rehabilitation research: the impact on your life after stroke
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Rehabilitation research: the impact on your life after stroke. Helen Rodgers Professor of Stroke Care Newcastle University. Acknowledgements. Stroke Unit Trialists Collaboration Early Supported Discharge Trialists Professor Anne Forster Professor Peter Langhorne Professor Tony Rudd - PowerPoint PPT PresentationTRANSCRIPT
Rehabilitation research: the impact on your life after stroke
Helen RodgersProfessor of Stroke CareNewcastle University
Acknowledgements
• Stroke Unit Trialists Collaboration
• Early Supported Discharge Trialists
• Professor Anne Forster
• Professor Peter Langhorne
• Professor Tony Rudd
• Professor Marion Walker
“to get over a strong attack of apoplexy is impossible, over a weak one is not easy”
‘A stroke of God’s hand’
Oxford English Dictionary 1599
Treatment
• Put to bed with head well raised• Bleed freely (1-2 pints)• Apply warm mustard poultices• Open bowels quickly and freely• Throw up a turpentine clyster• Cut off the hair• Apply rags of vinegar (or gin)
and water• 8-10 leeches on temple opposite
paralysed side
King’s Fund Forum
Consensus and controversy in stroke
The treatment of stroke
June 27, 28 and 29, 1988
Regent’s College, Inner Circle
Regent Park, London NW1
Problems in rehabilitation
• shortage of therapy
• long unoccupied periods
• failure to recognise and respond to mood disturbance
• delegation of care to inadequately trained medical staff
• confusion by too many people involved
Problems in rehabilitation
• misunderstandings and rivalries between professionals
• breakdown in communication between professionals, patients and carers
• insufficient appreciation of the impact of stroke on the family
• ill prepared discharge
Cornerstones of stroke care
• TIA clinic
• stroke unit
• early supported discharge
• long term support
Planning stroke services
• incidence
• outcome
• prevalence
• Oxford Community Stroke Register
• OXVASC Study
• South London Stroke Register
Stroke is an emergency
Features of stroke unit care
• Consultant doctor specialising in stroke care
• Links with patient and carer organisations
• Weekly meeting of all professionals
• Good information for patients about stroke
• Staff provided with up-to-date training
Early Supported Discharge
The case against hospital rehabilitation
• artificial environment
• promotion of dependence
• boring
• risk of infection
• poor nutrition
• emphasis on physical recovery
• isolation
The case for community rehabilitation
• Home is the most appropriate environment• Involvement and empowerment of patients
and carers• More emphasis on psychological and social
issues• Less isolation• Cheaper
The case against community rehabilitation
• carer stress
• may not be co-ordinated or timely
• intrusive
• travelling
• primary care work load
Absolute outcomes(additional events per 100 patients treated)
Alive (6-12 months) 1 (2-4) Not significant
Living at home 5 (1-9)P = 0.02
Independent 6 (1 – 10)P = 0.02
Early supported discharge
• improved satisfaction with services
• no impact on mood
• no adverse effect on carer mood or health
Economics of ESD services
• Length of stay reduced by 8 (5-11) days
• ESD is slightly cheaper
How should community stroke care be organised and
provided?
Outpatient Service Trialists
To assess the effects of therapy based rehabilitation services targeted towards stroke patients resident in the community within one year of stroke onset.
• 14 trials• heterogeneous interventions• including 1617 patients
Lancet 2004
Outpatient Service Trialists
“Patients receiving rehabilitation at home within one year of stroke onset are more likely to have a better outcome, in terms of independence and achievement of maximum level of function in all aspects of daily life.”
Developing services
Evidence
Professional knowledge,Judgement, values and expertise
Patient, carer and public knowledge, values and input
NICE: stroke quality standard
• 45 minutes of each therapy
• minimum 5 days per week
• level to meet rehabilitation goals
• as long as continuing to benefit
Nutrition
Swallowing
FOOD Trial
• food supplements• early tube feeding• PEG feeding
A Very Early Rehabilitation Trial (AVERT) - Phase III clinical trial
DesignRandomised controlled trial of very early rehabilitation
versus standard care.
Features• blinded assessment • intention to treat analysis • multi-centre• large (n = 2104)* largest stroke rehab study • multi-disciplinary rehabilitation focused intervention
Physiotherapy after stroke
‘Approaches’
Focused training
Muscle strengthening
Treadmill
Repetitive movements
Constraint induced movement
Van Peppen, Clin Rehab 2004
Task orientated
rehabilitation is best
Rehabilitation goals
Aerobic exercise
Mental Practice
Video Games
Outdoor Mobility Programme
• 42% of patients don’t get out of the house as much as they would like after stroke
• lack of information• physical limitations• fear of falling
Mobility Interventions
• Walking (23%)• Bus (17%)• Dial–A–Ride (13%)• Driving (10%)• Shop mobility (8%)• Scooter (8%)• Voluntary car (6%)• Wheelchair use (9%)• Passenger car (4%)• Taxi (4%)
• Mean 6 sessions
Results – comparison of groups
Four months Controln = 82
Interventionn = 86
Comparison
Yes I get out as much as I want to
30 (37%) 56 (65%) RR = 1.78(95% CI 1.29to 2.46)
JourneysMedian (mean)
15 (22) 38 (43) Mann-Whitneyp<0.001
EADL mobility section Median
6 9 Mann-Whitneyp<0.05
University of Nottingham
• Depression
• Anxiety
• Emotionalism
• Memory
• Concentration
Fatigue
Stroke family support workers
• improve outcome for patients with mild/moderate disability
• improve satisfaction with some aspects of service provision
Evaluating effect of a training programme for caregivers
TRAINING PROGRAMME
Stroke unit setting
Structured, competency based, with assessment
of carer skills
V
‘USUAL CARE’
Stroke unit setting
Information and advice available from MDT
High quality research leads to service improvement .......
...... and some surprises
Advances in stroke care
• there have been significant improvements in stroke care
• important and unacceptable gaps remain in service provision