approach and a combination of therapeutic modalities to address impairments of orientation, attention, and memory. There was an interesting and overlapping range of specific modalities identified. Inpatient and outpatient services were offered to survivors, primarily within the first year post-injury. These occupational therapists used various resources to develop expertise in cognitive rehabilitation. Possible implications of the pilot study findings for Canadian occupational therapists are high-lighted and discussed.     

脑卒中偏瘫患者早期康复的远期疗效观察

目的 探讨脑卒中偏瘫患者早期康复的远期疗效。方法 随访对象为参加前瞻性随机对照研究后出院的２００例脑卒中患者，采用电话和书信的形式进行随访，内容包括存活者的移动能力、活动空间、日常生活活动（ＡＤＬ）能力、生活质量（ＱＯＬ）及继发性损伤。结果对照组随访到５８例，其中１例因“心脏病”去世。康复组随访到６８例，无１例死亡。康复组与对照组比较，患者的移动能力、活动空间、ＡＤＬ、ＱＯＬ及继发性损匀有显著性差     

Effects of Cardiorespiratory Fitness and Muscle-Resistance Training After Stroke

Stroke is a leading cause of long-term disability. The physical and cognitive impairments after an ischemic or hemorrhagic stroke often lead to activity limitations and participation restrictions. Many persons after stroke have a sedentary lifestyle, are physically inactive, and have a low fitness level. Physical fitness training is known to be beneficial for persons with a number of comorbid conditions or risk factors for stroke. Although exercise and physical activity are considered valuable, the evidence of their benefits after stroke is still insufficient. In this review, we summarize published randomized controlled trials regarding the effects of cardiorespiratory fitness and muscle-resistance training after stroke on physical function, activity, participation, life satisfaction, and mood. We discuss various barriers that can impede the ability to perform exercise, and the importance of reducing these barriers to increase physical fitness levels after the completion of usual stroke rehabilitation, thereby enhancing leisure, well-being, and participation in society.     

Relationship between burden of care at home and functional independence level after stroke]

OBJECTIVE: To determine the relationship between functional disability assessed with the Functional Independence Measure (FIM) and burden of care in hemiplegic stroke patients living at home. METHOD: The population is constituted of stroke survivors, initially treated in an academic inpatient Physical Medicine and Rehabilitation unit. Assessments included an evaluation of impairments (aphasia, negligence, cognitive impairment, motor impairment : Fugl-Meyer (FM) scale), disability (Functional Independence Measure (FIM) ), and burden of care (physical assistance and supervision). RESULTS: Forty-five subjects and their caregiver completed the assessments. Time spent on physical assistance and supervision were significantly correlated with FM and FIM scores. Cognitive deficits correlated with supervision time but not with physical assistance time. DISCUSSION-CONCLUSION: These results confirm the predictive value of functional independence measure relative to burden of care in a population of stroke patients with hemiplegia living at home. These results show that cognitive impairments are more specifically correlated with supervision time. This must be confirmed by studies taking into account functional and cognitive conditions of the patient, functional and psychological conditions of life of caregiver and also economical and environmental conditions of life.     

脑卒中偏瘫病人早期康复护理的研究进展

脑卒中偏瘫病人的运动功能受损而导致日常生活活动能力下降。对脑卒中偏瘫病人进行早期康复护理能够有效防止并发症的发生,提高现有功能和最大限度地恢复其自理能力。现综述近几年国内外脑卒中偏瘫病人早期康复心理护理、康复时机的选择、康复体位护理、运动功能的康复护理等研究进展。     

Predictors of stroke outcome

Findings from several studies of stroke victims indicate that consistent negative predictors of outcome are significant perceptual or cognitive dysfunction, prior stroke, delay in initiating rehabilitation therapy, the presence of nystagmus, and poor motivation. Factors associated with a good prognosis after rehabilitation include early return of voluntary movements, bladder control, high intelligence and feeding skills.     

早期康复介入对急性脑卒中重度偏瘫患者运动功能恢复的影响

Hemiplegiaafterstrokecaninfluencelivingqualityofpatientsdirectly，wetookearlyrehabilitationinterventiononacutestrokepatientswithseverehemiplegia．Patients＇motorfunctionswereim－provedapparently．Reportasfollow：１Subjectandmethod１．１Subject７７strokecaseswerefromApril１９９９～January２００２，allthepatientsaccordedwiththecriteriainstitutedonthefourthnationalcerebrovasculardiseasemeetingin１９９５．AllthecaseswereconfirmedbyCTthatinternalcarotidarterialsystemsupplementareaandinternalcapsu…     

综合康复治疗对脑卒中偏瘫患者预后的影响

目的观察综合康复治疗对脑卒中偏瘫患者预后的影响。方法将90例脑卒中偏瘫患者分为康复组和对照组各45例,康复组采用神经肌肉促进技术,同时辅以功能性电刺激、经络导平针灸等方法进行6个月综合康复治疗;对照组仅给予临床常规药物治疗。于治疗前后,采用Fugl-Meyer评分评定患者的运动功能;用Barthel指数评定日常生活活动能力。结果康复组患者的Fugl-Meyer评分及Barthel指数明显提高,与对照组比较差异有统计学意义（P〈0.01）。结论综合康复治疗对脑卒中偏瘫患者的预后明显好于单纯药物治疗。