Reading to stroke unit patients: Perceived impact and potential of an innovative arts based therapy

Objective.?This study investigated the delivery of an arts based intervention to stroke patients and sought users' and professionals' views of any perceived benefits.

Setting.?The study was undertaken on the stroke rehabilitation ward of a London teaching hospital.

Design.?Semi-structured interviews were carried out with 21 patients, 3 health care professionals and 5 reading service personnel. Observation sessions were carried out weekly for the 10-month duration of the project. Data were analysed using the Framework method.

Intervention.?The reading service, run by Interact, a registered charity, aims to entertain, stimulate and engage patients. Readers are professional actors trained to work specifically with stroke patients. Interact provide a selection of reading materials or alternatively patients provide their own material.

Results.?Participants' accounts suggested that the service met its aim of providing entertainment and stimulation. Additionally, there was some evidence that taking part in the reading service was associated with participants' emotional well being, the processes of adjusting to hospitalisation and to their engagement in rehabilitation therapies. Hospital staff acknowledged the service benefited patients with regard to spiritual, emotional/psychological needs. However they maintained that the service, as entertainment rather than therapy, was of minor importance.

Conclusion.?This arts based intervention was welcomed by patients and seemed to address some needs not met in the current configuration of care. These findings suggest that interventions such as the reading service point to ways in which it is possible to enhance the rehabilitation environment and perhaps facilitate better outcomes for stroke patients.     

Family carers of stroke survivors: needs, knowledge, satisfaction and competence in caring

Purpose. To examine the support required by family carers for stroke survivors.

Methods. Forty-two family carers were recruited for surveys of needs, knowledge, satisfaction, and competence in caring before and 4 - 6 weeks after discharge from an Acute Stroke Unit (ASU).

Results. Information deficits about dealing with psychological, emotional, and behavioural problems and local service information were priorities before and after discharge. Younger female carers (under 56 years) were least satisfied with communication with ASU staff. Face to face contact was valued. After discharge younger female carers, particularly of non-White ethnic groups, reported lower levels of competence in caring and higher burden. Knowledge of stroke risk factors was low in all groups. High satisfaction with treatment and therapy in the ASU, was not transferred to the community. Carers reported feeling alone and described uncoordinated services.

Conclusions. Carers are able to anticipate and prioritise their needs, value communication with staff and involvement with discharge-planning, but particular difficulties were experienced by younger female carers and those from non-White ethnic groups. This requires particular attention when developing targeted interventions for family carers from a mixed ethnic community. In-depth and longitudinal studies are needed to detail psychosocial needs and guide practice particularly amongst non-White family carers.     

Psychological comorbidity in medical rehabilitation--the need for education

Purpose. Prevalence of comorbid mental disorders in rehabilitation patients is high. In spite of the bio-psycho-social approach in rehabilitation, recognition and treatment rates of comorbid mental disorders during rehabilitation are low. The purpose of the study was to raise specific information about current clinical practice concerning comorbid mental disorders and training needs of rehabilitation personnel.

Method. 435 questionnaires were sent out to medical personnel in 54 rehabilitation hospitals in south-west Germany.

Results. Psychologists in rehabilitation spend most of their time on counselling (45%) and group interventions (29%). Physicians and psychologists both feel highly responsible for recognizing mental disorders and motivating patients to seek aftercare. Screeners are rarely used by psychologists and physicians. Seventy-six percent of the participants would take part in specific training sessions. High training needs were stated for affective, anxiety and somatoform disorders. A specific training session for mental health in rehabilitation should last at least half a day and cover affective, anxiety and somatoform disorders.

Conclusions. Taking these results into account, it is possible to put together a training program in diagnostics of comorbid mental disorders, which fits the needs of the professionals.     

The system for medical rehabilitation in Croatia

Purpose. To describe the framework for medical rehabilitation in Croatia and to discuss its influence on the practice of the specialty.

Methods. Collection, analysis and interpretation of data pertaining to the need for medical rehabilitation in the country and to its elements of structure, process and outcome of care.

Results. The practice of medical rehabilitation in Croatia has evolved without strategic planning on the national level and therefore without a designed system. This lack in the present framework causes shortcomings in all three elements of rehabilitation care and impedes the advancement of the specialty.

Conclusion. Medical rehabilitation in Croatia needs a national strategic plan for a three-level system that incorporates inpatient, outpatient and community-based rehabilitation.     

Physiotherapy in Afghanistan: an analysis of current challenges

Introduction. Afghanistan has high levels of disability due to prolonged conflict. An important part of the reconstruction process in Afghanistan is strengthening health service capacity and, within this, rehabilitation services.

Aims: To identify training needs of, and key issues affecting, Afghan physiotherapists.

Methods. 20 interviews and clinical accompaniment of 15 physiotherapists/physiotherapy assistants (APA) carried out in the second quarter of 2003. Analysis was using a grounded theory approach.

Results. Five themes emerged: (1) Low professional profile of physiotherapy; (2) Difficult working conditions; (3) Difficulty identifying personal training needs; (4) Difficulty with clinical reasoning at undergraduate level; (5) Variable levels of clinical competence.

Discussion. Many of the challenges facing Afghan physiotherapists are not unique to Afghanistan but are exacerbated by a lack of government recognition of the profession. War has isolated Afghan physiotherapists from completed professional links and consequently the undergraduate curriculum had not matched developments in other comparable countries. This has contributed to the difficulties therapists' experience with current clinical reasoning and accessing new practice developments. Culture also influences attitudes towards training and has restricted female travel and access to education.

Conclusions. Core training needs include disability sensitization, reflective practice and clinical reasoning. The physiotherapy curriculum needs updating and links with ongoing research need to be established to keep abreast of new developments.     

The development of a clinical practice stroke guideline for physiotherapists in The Netherlands: a systematic review of available evidence

Purpose. To develop a clinical practice guideline for the physiotherapy management of patients with stroke as support for the clinical decision-making process, especially with respect to the selection of appropriate interventions, prognostic factors and outcome measures.

Introduction. Physiotherapists have a high caseload of patients with stroke, so there is a need to identify effective evidence-based physiotherapy procedures. The availability of a guideline that includes information about prognostic factors, interventions, and outcome measures would facilitate clinical decision-making.

Method. A systematic computerized literature search was performed to identify evidence concerning the use of: (i) prognostic factors related to functional recovery; (ii) physiotherapy interventions in patients with stroke; and (iii) outcome measures to assess patients' progress in functional health. Experts, physiotherapists working in the field of stroke rehabilitation, and a multidisciplinary group of health professionals reviewed the clinical applicability and feasibility of the recommendations for clinical practice and their comments were used to compose the definitive guideline.

Results. Of 9482 relevant articles, 322 were selected. These were screened for methodological quality. Seventy-two recommendations for clinical practice were retrieved from these articles and included in the guideline: Six recommendations concerned the prediction of functional recovery of activities of daily living (ADL), including walking ability and hand/arm use; 65 recommendations concerned the choice of physiotherapy interventions; and 1 recommendation concerned the choice of outcome instrument to use. A core set of seven reliable, responsive, and valid outcome measures was established, to determine impairments and activity limitations in patients with stroke.

Conclusions. The guideline provides physiotherapists with an evidence-based instrument to assist them in their clinical decision making regarding patients with stroke. As most of the recommendations included in the guideline came from studies of patients in the post acute and chronic phase of stroke, and in general involved patients with less severe and uncomplicated stroke, more needs to be learned about the more complex cases.     

Rehabilitation medicine in countries of Central/Eastern Europe

Purpose. To describe attributes of rehabilitation medicine common to the five countries of Central Eastern Europe (CEE) and their implications for future challenges.

Methods. Critical collection and study of pertinent data on evolvement and present state of rehabilitation medicine in CEE countries by a coordinated team of rehabilitation experts from each of the relevant countries.

Results. CEE countries are similar in their need for rehabilitation medicine, its evolvement, present state and current practice. Settings largely emerged without strategic planning on the national level and lagged behind those in Central and Western Europe both in time and content.

Conclusion. The framework that evolved in all except Slovenia is not appropriate to needs. In order to meet future challenges all five CEE countries need the incorporation of inpatient, outpatient and community-based rehabilitation into one system.     

A comparison of a hospital-based and two home-based rehabilitation programmes

Purpose. This paper compares the service models of three different types of rehabilitation programmes provided in Victoria, Australia: One hospital-based and two types of rehabilitation in the home (RITH).

Method. Nine focus group interviews were conducted with multidisciplinary staff working in rehabilitation teams in one hospital-based and eight RITH programmes. Additional data were collected for 164 clients and 75 carers from eight of these programmes at admission, discharge and three months post discharge. Interviews were conducted with 32 clients and 14 carers.

Results. The criteria for admission and model of rehabilitation adopted in the three programmes were similar. There were differences in programme aims, characteristics of the clients admitted and the type and level of therapy clients received, both between hospital and home-based programmes and between the three programmes. In general, staff and clients saw the home as providing a relevant context that enabled individualized, goal directed therapy for medically stable rehabilitation clients. The hospital offered an opportunity to socialize with others and specialized equipment.

Conclusions. Results of this study suggest clients and carers require a mix of hospital and home-based rehabilitation that is able to respond to their needs and preferences at each phase of the rehabilitation continuum.     

Healing care? Rehabilitation of female immigrant patients with chronic pain from a family perspective

Purpose. This pilot study aimed to address the social context of rehabilitation by exploring the perspectives of family members regarding rehabilitation of female immigrant patients with a chronic pain condition.

Method. In-depth semi-structured, face-to-face interviews were conducted with family members of nine patients. The interviews were transcribed and subsequently coded and analysed according to themes.

Results. All participants acknowledged that their respective relative experiences pain. Pain is considered a symptom of the malfunctioning body and different explanatory notions are given. Participants regarded medication, warmth, rest or gentle exercise to be appropriate treatment options. Most participants had limited awareness of, and involvement in, rehabilitation. The role of family members in illness management lies mainly in providing advice and in taking over or assisting in domestic activities.

Conclusion. The importance of considering the patient's social context and involving family in the treatment process is indicated in the literature. However, awareness of the aim and content of rehabilitation was limited among most participating family members as was their involvement in the rehabilitation process of their relative. It is recommended that further research needs to look at factors influencing involvement of family members before effective strategies for involving family members of patients of various socio-economic and/or cultural backgrounds can be developed.     

Deep vein thrombosis and pulmonary embolism in an ambulatory chronic stroke patient

Purpose: Deep vein thrombosis (DVT) is a well-known complication of stroke and frequently develops in acute stroke patients. Immobility in stroke patients increases the risk of DVT and pulmonary embolism (PE). The incidence of DVT in non-ambulatory stroke patients is more frequent than the incidence in ambulatory stroke patients. We report a case of DVT and PE in an ambulatory chronic stroke patient.

Method: Initial physical examination showed heat and swelling of hemiplegic leg. The patient was only able to ambulate with the assist of a monocane and a plastic leaf spring orthosis due to ankle dorsiflexor weakness. The patient was treated with anticoagulation and inferior vena cava filter placement.

Results: After long-term anticoagulation, follow-up studies revealed satisfactory resolution of DVT and PE.

Conclusions: We present a case of DVT and PE which developed during the chronic stage of stroke, 2 years from the onset of stroke, and review the cause of DVT.     

Living setting and utilisation of ADL assistance one year after a stroke with special reference to gender differences

Purpose. To examine living setting and need for ADL assistance before and one year after a first-ever stroke with special focus on gender differences.

Methods. One-year survivors from a population-based stroke study (n = 377) were studied with regard to place of living, need for ADL assistance and who provided the help. Stroke severity, cognitive impairment, post-stroke depression as well as risk factors were evaluated.

Results. Before the stroke 48 patients (13%) lived in special housing (service flats or nursing homes), and one year after the stroke, 50 of the survivors (20%) lived in such accommodations. Before the stroke, 80 (21%) of the patients needed help with their personal ADL, while 90 (36%) needed help after one year. The increased need was fulfilled by relatives. Female spouses more often helped their male counterparts, and they tended to accept a heavier burden. Age, living alone, stroke severity, cognitive impairment, pre-stroke ADL dependency and depression were predictors for special housing.

Conclusions. In a time when more and more stroke survivors are cared for at home, it is important to pay attention to the situation of the caregivers. Female caregivers seem to be in an especially exposed position by accepting a heavier burden.     

Effects on work resumption of a co-operation project in vocational rehabilitation. Systematic, multi-professional, client-centred and solution-oriented co-operation

Purpose. The present aim was to evaluate the effect of systematic multi-professional co-ordinated rehabilitation (the Stockholm Co-operation Project) on the number of days' sick leave during the first and second half-years after the rehabilitation co-ordination period, compared to the year before. Another aim was to evaluate the economic effects at national level.

Method. A matched-pairs design was used. The study group was based on 64 rehabilitees employed by a public employer in Stockholm, who took part in a systematic multi-professional co-operation project. To obtain pairs, the 64 individuals were individually matched with 64 people who received conventionally organised rehabilitation. Thus, there were 128 subjects altogether.

Results. The study group had substantially less sick leave days per month than the comparison group during the second half-year after the rehabilitation co-ordination period. The effect was even greater in a subgroup with more previous sick leave. During the first half-year after the intervention the comparison group had relatively more sick leave. No effect was found for a subgroup with less previous sick leave. The economic benefit of the intervention was estimated to €1,278 per month and person based on the whole group, and to €2,405 per month and person based on those with more sick leave.

Conclusions. People who undergo co-ordinated rehabilitation have more working days after the intervention period than those with conventional rehabilitation. This way for rehabilitation actors to co-operate gives better outcomes for rehabilitation cases with long previous sick leave, but not for cases with less previous sick leave. It also generates economic gains at several levels.     

Investigation of factors related to employment outcome following traumatic brain injury: a critical review and conceptual model

Purpose: The purpose of this article is to critically review the literature to examine factors that are most consistently related to employment outcome following traumatic brain injury (TBI), with a particular focus on metacognitive skills. It also aims to develop a conceptual model of factors related to employment outcome.

Method: The first stage of the review considered 85 studies published between 1980 and December 2003 which investigated factors associated with employment outcome following TBI. English-language studies were identified through searches of Medline and PsycINFO, as well as manual searches of journals and reference lists. The studies were evaluated and rated by two independent raters (Kappa = 0.835) according to the quality of their methodology based upon nine criteria. Fifty studies met the criteria for inclusion in the second stage of the review, which examined the relationship between a broad range of variables and employment outcome.

Results: The factors most consistently associated with employment outcome included pre-injury occupational status, functional status at discharge, global cognitive functioning, perceptual ability, executive functioning, involvement in vocational rehabilitation services and emotional status.

Conclusions: A conceptual model is presented which emphasises the importance of metacognitive, emotional and social environment factors for improving employment outcome.     

The work of rehabilitation

Purpose. To describe three years of activity of a rehabilitation unit and to make comparisons between clients who receive different levels of active rehabilitation.

Method. A retrospective study set in an inpatient rehabilitation facility located in Dunedin, New Zealand, examining 874 inpatient admissions over three financial years (2000 - 2002). Outcome measures include Functional Independence Scores (FIM) at admission and discharge, length of stay, weekly gains in FIM scores, and changes in FIM sub-scores.

Results. Assessment and rehabilitation patients made significant FIM gains in comparison to assessment only and social relief (respite care) patients. Assessment and rehabilitation patients showed greater gains in the Physical dimensions of the FIM in comparison to the Cognitive although this is probably a function of different scaling. Floor and ceiling effects were not present in the FIM.

Conclusions. The interdisciplinary rehabilitation program brings about real functional and cognitive gains in a range of patients as measured with the FIM. This adds to the considerable body of research which documents FIM gains and further provides evidence that physical and cognitive gains differ.     

Rehabilitation of stroke patients needs a family-centred approach

Purpose. To highlight the importance of the spouse in stroke rehabilitation. Stroke not only affects the patients, but also their families, but rehabilitation practice is still primarily focused on the patient only.

Method. Analysis of the position of the spouse and possible consequences of stroke for the spouse, based on the literature.

Results. Three roles of spouses are described: (i) the role of caregiver, as the spouse often provides extensive and comprehensive care for the patient; (ii) the role of client, as this informal care may lead to physical and emotional strain; and (iii) the role of family member, as the stroke affects the interpersonal relationships within the family system, not least the emotional and sexual relationship between the partners. This analysis provides an understanding of problems experienced by spouses as roles conflict and identifies topics for assessment and interventions directed at the spouse in the acute phase, rehabilitation phase and chronic phase of stroke.

Conclusion. We support a family-centred approach in which the strengths and needs of all family members, the patient with stroke included, are considered throughout all phases of the rehabilitation process.     

Falling between two stools; how a weak co-operation between the social security and the unemployment agencies obstructs rehabilitation of unemployed sick-listed persons

Purpose. To explore significant factors behind the weak co-operation between local social insurance and unemployment agencies impairing the rehabilitation of unemployed sick-listed persons.

Method. Individual, semi-structured face-to-face interviews with main actors directly involved in the sick-listing and rehabilitation process were conducted in the year 2000. In all 39 persons were interviewed: 25 professionals (physicians, public employment and social insurance officers) and 14 clients. Data were analysed according to Grounded theory method.

Results. The majority of unemployed sick-listed persons were declared too sick to work and were erased from the unemployment registers. This measure weakened the incentives for co-operation between the two main rehabilitation actors. The implication was that the unemployed sick-listed persons lost the opportunity of the co-ordinated rehabilitation they were entitled to. Three significant factors behind this process were identified by the main actors: indistinct regulation of co-operation, shifting political goals over time and conflicting goals between agencies; the last factor mainly a consequence of the other two.

Conclusions. The findings suggest that labour market changes and manifest political goals influence the rehabilitation efforts giving low priority to difficult-to-place individuals such as unemployed sick-listed persons. In fact, a labour market problem turns into a medical problem. The hypothesis needs further testing in quantitative studies.     

Work-related hand injuries: case analyses in a Brazilian rehabilitation service

Purpose. Professionals who work with rehabilitation of the hand usually assess performance components as their main outcome measures. Intervention is aimed at normalization of deficits of these components, with the expectation that the integrity of the structures and functions of the body will revert to improvements in the client's functional performance. The objectives of this study were to describe changes in patients who received rehabilitation in a Brazilian public hospital after having suffered hand injuries due to workplace accidents, and to examine the relations between performance components and levels of functioning.

Methods. Observational cross-sectional study was used. A convenience sample was selected, including 42 patients assessed at service admission and at discharge. Assessed characteristics included grip strength, wrist and finger range of movement (ROM), sensitivity, and self-perceptions of functional performance (COPM). Statistical procedures included correlations between performance components and COPM scores and differences on selected variables at admission and discharge.

Results. Significant improvements in all assessed functional components. COPM values increased more than 100% after intervention (effect size d = 1.996 for performance and d = 1.553 for satisfaction) demonstrating improvements in both domains. Low correlations between grip strength and COPM scores were found only at admission (r = 0.314; p = 0.045). When the relationship between gains in strength and COPM scores at discharge were examined, significant correlations were found with the performance (r = 0.324; p = 0.039) and satisfaction (r = 0.0326; p = 0.038) subscales.

Conclusions. Results of this study provide evidence for functional gains in clients treated in a rehabilitation service and supply information about the relation between specific components and functional performance.     

A study of the physical rehabilitation and psychological state of patients who sustained limb loss as a result of terrorist activity in Northern Ireland 1969-2003

Objective. To benchmark the psychological state and physical rehabilitation of patients who have sustained limb loss as a result of terrorist activity in Northern Ireland and to determine their satisfaction with the period of primary prosthetic rehabilitation and the artificial limb.

Method. All patients who sustained limb loss as a result of the Troubles and were referred to our rehabilitation centre were sent a questionnaire. The main outcome measures were the SIGAM mobility grades, the General Health Questionnaire (GHQ12) and three screening questions for Post Traumatic Stress Disorder (PTSD).

Results. Out of a 66% response rate, 52 (69%) patients felt that the period of primary prosthetic rehabilitation was adequate; 32 (54%) lower limb amputees graded themselves SIGAM C or D; 45 (60%) patients stated that they were still having significant stump pain. Significant stump pain was associated with poorer mobility. Nine (56%) upper limb amputees used their prosthetic limb in a functional way; 33 (44%) patients showed “psychiatric caseness” on the GHQ 12 and 50 (67%) had symptoms of PTSD.

Conclusions. Most patients felt that the period of physical rehabilitation had been adequate; those who did not were more likely to be having ongoing psychological problems. A high percentage of patients continue to have psychological problems and stump pain.     

Upper limb recovery after stroke: the stroke survivors' perspective

Purpose. This study investigated stroke survivors' perspective of upper limb recovery after stroke. The aim was to determine factors other than medical diagnosis and co-morbidities that contribute to recovery. The objectives were to explore how stroke survivors define recovery, identify factors they believe influence recovery and determine strategies used to maximize upper limb recovery.

Method. A qualitative study consisting of three focus groups and two in-depth interviews was conducted with stroke survivors (n = 19) and spouses (n = 9) in metropolitan, regional and rural Queensland, Australia. Data were analysed using principles of grounded theory.

Results. Stroke survivors maximize upper limb recovery by 'keeping the door open' a process of continuing to hope for and work towards improvement amidst adjusting to life with stroke. They achieve this by 'hanging in there', 'drawing on support from others', 'getting going and keeping going with exercise', and 'finding out how to keep moving ahead'.

Conclusions. This study provides valuable insight into the personal experience of upper limb recovery after stroke. It highlights the need to develop training strategies that match the needs and aspirations of stroke survivors and that place no time limits on recovery. It reinforces the benefits of stroke support groups and advocates their incorporation into stroke recovery services. These findings can be used to guide both the development and evaluation of stroke survivor centred upper limb training programmes.     

No advantages of Gamma nail over sliding hip screw in the management of peritrochanteric hip fractures: a meta-analysis of randomized controlled trials

Purpose. There is a lack of consensus regarding the best option for the operative treatment of peritrochanteric fractures. A meta-analysis was performed to assess the surgical outcomes of peritrochanteric fractures.

Methods. Only prospective, randomized studies comparing Gamma nail and sliding hip screw (SHS) fixation in adults were included. Eleven studies met the inclusion criteria: the target population consisted of patients with peritrochanteric fractures, while subtrochanteric fractures were not included; the intervention was SHS compared with Gamma nail; the study was a published randomized trial. Each outcome measure tested was assessed for heterogeneity. If significant heterogeneity was present, data from the studies were not combined. If there was no significant heterogeneity, a combined relative risk was calculated using a fixed effects model and a Z-test was performed to test the overall effect.

Results. A total of 1344 peritrochanteric fractures entered into the included studies. There were no differences of mortality, cut-out, non-union, re-operation, wound infection, intra-operative fractures of femur, blood loss or surgical time.

Conclusions. It seemed that there were no obvious advantages of Gamma nail fixation over SHS fixation in treating peritrochanteric fractures.