Stroke rehabilitation. Minimizing the functional deficits

Stroke rehabilitation has evolved into a complex multidisciplinary team approach that aims to return the patient with significant neurologic and functional deficits to as independent and productive a lifestyle as possible. Stroke patients should be evaluated from a rehabilitation standpoint; disabilities should be assessed in terms of their impact on function at home and in the community, both in the vocational and in the avocational sphere, and specific rehabilitation needs should be identified. Rehabilitation is expensive; however, the cost of institutionalized care in a nursing home for a long time is much greater. With effective rehabilitation programs and positive support from families and friends, about 80% of stroke patients can be successfully returned to their home environment.     

急性脑卒中患者早期康复的临床研究

目的　对比研究早期康复治疗对脑卒中患者发病早期的神经功能缺损程度、平衡功能、运动功能及日常生活活动能力 (ADL)的影响。方法　 64例急性脑卒中患者随机分为康复组及对照组 ,康复组采用综合疗法 (包括药物治疗、Bobath疗法、PNF疗法及神经肌肉电刺激等治疗 )。对照组采用药物治疗。 2 8d后分别评价两组患者的神经功能缺损程度、平衡功能、运动功能及ADL。结果　所有受试者治疗后神经功能缺损积分均明显减少 ,平衡功能、运动功能、ADL积分均明显增加 ,两组的变化均数相比 ,康复组优于对照组 (P<0 .0 5 )。结论　急性脑卒中患者早期综合康复与药物治疗相比 ,在降低其神经功能缺损积分 ,提高平衡功能、运动功能、ADL的积分上效果更好     

Le réentra?nement à l’effort au cours de l’hémiplégie vasculaire

The consequences of stroke do not include only motor and cognitive impairment, as vascular hemiplegia, but also reduced aerobic capacity. The ??Haute Autorité de santé?? is very concerned by hemiparetic stroke patients, because of the number of stroke each year, and the cost of their management. Even if training and exercise programs in stroke rehabilitation are promising for improving aerobic capacity, any specific procedures are recommended. The aim of this work is to describe the effects of exercise, and training programs in stroke patients, and to analyze the specific procedures.     

Comprehensive care of adults with acute ischemic stroke

Stroke continues to represent the leading cause of long term disability despite positive achievements in the last few years. An estimated 50 million stroke survivors world wide currently cope with significant physical, cognitive, and emotional deficits, and 25% to 74% of these survivors will require some assistance or are fully dependent on caregivers for activities of daily living. The interdisciplinary team approach, with the nurse playing the central role, is important across the continuum of care. Families must cope with the impact of stoke on their daily lives once the acute phase of stroke care is over. Studies have shown personal and environmental factors influence outcomes after stroke. Patient and family education during the acute phase of stroke care is vitally important. There is also a need to educate nursing and other members of the interdisciplinary team about the potential for recovery in the later or more chronic phases of stroke care. The goal of hospitals seeking and obtaining certification as a Primary Stroke Center is to provide the best possible outcomes for patients suffering a stroke. An organized evidence-based approach to each aspect of stroke care contributes to the quality of the outcomes and requires an infrastructure that the organized center can provide. Stroke is a complex disease process that requires the skills of an interdisciplinary team. Prevention of medical complications and neurologic deterioration is key in managing patients with acute ischemic stroke. The use of clinical pathways and physician standing orders helps to guide the team in managing the care of stroke patients in the acute phase of care. Traditionally the role of educating patients and families about the modifiable and treatable risk factors, and the nonmodifiable risk factors for stroke has been a nursing responsibility. Because patient education is a performance standard for primary stroke centers, nurses must be well informed regarding evidence-based practices associated with effective lifestyle modification strategies for a diverse population.     

Late multidisciplinary rehabilitation in young people after stroke

Purpose: Stroke has a major impact on physical and cognitive ability, and quality of life. This study aims to examine the effect of multidisciplinary rehabilitation on outcome in an Irish young stroke population.

Method: Fifty consecutive patients younger than 65 were prospectively recruited to this observational study. Physical and cognitive ability, and quality of life were measured on admission and discharge.

Results: All patients were transferred to the rehabilitation unit from the acute hospital where they had received their initial management. Median length of time from stroke onset to transfer was 112 days. After a median of 70 days, 43 patients were discharged home. Patients made significant gains in physical (Barthel index 12 to 18) and cognitive ability (mini-mental state examination 22 to 25). Quality of life improved in all eight domains of the 36-item Short Form with four domains returning to levels seen in the general population.

Conclusions: This study documents the improvements in physical and cognitive abilities, and quality of life in a sample of patients in rehabilitation. A comprehensive rehabilitation programme that includes acute and late multidisciplinary phases can improve the outcome of patients following stroke.     

INTERDISCIPLINARY REHABILITATION

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A self-medication program in a rehabilitation setting

Self-medication, while not a new concept, is infrequently used in a hospital setting. It has been utilized to a limited extent in geriatric, obstetric, pain control, and rehabilitation programs. This article describes the process of initiating a self-medication program on a rehabilitation unit, provides criteria for inclusion into the program, and discusses program results. Instituting the self-medication program required a concerted interdisciplinary effort that included nurses, physicians, and pharmacists. The program identified the difficulties rehabilitation patients have in taking their medications and allowed development of adaptive techniques. The program also identified patients who were unable to take medications properly. The self-medication program was of great benefit in the rehabilitation setting and is applicable in any institutional setting.     

三级康复训练对改善脑卒中患者运动和认知功能障碍的效果研究

目的 探索规范的三级康复训练对脑卒中偏瘫患者运动和认知功能障碍的影响.方法 采用前瞻性随机对照研究,逐步回归分析影响脑卒中患者综合功能恢复的早期变异因素,根据变异因素制订规范的三级康复训练方案.分别在各研究中心随机选取患者200例,按脑梗死和脑出血分类,以区组随机化纳入康复组和对照组各100例.2组均进行一般的神经内科常规诊疗,康复组另给予规范的三级康复训练.观察比较2组运动和认知功能改善情况.结果 脑卒中发病后6个月时综合功能结局的早期变异因素包括治疗方案、神经功能缺损(CNFD)评分、年龄、糖尿病、简化Fugl-Meyer运动功能评分(S-FMA评分)、吸烟和劳动强度;根据早期变异因素进行规范三级康复训练,发病后1、3、6个月时康复组患者运动和认知功能评分显著高于对照组,也显著高于自身入院时.结论 规范的三级康复训练对于脑卒中患者各阶段运动和认知功能的提高具有明显的促进作用.     

脑卒中认知功能损害的早期康复护理

目的 探讨脑卒中患者认知功能损害的早期康复护理。方法将68例脑卒中患者随机分为康复护理组36例和常规护理组32例,采用中文版智力状态检查表（MMSE）作为评价标准。康复护理组进行以认知功能训练为主的康复护理训练。结果对患者进行认知功能训练能明显改善患者的智能,优于治疗前和对照组（P〈0．05）。结论认知功能训练能改善脑卒中患者的智能,减少脑卒中患者痴呆的发生率,提高患者的生命质量。     

早期康复对急性脑卒中患者认知功能的影响

目的：探讨早期康复治疗对急性脑卒中患者认知功能的影响。方法：90例急性脑卒中患者分为康复组47例和对照组43例，均予以神经内科常规治疗与护理；康复组同时由经过专业训练的治疗师给予系统的康复训练。治疗前后采用简易精神状态量表（MMSE）、长谷川智力量表（HDS）、韦氏记忆量表（WMS）、临床痴呆量表（CDR）、老年临床评定量表（SCAG）、日常生活能力量表（ADL）定期对2组患者进行认知功能评价。结果：治疗第4周时康复组MMSE、WMS、SCAG、HDS和ADL评分与治疗前比较均明显改善，对照组仅WMS和HDS评分有明显改善（均P〈0.05或0.01）；治疗8周后,康复组CDR评分下降（P〈0.05），对照组MMSE、ADL、SCAG评分出现明显改善（P〈0.05或0.01），CDR则无改变。治疗后各时间段各项指标评分比较,康复组均优于对照组（P〈0.05）。结论：早期康复治疗对急性脑卒中安全有效,可明显改善脑卒中患者的认知功能。     

Short term results of outpatient vs. inpatient rehabilitation after stroke

Fifty stroke patients who had already regained basic ADL-functions were investigated at the beginning and end of either inpatient or outpatient rehabilitation of similar therapeutic intensity in the same institution. For geographic reasons, outpatient treatment could only be offered to a subgroup of patients. Neurological deficits, extended ADL-functions and quality of life (SF-36) were assessed. Patients who chose outpatient rehabilitation exhibited milder neurological deficits and better ADL-function at onset. On average, outpatient rehabilitation took about 8 days more than inpatient treatment. Under rehabilitation, gains with respect to ADL-functions and the QoL-dimensions "physical role function" and "physical functional ability" were realized. The magnitude of changes did not depend on setting. A decrease in "general health perception" may be related to the inpatient treatment of patients who would have preferred an outpatient setting. Brief periods between stroke and onset of rehabilitation and longer duration of rehabilitation treatment were significantly associated with better outcome with respect to ADL-functions.     

Quality management: program design. An interdisciplinary approach

Concepts of quality management related to program design and implementation are relatively new to the health care field. The process used to satisfy the requirements of program evaluation, business planning, and clinical care quality assurance within the framework of quality management is discussed. Using an interdisciplinary approach, the authors trace the development of a specific rehabilitation program. Such programs can allow the health care provider to be more fruitfully involved in a health care service design beneficial to the patients served.     

Comprehensive,technology-based,team approach for a patient with locked-in syndrome: A case report of improved function & quality of life

One of the most severe types of stroke is locked-in syndrome (LIS) due to the loss of almost all voluntary motor functions and a high mortality rate. The majority of the literature regarding LIS is based on case reports that utilized multidisciplinary interventions focused on improving functional communication and respiratory care with minimal focus on motor retraining. These reports were neither dynamic nor multi-sensory, and the only technology utilized was in the form of augmentative communication. There are additional types of technology frequently used in the general stroke population that can address similar motor deficits that occur in the LIS population. This case report explains an interdisciplinary approach using motor and communication interventions that are multisensory, progressive, multi-modal, and technology- based. The length of stay was 153 days in acute rehabilitation, after which the patient returned home making significant gains in overall function. In this patient, the FIM changes in motor (+42), cognitive (+29) and total change score of (+71) surpassed what was determined to be a minimal clinically important difference. These results suggest that this treatment program and approach may be a key reason why this patient was able to achieve significant functional gains and report improved quality of life.     

认知功能训练用于脑卒中后认知障碍干预的探讨

摘要：目的 探讨认知功能训练在脑卒中患者认知功能障碍康复中的价值，为临床实施认知干预提供依据。方法 将36例符合入组标准的脑卒中后认知功能障碍患者以随机分为干预组与对照组，两组均接受物理治疗、常规的作业治疗以及必要的药物治疗，干预组在此基础上还进行专门的认识训练。两组出入院时均采用神经行为认知状态检查（NCSE）量表、FIM量表评定。结果 干预组NCSE评分：干预组治疗后为43.39±3.24，明显高于治疗前35.50±3.26和对照组治疗后37.50±2.50（t=6.104 P=0.000 P<0.001）。FIM评分：干预组治疗后为76.90±17.76，明显高于治疗前54.42±22.02和对照组治疗后63.0±17.23（t=12.57 P<0.05）。结论 认知训练不仅能改善脑卒中后患者的认知功能障碍，而且还能促进患者日常生活能力的恢复。关键词：认知功能训练、认知障碍、日常生活活动、脑卒中。     

Rehabilitation of stroke patients with apraxia: the role of additional cognitive and motor impairments

Purpose : The present study investigated which additional cognitive and motor impairments were present in stroke patients with apraxia and which of these factors influenced the effects of treatment. Method : A group of 33 patients with apraxia were treated according to the guidelines of a therapy programme based on teaching patients strategies to compensate for the presence of apraxia. Patients were treated at occupational therapy departments in general hospitals, rehabilitation centres and nursing homes. The outcome of the strategy training was studied in a pre-post test design; measurements were conducted at baseline and after 12 weeks of therapy. The pretreatment scores of the patients with apraxia were compared to normscores and scores of a control group of patients without apraxia ( n = 36) to investigate which impairments are present. The following variables were analysed in order to determine which factors influence outcome: additional neuropsychological deficits (comprehension of language, cognitive impairments due to dementia, neglect and short term memory), level of motor functioning, severity of apraxia and performance on activities of daily living (ADL), and some relevant patient characteristics (gender, age, type of stroke, time since stroke, and location of treatment). Results : The results showed that the presence of apraxia is associated with the presence of additional cognitive and motor impairments. The successful outcome of strategy training was not negatively influenced by cognitive comorbidity. The outcome seemed to be more prominent in patients who were more severely impaired at the start of rehabilitation in terms of the degree of motor impairments, the severity of apraxia and the initial ADL dependence. The ADL observations, however, displayed a ceiling effect, which was taken into account in discussing the results. Demographic variables, especially age, did not predict the outcome of treatment. Conclusions : We suggest that the effect of this training is stronger in more severely disabled patients. However, neither the presence of additional cognitive impairments nor the severity of motor problems nor old age should be an indication for refraining from treating apraxia.     

The association between patients' cognitive status and rehabilitation outcome in a geriatric day hospital

PURPOSE: To assess whether and to what extent cognitive status affects functional gain in mobility and extended activities of daily living (ADL) in patients admitted to a geriatric day hospital. METHODS: During 2003, 135 older patients admitted to a rehabilitation day hospital were evaluated by the Mini Mental State Examination (MMSE) and the Cognitive Functional Independence Measure (FIM). On admission and at discharge, they were assessed by the Nottingham Extended ADL Index (NEAI) and the Timed Get Up and Go test (TUG). RESULTS: Orthopedic and stroke patients achieved significant functional gain in mobility regardless of their cognitive status. Nevertheless, cognitively intact stroke patients achieved higher admission and discharge NEAI scores, manifesting greater absolute functional gain than cognitively impaired patients. The patients' ability to extract their rehabilitation potential was significantly better. CONCLUSIONS: Cognitively impaired patients can improve in mobility and performance of extended ADL during day hospital rehabilitation. Evaluation of the patients' cognitive status may enable the multidisciplinary team to develop suitable individual programs and better allocate resources. Cognitively intact stroke patients may benefit from extended rehabilitation treatment compared to impaired stroke patients as they are more capable of utilizing their potential to achieve independence in daily tasks.     

Cognitive assessment and neurological rehabilitation

Two recent studies evaluating cognitive assessment in patients with multiple sclerosis and stroke found no benefit from providing information derived from a full cognitive assessment, and one study also failed to find any benefit following specific 'cognitive treatments'. These studies might suggest that rehabilitation teams do not need clinical psychologists. However it is already known that isolated assessment does not affect outcome, and the nature and context of the assessments and interventions in these studies simply reinforces this. Thus, given the frequency of cognitive deficits in these patients and given the strong evidence in favour of multidisciplinary teamwork in rehabilitation, these studies could be used as strong evidence that clinical psychologists should be integral members of all neurological rehabilitation teams.     

THE MEDICAL MANAGEMENT OF STROKE

The management of stroke, so long a ‘Cinderella’ condition, is changing rapidly as new developments appear for acute treatment, rehabilitation and secondary prevention. Most patients with acute stroke now need rapid assessment at hospital following the onset of symptoms. Those needing admission should be managed on an acute stroke unit for stabilisation, CT scanning and other investigation, and diagnosis, and then referred, as appropriate, to a specialist stroke rehabilitation unit. Aspirin is now the recognised treatment for acute ischaemic stroke (once primary Intracerebral haemorrhage has been excluded), and can be continued for secondary prevention. Attention should be paid to risk factors to prevent recurrence, especially treatment of hypertension, atrial fibrillation, and severe ipsilateral carotid stenosis. Patients with mild cerebrovascular disease should be managed in a specialist stroke/TIA clinic. Stroke is no longer an untreatable or unpreventable condition, and It is vital that hospitals design appropriate systems to manage patients in an interdisciplinary environment.     

Post-Stroke Rehabilitation

This Quick Reference Guide for Clinicians contains highlights from the Clinical Practice Guideline on Post-Stroke Rehabilitation: Assessment, Referral, and Patient Management , which was developed by a multidisciplinary panel of private-sector health care providers and a consumer representative. The Quick Reference Guide for Clinicians is an example of how a clinician might implement the panel's findings and recommendations on the overall management of stroke patients who need post-stroke rehabilitation programs or services before returning to a family or other living environment. Topics include medical management of patients, systematic assessment and evaluation of patients throughout acute care and rehabilitation, referring patients to appropriate rehabilitation programs, managing the rehabilitation process, discharging patients from rehabilitation programs, and reintegrating patients into family and community environments.