A blueprint for transforming stroke rehabilitation care in Canada: the case for change

Teasell RW, Foley NC, Salter KL, Jutai JW. A blueprint for transforming stroke rehabilitation care in Canada: the case for change.Stroke is a major source of disability in Canada and other developed countries, which carries with it a high toll in terms of personal suffering for the stroke survivor and their family in addition to the associated economic costs. Despite the impressive body of evidence describing effective and feasible stroke rehabilitation practices, stroke survivors, their families, and health professionals currently do not benefit from a rehabilitation system that is well organized and evidence based. Using the principles of best evidence, we make the case for needed changes to the current system based on 5 processes of care known to be important in the pursuit of optimal outcomes: (1) admission to specialized stroke rehabilitation units, (2) early admission to stroke rehabilitation units, (3) intensive stroke rehabilitation therapies, (4) task-specific rehabilitation therapies, and (5) well-resourced outpatient programs. Implementation of these strategies will be expected to result in improved functional gain, fewer complications, decreased mortality, and reduced need for institutionalization. In addition to providing improved care for both the stroke survivor and their family, evidence-based stroke rehabilitation care is more efficient and may reduce costs. Our experience in Canada suggests that instituting these 5 measures alone will result in significant improvements to the health care system.     

Early rehabilitation for stroke patients: a new look

Many investigators have argued that early rehabilitation is important to maximize recovery from stroke and have documented a correlation between better outcomes and earlier admission to rehabilitation. But is this correlation good evidence for causation? In a sample of 94 stroke patients admitted to a comprehensive rehabilitation hospital, shorter onset-admission intervals definitely correlated with functional status outcomes (r = 0.27, p less than or equal to 0.006). However, when functional status upon admission, prior acute care improvement, level of consciousness shortly after the stroke, and other patient characteristics were partialled out, the correlation disappeared (partial r = -0.03, ns). The putative effect of early rehabilitation was attributable to the better health of stroke patients who could be admitted earlier to rehabilitation. Indications were that optimal timing for rehabilitation may differ depending upon side of paralysis. Rather than assuming that earlier is always better, future research and practice should concentrate on grading rehabilitative efforts to the capacities and needs of patients.     

A cross-sectional assessment of stroke rehabilitation in nebraska hospitals

Jones KJ, Cochran TM, Jensen LE, Roehrs TG, Volkman KG, Goldman AJ. A cross-sectional assessment of stroke rehabilitation in Nebraska hospitals.ObjectiveTo assess the structure and process of stroke rehabilitation in Nebraska hospitals.DesignCross-sectional mail survey using the Dillman tailored-design method of administration.SettingHospitals in Nebraska.ParticipantsApproximately 77% of the 84 Nebraska hospitals that provide stroke rehabilitation are critical access hospitals (CAHs) that are limited to 25 beds. Our study sample of hospitals (N=53) included the 19 hospitals licensed for 47 to 689 beds (non-CAHs) and a stratified random sample of 34 of the 65 CAHs.InterventionsNot applicable.Main Outcome MeasuresSelf-reported stroke rehabilitation team structure and processes, purposes of and barriers to the use of evidence-based standardized assessments, specific assessments used, and access to specialized stroke rehabilitation services and community resources.ResultsThirty-six (68%) of the 53 hospitals responded to the survey. Approximately 61% of the hospitals used an organized team to provide stroke rehabilitation; 8% of the hospitals—all non-CAHs—had a team dedicated to stroke rehabilitation. After adjusting for hospital size, having an organized team was significantly associated with the use of standardized assessments to improve communication, measure progress and outcomes, evaluate effectiveness of practice, and compare patient outcomes across conditions. Access to specialized stroke rehabilitation professionals and services was significantly greater in non-CAHs.ConclusionsHospital size and the presence of a team are determinants of the structure and process of stroke rehabilitation in Nebraska hospitals. Further research is needed to determine (1) whether team structure is a determinant of stroke rehabilitation outcomes across the continuum of care settings, (2) the needs of rural stroke survivors, and (3) whether technology can facilitate the use of stroke rehabilitation standardized assessments by rural health care professionals.     

Nursing Interventions in Stroke Rehabilitation: A Study of Nurses' Views of Their Pattern of Care in Stroke Units

The care given to stroke patients in acute care general wards has been described as of a poor standard, with resultant poor outcomes. Systematic reviews have established the benefits of stroke units on patient, outcomes such as functional ability and mortality. The trials have also hypothesized on the reasons for such improvements. One explanation is that the establishment of an interested, enthusiastic, and specialized nursing workforce within a stroke unit improves levels of care and hence, outcomes. However, there has been no research to identify the nature of the nursing care that is provided. To identify the nursing interventions of such a work force, we asked 90 nurses in 21 stroke units about the care that they provide for stroke patients and their caregivers. Our study suggests that nursing interventions in stroke care can be discussed within the criteria and concepts of six themes—focus of care, outcomes of care, direct care, continuity of care, mode of care, and context of care. These themes are dependent on one another for the successful delivery of the care that the nurses expect to deliver. The implications of these findings for the delivery and organization of rehabilitative nursing care are discussed.     

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.     

Experiences of nurses working in a stroke rehabilitation unit

Title. Experiences of nurses working in a stroke rehabilitation unit. Aim. This paper is a report of a study to explore the perceptions, beliefs and feelings of a group of nurses who provided care to individuals admitted to a stroke rehabilitation unit. Background. Following a stroke, survivors should ideally be referred to multidisciplinary inpatient rehabilitation programmes, which attain better outcomes compared to the care provided on general medical wards. However, to achieve these outcomes, team members must work closely together. Communication problems have been reported in these teams, and other members may consider that nurses do not practise functional activities with patients. Methods. An interpretive phenomenological approach was adopted. Eight nurses in one Canadian stroke rehabilitation unit were interviewed during 2004–2005 about their experiences of providing care to stroke survivors. Findings. The nurses enjoyed giving this type of care, feeling that their role was pivotal to the rehabilitation process. At times, they found it difficult to let patients struggle to complete their activities of daily living. The nurses felt that lack of resources, including time, contributed to stroke survivors being short-changed in their rehabilitation nursing care. Despite holding strong views that others devalued their role within the stroke team, the nurses retained positive attitudes. Conclusion. Stroke teams need to recognize the constraints nurses experience in fulfilling their stroke rehabilitation role in order to foster the collegial support that could contribute to a more interactive and respectful work environment. They also need to consider ways to increase the job satisfaction of nurses working in stroke rehabilitation settings.     

Task-oriented training in rehabilitation after stroke: systematic review

Title.  Task-oriented training in rehabilitation after stroke: systematic review.
Aim.  This paper is a report of a review conducted to provide an overview of the evidence in the literature on task-oriented training of stroke survivors and its relevance in daily nursing practice.
Background.  Stroke is the second leading cause of death and one of the leading causes of adult disability in the Western world. The use of neurodevelopmental treatment in the daily nursing care of stroke survivors does not improve clinical outcomes. Nurses are therefore exploring other forms of rehabilitation intervention, including task-oriented rehabilitation. Despite the growing number of studies showing evidence on task-oriented interventions, recommendations for daily nursing practice are lacking.
Data Sources.  A range of databases was searched to identify papers addressing task-oriented training in stroke rehabilitation, including Medline, CINAHL, Embase and the Cochrane Library of systematic reviews. Papers published in English between January 1996 and September 2007 were included. There were 42 papers in the final dataset, including nine systematic reviews.
Review methods.  The selected randomized controlled trials and systematic reviews were assessed for quality. Important characteristics and outcomes were extracted and summarized.
Results.  Studies of task-related training showed benefits for functional outcome compared with traditional therapies. Active use of task-oriented training with stroke survivors will lead to improvements in functional outcomes and overall health-related quality of life.
Conclusion.  Generally, task-oriented rehabilitation proved to be more effective. Many interventions are feasible for nurses and can be performed in a ward or at home. Nurses can and should play an important role in creating opportunities to practise meaningful functional tasks outside of regular therapy sessions.     

IMPACT OF REHABILITATION START TIME ON FUNCTIONAL OUTCOMES AFTER STROKE

ObjectiveTo investigate the optimum rehabilitation start timing for improved functional outcomes after stroke in Japan.DesignA retrospective database study.SubjectsA total of 140,655 patients with stroke from 1,161 acute hospitals in Japan. Only data for those patients who were discharged alive was included in the analysis.MethodsActivities of daily living were assessed. Comparisons were made using the rehabilitation start day after hospital admission. Reference day 2 was compared with days 1, 3, 4, 5, and 6 or later. Modified Rankin Scale at time of discharge was used as the primary outcome. In addition, cases of ischaemic stroke and haemorrhagic stroke were analysed as separate subgroups.ResultsUnivariate and multivariate logistic regression analyses showed that starting rehabilitation on day 2 resulted in a better outcome than starting on day 3 or later. There was no significant difference in outcome between starting rehabilitation on days 1 or 2 in all cases and subgroup of patient with infarction stroke. For a subgroup of patients with haemorrhagic stroke, starting rehabilitation on day 2 resulted in a better outcome than starting on day 1.ConclusionStarting post-stroke rehabilitation on the day of admission or second day of hospitalization may be the optimum timing for functional outcomes. However, for haemorrhagic stroke, starting rehabilitation on the second day of hospitalization may be more effective than on the day of admission.LAY ABSTRACTThis study examined the effect on functional outcomes of the time after stroke of starting rehabilitation. A large national database was searched for eligible stroke patients, resulting in a total of 140,655 patients from 1,161 hospitals. Starting rehabilitation on the day of admission or second day of hospitalization after stroke was found to be associated with better functional outcomes at discharge than starting rehabilitation on the third day or later. For patients with haemorrhagic stroke, those who started rehabilitation on the second day of hospitalization had better functional outcome at discharge than those who started on the day of admission. Thus, starting rehabilitation on the day of admission or the second day of hospitalization after stroke may be the best timing for improved functional outcomes. However, among patients with haemorrhagic stroke, starting rehabilitation on the second day of hospitalization may result in better outcomes than starting on the day of admission.Key words: early ambulation, recovery of function, stroke, time factor

Stroke is a major factor in causing functional impairment and often requires more resources for long-term care according to the Comprehensive Survey of Living Conditions in Japan (1). The number of people requiring nursing care and support in Japan’s long-term care insurance system has been increasing every year, with more than 6 million elderly people in 2015. In recent years, there has been increasing emphasis on stroke prevention and quality stroke care to control the further expansion of the number of people requiring care (2).For good-quality stroke care, early rehabilitation after stroke onset has been proposed in several Stroke Treatment Guidelines (3–5). Mechanism that may support the effectiveness of early rehabilitation include restoration of brain function, which promotes neuroplasticity (6), and reduction of bedridden syndrome, infections, deep vein thrombosis, and pressure sores (7). However, some researchers are concerned that starting too early rehabilitation may be harmful. One reason is that a head-up position reduces reperfusion of the penumbra region (8). Another reason is that the destabilization of blood pressure with exercise can inhibit the recovery of brain function (9). In addition, most stroke specialists have concerns about very early rehabilitation, especially in cases of haemorrhagic stroke. A possible reason is that patients with haemorrhagic stroke tend to die early after the attack, although the evidence regarding the timing of rehabilitation is insufficient (10).Several randomized controlled trials (RCTs) have examined the effectiveness of early rehabilitation, but it remains a controversial topic. Two RCTs have provided evidence that early rehabilitation is effective for physical functioning (11, 12), while other RCTs (13, 14) have not found such evidence. The latest multicentre RCT (14) concludes that very early rehabilitation leads to poor outcomes for physical functioning. However, some researchers have criticized the study design due to the short mean difference in rehabilitation start times between the intervention and control groups, being only 4 h. In addition, the variation in the timing of rehabilitation initiation in each RCT makes it difficult to interpret the effectiveness of early rehabilitation. For example, in the AKEMIS study (13), the mean time from stroke onset was set at 13.1 h in the intervention group and 33.3 h in the control group, compared with 18 and 22 h in the AVERT III study, and 27 and 32 h in the VERITAS study (12). Hence, the results of these RCTs may lead many clinicians to query when is the optimum time to start early rehabilitation after stroke.From the clinician’s point of view, it is important to determine whether rehabilitation should be provided very early after stroke, and when is the optimum time to start rehabilitation for good physical functioning outcomes. This study aimed to clarify these clinical questions, by investigating the impact of the timing of rehabilitation initiation after acute stroke on functional outcomes, using patient data from a Japanese multicentre database.     

Factors affecting dysphagia management and compliance with recommendations in non-metropolitan healthcare settings

It is acknowledged that a team approach to management of stroke is essential to improving patient outcomes. For the speech-language pathologist (SLP), communication and swallowing are key concerns in stroke rehabilitation. However, little is known about how services are provided following stroke in non-metropolitan areas. This paper presents findings from a study investigating issues related to the provision of dysphagia services in non-metropolitan New South Wales (NSW) and Victoria. The theme 'You've got to have an impact' was one of the major themes identified from analysis of data gathered via semi-structured interviews with eight SLPs. Participants in this study highlighted compliance with recommendations as a point of breakdown in the care of the patient with dysphagia. Underlying compliance were issues related to team functioning that could hold the key to improving outcomes. These findings have implications for non-metropolitan SLPs' ability to participate within a stroke team, for the way care for patients with dysphagia is conceptualized, and for improvement of compliance with SLP recommendations.     

Maximizing post-stroke upper limb rehabilitation using a novel telerehabilitation interactive virtual reality system in the patient's home: study protocol of a randomized clinical trial

BackgroundTelerehabilitation (TR), or the provision of rehabilitation services from a distance using telecommunication tools such as the Internet, can contribute to ensure that patients receive the best care at the right time. This study aims to assess the effect of an interactive virtual reality (VR) system that allows ongoing rehabilitation of the upper extremity (UE) following a stroke, while the person is in their own home, with offline monitoring and feedback from a therapist at a distance.Methods/designA single-blind (evaluator is blind to group assignment) two-arm randomized controlled trial is proposed, with participants who have had a stroke and are no longer receiving rehabilitation services randomly allocated to: (1) 4-week written home exercise program, i.e. usual care discharge home program or (2) a 4-week home-based TR exercise program using VR in addition to usual care i.e. treatment group. Motor recovery of the UE will be assessed using the Fugl-Meyer Assessment-UE and the Box and Block tests. To determine the efficacy of the system in terms of functional recovery, the Motor Activity Log, a self-reported measure of UE use will be used. Impact on quality of life will be determined using the Stroke Impact Scale-16. Lastly, a preliminary cost-effectiveness analysis will be conducted using costs and outcomes for all groups.DiscussionFindings will contribute to evidence regarding the use of TR and VR to provide stroke rehabilitation services from a distance. This approach can enhance continuity of care once patients are discharged from rehabilitation, in order to maximize their recovery beyond the current available services.     

Perceived value of stroke outcome measures across the post-acute care continuum: A qualitative case study

Connecting the continuum of post-acute care stroke services may be important for easing patients' transition between settings and facilitating recovery and community reintegration. The use of outcome measures is suggested as one means of connecting the continuum. The purpose of this qualitative case study is to describe administrators' and physiotherapists' perceived value of an outcomes program across the post-acute care stroke continuum at a rehabilitation hospital. Data were collected through individual interviews and focus groups with 18 participants. Three themes emerged on the value of the outcomes program: 1) enhanced communication; 2) supports clinical decision-making; and 3) value of objective data. These findings lend support for the use of standardized outcome measures by physiotherapists in stroke rehabilitation. Findings from this study may be useful for organizations and physiotherapists who wish to integrate outcome measures into practice.     

Factors affecting dysphagia management and compliance with recommendations in non-metropolitan healthcare settings

It is acknowledged that a team approach to management of stroke is essential to improving patient outcomes. For the speech-language pathologist (SLP), communication and swallowing are key concerns in stroke rehabilitation. However, little is known about how services are provided following stroke in non-metropolitan areas. This paper presents findings from a study investigating issues related to the provision of dysphagia services in non-metropolitan New South Wales (NSW) and Victoria. The theme ‘You've got to have an impact’ was one of the major themes identified from analysis of data gathered via semi-structured interviews with eight SLPs. Participants in this study highlighted compliance with recommendations as a point of breakdown in the care of the patient with dysphagia. Underlying compliance were issues related to team functioning that could hold the key to improving outcomes. These findings have implications for non-metropolitan SLPs' ability to participate within a stroke team, for the way care for patients with dysphagia is conceptualized, and for improvement of compliance with SLP recommendations.     

Brain attack. The stroke continuum.

Modern advances in stroke research, diagnosis, and management cast increasing hope for stroke patients. What was once a disorder with a pessimistic prognosis has become a treatable disease. Expert nursing is required to care for a stroke patient through the manifold stages of treatment and recovery. This article presents salient information on stroke epidemiology, classification, pathogenesis, and symptomatology. Investigative options, treatment modalities, stroke rehabilitation aspects, and future trends are discussed. Moreover, nursing practice guidelines for risk factor modification, acute phase interventions, rehabilitation interventions, and patient/caregiver education are presented.     

The structure and structural effects of VA rehabilitation bedservice care for stroke

The purpose of this study was to: 1) examine the variation in organizational structure within rehabilitation bed-service units (RBU) in the Veterans Health Administration (VHA), and 2) evaluate the effects of RBU and parent hospital structure on stroke rehabilitation outcomes. Two VHA-wide surveys of acute and rehabilitation services for stroke were linked with 2 y of VHA rehabilitation outcomes for stroke patients. A random effects mixed model was used to adjust for patient level covariates, control for unique site effects, and test for facility level structural effects. After adjusting for patient covariates, four structural variables were associated with length of stay or patient functional gain. These results indicate that rehabilitation structure is important to rehabilitation outcome. The individual variables identified in this study, namely, diverse multidisciplinary staff, expert physician leadership, staff participation in team care, and richer rehabilitation equipment resources, may represent the distinct aspects of a successful, comprehensive rehabilitation unit.     

Catastrophic case management. A case study

For the best clinical outcomes, catastrophic case management begins within the critical/intensive care units. The critical care nurse can facilitate this process by (1) documenting clearly, concisely, and legibly the patient's status in a holistic manner, as much of this information will be used to translate complex medical verbiage to clinical outcomes for financial authorization; (2) providing a receptive environment for the rehabilitation nurse case manager; (3) supporting the role of the rehabilitation nurse case manager in communications with the patient and family; (4) providing professional courtesy and dialogue when interacting with the rehabilitation nurse case manager; (5) understanding that although roles are different, the rehabilitation nurse case manager provides the continuous coordination of services and resources for optimal outcomes, and (6) including the rehabilitation nurse case manager in team or patient conferences so problems can be identified, allowing rehabilitation goals to be modified or expanded. Frequently, the rehabilitation nurse case manager is aware of the limitations of the health plans or capitated financial limitations of the benefit plans. With an informed understanding of the patient's problems, planning will maximize resources to achieve the best possible outcomes. For example, some benefits have a maximum number of home care visits annually or do not include acute rehabilitation hospitalization within the benefit plans. By matching the patient's needs to the benefit services within the time frame, resources are maximized. Most people are not aware of their health care plan services until the need arises. A rehabilitation nurse case manager possesses the expertise to advocate, negotiate, and use the benefits fittingly.     

卒中单元简介

卒中单元(stroke unit,SU)是指有组织地管理脑卒中住院病人.现有循证医学研究证据表明,目前脑卒中治疗的最有效措施是卒中单元.本文就卒中单元的实质、分类、组成等要素进行简单介绍,以促进对卒中单元的正确理解.     

The Possible Effect of Oxytocin in Postpartum Recovery From a Stroke: A Case Report

Pregnancy is a risk factor for stroke in young women, but the effect of delivery on recovery and rehabilitation after stroke has not been elucidated in pregnant patients with stroke. This case report presents a pregnant patient with stroke who recovered successfully after cesarean delivery during rehabilitation. The possible effect of oxytocin is discussed as a factor promoting recovery from stroke.

Adherence to clinical guidelines improves patient outcomes in Australian audit of stroke rehabilitation practice

Hubbard IJ, Harris D, Kilkenny MF, Faux SG, Pollack MR, Cadilhac DA. Adherence to clinical guidelines improves patient outcomes in Australian audit of stroke rehabilitation practice.ObjectiveTo study the correlation between adherence to recommended management and good recovery outcomes in an Australian cohort of inpatients receiving rehabilitation.DesignProcesses of care were audited and included those recommended in the Australian Clinical Guidelines for Stroke Rehabilitation and Recovery.SettingNational audit data from 68 rehabilitation units were used, with each hospital contributing up to 40 consecutive cases.ParticipantsNot applicable.InterventionsNot applicable.Main Outcome MeasuresDischarged home or an increase of greater than or equal to 22 in FIM scores between admission and discharge. Multivariable logistic regression models controlling for patient clustering were used to assess the associations between adherence to recommended management and recovery outcomes (dependent variables).ResultsHospitals contributed 2119 patients (median age 75y, 53% men). We found that rehabilitation units providing evidence-based management (eg, treatment for sensorimotor impairment 38%, hypertonicity 56%, mobility 94%, and home assessments 71%) were more likely to provide better recovery outcomes for people with stroke. A discharge FIM score of 100 was clinically relevant and was strongly correlated with whether or not a patient was discharged home. We found very good correlation between admission and discharge FIM scores in stroke rehabilitation.ConclusionsThis is one of the first study comparing adherence to recommended management in Australian rehabilitation units and stroke recovery outcomes based on national audit data. Novel findings include the significance of an FIM score between 80 and 100 and the clinical significance of various management processes.     

Movement therapy induced neural reorganization and motor recovery in stroke: a review

This paper is a review conducted to provide an overview of accumulated evidence on contemporary rehabilitation methods for stroke survivors. Loss of functional movement is a common consequence of stroke for which a wide range of interventions has been developed. Traditional therapeutic approaches have shown limited results for motor deficits as well as lack evidence for their effectiveness. Stroke rehabilitation is now based on the evidence of neuroplasticity, which is responsible for recovery following stroke. The neuroplastic changes in the structure and function of relevant brain areas are induced primarily by specific rehabilitation methods. The therapeutic method which induces neuroplastic changes, leads to greater motor and functional recovery than traditional methods. Further, the recovery is permanent in nature. During the last decade various novel stroke rehabilitative methods for motor recovery have been developed. This review focuses on the methods that have evidence of associated cortical level reorganization, namely task-specific training, constraint-induced movement therapy, robotic training, mental imaging, and virtual training. All of these methods utilize principles of motor learning. The findings from this review demonstrated convincing evidence both at the neural and functional level in response to such therapies. The main aim of the review was to determine the evidence for these methods and their application into clinical practice.