care of acutly ill patients
TRANSCRIPT
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Introduction
Cerebrovascular disease or the term stroke is used to describe the effects of an interruption of the
blood supply to a localised area of the brain. It is characterized by rapid focal or global impairment of
cerebral function lasting more than 24 hours or leading to death (Hatano, 1976). As such it is a
clinically defined syndrome and should not be regarded as a single disease. Stroke affects 174-216
people per 10,000 population in the UK per year and accounts for 11% of all deaths in England and
Wales (Mant et al, 2004). The risk of recurrent stroke within 5 years is between 30-43%. One
problem is that the incidence of stroke rises steeply with age and the number of elderly people in
the UK is on the increase. To date people who experience a stroke occupy around 20 per cent of all
acute hospital beds and 25 per cent of long term beds (Stroke Association, 2004). The British
Government now identifies stroke as a major economic burden on the National Health Service (DoH,
2002).
Fifty percent of stroke survivors will experience some residual impairment (physical and cognitive),
which is devastating to the individual and their families (Rudd et al, 2002). It is therefore vital forpatients and resources that maximum functional recovery is achieved as fast as possible. The
physiotherapist has a key role to play in the management of stroke patients, through assessment,
prevention strategies, acute management and recovery. This essay aims to critically discuss
physiotherapeutic management and examine how it has and may be influenced by a number of
factors (e.g. type of organized system for the delivery of post stroke care, setting of therapy,
evidence based practice from which National Guidelines are produced etc). The first stage is to
outline stroke pathology, of which forms the basis of appropriate management.
Pathology
There are two major stroke sub groups, those resulting from infarction (ischemic stroke) and those
resulting from haemorrhage (intracerebral and subarachnoid). Each of the types can produce clinical
symptoms that fulfil the definition of stroke. The types often differ with respect to survival and long-
term disability, from recovery in a day to incomplete recovery, severe disability and death (Warlow
et al, 2001).
Ischemic stroke is the most common type of stroke, which accounts for approximately 85% of all
cases (Rudd et al, 2002). It affects 35 people per 100,000 of the population per year (Coull et al,
2004). Ischemic stroke can be caused by a sudden occlusion of arteries supplying the brain, as a
result of thrombosis formed directly at the site of occlusion (i.e. thrombotic ischemic stroke), or in
another part of the circulation, which eventually obstructs arteries in the brain (i.e. embolic ischemic
stroke). Diagnosis is usually based on neuro-imaging recordings, however, it may not be possible to
decide clinically or radiological whether it is a thrombotic or embolic ischemic stroke (Rudd & Wolf,
2002).
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Intracerebral haemorrhage is a bleeding from one of the brains arteries into the brain tissue. The
lesion causes symptoms that mimic those seen for ischemic stroke. Diagnosis is based on neuro-
imaging, which can differentiate it from ischemic stroke. Hypertension is the single most underlying
cause of intracerebral haemorrhage (Poungvarin, 1998).
Subarachnoid haemorrhage is characterised by arterial bleeding in the space between the two
meninges pia mater and arachnoidea (The university of Virginia, 2004). Typical symptoms are
sudden onset of very severe headache, vomiting and usually impaired consciousness.
To date there appears to be no single, specific cause of stroke but rather several factors that may
increase the risk of an individual having a stroke. The causes of the first stroke are generally identical
to those that result in subsequent stroke. It is therefore important to identify risk factors in order to
provide appropriate management.
Risk Factors
People with more than one risk factor have an "amplification of risk", in which multiple risk factors
compound their destructive effects creating an overall risk greater than the simple cumulative
effect. Generally, risk factors for stroke can be classified as non-modifiable, potentially modifiable
and modifiable (Sacco et al., 1997).
Non-modifiable risk factors for stroke include age, gender, family history and ethnicity. For example,
age is the single most important risk factor for stroke (National Institute of Neurological Disorders
and Stroke -NINDS, 2004). Indeed, for each 10 years after age 55, the stroke rate more than doubles
for both men and women (The Stroke Association, 2004). Men have a higher risk for stroke; with the
stroke risk for men at 1.25 times that as for women (Sacco, et al, 1997).
Potentially modifiable risk factors include diabetes and heart disease (and some controversial factors
such as alcohol and drugs)(Goldstein, 2001). Diabetes is associated with stroke, independently of the
various cardiovascular risk factors that usually accompany this disease (hypertension, dyslipidemia
and obesity) (American Stroke Association (ASA), 2004).
Modifiable risk factors include hypertension, smoking, physical inactivity and obesity (Rudd & Wolf,
2002). In middle and late adult life, hypertension is undoubtedly the strongest modifiable risk factor
for both ischemic and hemorrhagic stroke (Rothwell, 2004) and is present in 70% of stroke cases.
Another powerful modifiable stroke risk factor is smoking, (which amongst other things promotes
atherosclerosis) and which almost doubles a person's risk for ischemic stroke (ASA, 2004). As part of
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therapeutic management a physiotherapist would refer the patient to a smoking cessation program.
Ideally, health care providers (including physiotherapists) should screen individuals for risk factors
that could lead to cerebrovascular disease and use this opportunity for education.
Given the pathology of stroke and the number of risk factors, it is not surprising that the spectrum ofclinical presentations is also extensive (Warlow et al, 2001). It is important to recognise that each
person should be considered on an individual basis, as no two cases will present the same (Moser &
Ward, 2000). The following section therefore provides an overview.
Clinical Presentation
The types of disability that follow a stroke depend upon which area of the brain is damaged and may
correlate to the patient's neurological deficits with the expected sites of arterial compromise
(Warlow et al, 2001). The effects of the stroke will also depend on the patients general health at the
time (Harridge, 2000; Malbut-Shennan, 2000). Disabilities can range from isolated motor or sensory
deficits to coma. The symptoms may occur alone, but they are more likely to occur in combination
(Malbut-Shennen, 2002). Predictions as to the outcome of stroke are therefore difficult to
determine.
Movement and sensory deficits -Paralysis is one of the most common disabilities resulting from
stroke. An individual who suffers a stroke in the left hemisphere of the brain will show right-sided
paralysis or paresis (weakness) and vice versa (the extent of which will be dependant on an
individuals basic organisation of the brain). The paralysis may only affect the face, an arm, or a leg
or it may affect one entire side of the body. One-sided paralysis is known as hemiplegia and one-
sided weakness, hemiparesis. Individuals often experience pain, numbness or odd sensations of
tingling or prickling in the paralyzed or weakened limbs (i.e. paresthesia). These sensory deficits may
hinder the ability to respond to objects or sensory stimuli located on one side of the body known as
inattention (neglect).
Damage to a lower part of the brain, the cerebellum, can affect the body's ability to coordinate
movement (i.e. ataxia) and may lead to problems with body posture, walking and balance. Initiating
and controlling movement may also be impaired (Bear et al, 2001). This combination of impairments
may impact upon activities of daily living (ADLs) such as walking, dressing and eating. These skills
often require the mobility and strength developed during physiotherapy. However training in ADLs
involves the entire rehabilitation team.
Cognitive problems -Stroke may induce cognitive problems (e.g. impaired: thinking, awareness,
attention span, learning, judgment and memory). Severe cognitive problems may include apraxia
(i.e. loss of ability to plan and carry out steps involved in complex tasks) and therefore patients may
have problems following a set of instructions (NINDS, 2004).
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Language impairments, such as the loss in the ability to speak or form words (i.e. dysarthia) and
understand speech (aphasia) or written language are experienced by a quarter of all stroke survivors
(NINDS, 2004). Cognitive and language impairments may adversely affect an individuals ability to
participate in therapy and must be taken into account by the physiotherapist as an important
determinant for functional recovery (Hochstenbach et al, 2003).
Emotional factors - Many people whom survive a stroke often experience fear, anxiety, frustration
and anger (a natural response to trauma). The most common major emotional concomitant of
stroke however, is depression (Aben et al, 2001). Signs of clinical depression include sleep
disturbances, change in eating patterns, lethargy, social withdrawal, irritability, fatigue, self-loathing,
and suicidal thoughts. It is therefore essential that physiotherapists are aware of this as depression
can hamper recovery and rehabilitation (Maclean et al. 2000).
Motivation - Stroke patients may loose their motivation for restoring lost function and returning to
the community (Dowswell et al, 2000). Physiotherapists who specialise in mental health may help
patients overcome these adverse emotional states and focus on functional recovery (Maclean et al.2000).
Functional recovery often depends on the assessment and treatment of stroke patients, which in
turn are influenced by various factors other than clinical presentation (e.g. National Service
Frameworks, clinical guidance etc). It is therefore essential to outline physiotherapeutic
management of stroke patients taking into account these factors.
Organisation of Early stroke care health care provision
National Service Framework (NSF) -In 1999 a national survey (Ebrahim & Redfern, 1999) revealed
that the hospital care of stroke patients was a matter of chance, with half of patients receiving less
than optimal care. The report estimated that up to 7, 000 deaths could be attributed to care
deficiency. The NSF for Older People (England) was launched (DoH, 2001) in order to address some
of the issues raised. Standard 5 of the Framework focused on national standards and service models
for stroke care. It stated that people should have access to diagnostic services, are treated
appropriately by a specialist stroke service and (with carers) participate in a multidisciplinary
programme of secondary prevention and rehabilitation.
Stroke units - One of the main recommendations of the Framework was that all hospitals caring for
people with stroke should have a specialised stroke service by April 2004. The Royal College of
Physicians' National Clinical Guidelines on Stroke (2002) recommend that treatment is carried out in
a designated stroke unit (DSU). Recent evidence supports this view, as the Stroke Association (TSA)
(2004) found that for every 16 stroke patients admitted to a general hospital ward, there will be one
extra death compared with those admitted to a DSU. Dedicated Stroke Units differ from general
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medical wards in that they deal specifically with stroke patients, theoretically offering holistic care
from several disciplines.
In spite of overwhelming evidence, only 82% of hospitals in England have a DSU (National Sentinel
Stroke Organisational Audit-NSSOA, 2004) and 39 more are needed to achieve the target set by NSF(2002). Variations have also been identified in terms of the care they deliver, treatment strategies,
organisation of services and clinical outcomes. However, the benefits of a stroke unit clearly
outweigh those of a general hospital ward, particularly in the holistic approach to management by a
multidisciplinary team.
Multidisciplinary teams (MDT) Aim to provide seamless holistic care from the immediate post-
stroke period throughout all stages of rehabilitation to hospital
discharge. The NCGS (RCP, 2004) and DoH, (2001) specify a number of specialists whom should be
involved (e.g. a consultant physician, physiotherapist, occupational therapist etc). The precise
composition and number for such a team will vary according to the size of the unit and its
objectives (NCGS, p.16). However, this ambiguity (e.g. composition, facility size, availability and
staffing levels) has possibly contributed to the wide variations in quality of service outlined by the
NSSAOA (2004). In addition, according to NSSAOA (2004) the acute phase is often being treated on a
general medical ward where resources (e.g. staffing and finances) are not always available to
achieve the ideal MDT.
Ideal interdisciplinary working involves acknowledging the overlap between professional disciplines,
with greater sharing of duties and responsibilities including, collaborative clinical records, closer
working practices and shared rehabilitation (Gibbon, 1999). For example, physiotherapists may focus
on limb weakness, abnormal tone (flaccid or spastic) and balance, to meet the agreed aim of
independent mobility, but would work closely with an occupational therapist in order to achieve
this. Research suggests that poor team working can become dysfunctional, hierarchical and hindered
by professional boundaries (Strasser et al, 1994). However, In the UK to date, post registration
courses in rehabilitation and MDT working are rare.
Regular MDT meetings may be used as a tool to enable the provision of a quality rehabilitation
service and to discuss differences and potential problem areas of management, training needs etc.and is considered good practice. A central aim of physiotherapy within the team is to promote the
recovery of movement and mobility of the stroke patient. This will involve planning and
implementing treatments for the individual patients, based on an assessment of their unique
problems. Key elements of these patient specific treatment strategies may entail restoring balance,
re-educating mobility and promoting functional movement. Plans can all be conveyed to the MDT
and modified accordingly via written or verbal communication. Recent evidence suggests that this
combined expertise improves patient outcome (Stroke Unit Trialists Collaboration, 2004). The NCGS
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(2004) recommend that MDT meet at least once a week to exchange information regarding
individual patients. However, in reality this may not be practicable, due to lack of resources (e.g.
time, staffing levels etc).
Continued education and training programmes - The NSF recommends that all staff in contact withstroke patients should undertake a wide range of training (e.g. covering acute and rehabilitation
care, how to address patient and carer needs). It is important that physiotherapists are provided
with regular training, to keep up to date with evolving evidence based practices and therefore offer
patients the most appropriate treatment. High quality treatment saves lives and reduces disability
(NCGS, 2004).
Care pathways -Many hospitals now have central medical admission units where early medical
stroke care can be guidance driven. Clinical guidelines (i.e. known as care maps, or care pathways)
are often used for diagnosis, treatment, prevention of complications and rehabilitation(Pushpangadan et al, 1999). A care pathway focuses on the practical delivery of multidisciplinary
care in the form of a daily written care plan, which highlights any important interventions. It is
intended to assist healthcare professionals to achieve pre-specified patient goals efficiently while
improving quality of care based on best evidence and guidelines. However, there is debate as to the
usefulness of these plans.
There is some evidence to suggest that when a care pathway is used the patient may be more likely
to have the tests they need, less likely to get an infection and less likely to be re-admitted to hospital
(Kwan & Sandercock, 2003). However, others (e.g. Low, 1999; Brooks & Anthony, 2000) suggest that
care pathways may be a hindrance to professional advancement, by removing the healthcare
professionals autonomy and ability to critically evaluate individual needs. Physiotherapeutic
management relies heavily on autonomy and clinical reasoning. If this is removed poorly developed
clinical guidelines may underpin ineffective and possibly dangerous practice (a one size fits all
attitude is not appropriate). More research needs to be undertaken in this area.
The factors identified above clearly have implications for practice, such as assessment, goal setting
and treatment. In parallel to the National framework and in order to improve stroke care nationally,
the Royal College of Practitioners (RCP) developed the Intercollegiate Working Party (IWP) for
Stroke. This led to the production of National Clinical Guidelines for Stroke (NCGS, 2000, 2002,
2004). The guidelines outline current evidence based practice of which can be used by all
professionals in the management of stroke patients. In terms of physiotherapy, the guidelines cover
in particular, the use of assessments, team working, goal setting and underlying approaches to
therapy (CSP, 2002).
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Assessment, goal setting and outcome measures
Assessment -Each member of the multidisciplinary team should provide thorough and repeated
assessment, to ensure problems are not overlooked. A physical and neurological examination
establishes the baseline with which all future evaluations are compared and must be the basis for
effective determination of the patients problems (Association Chartered Physiotherapists In
Neurology-ACPIN, 2004). The ability to collect specific information during the assessment and
efficiently communicate this to other health care providers can significantly affect patient outcomes.
According to Schretzmen (2001, pg 7) time equals brain. Irreversible neural damage occurs
shortly after the stroke begins, but secondary damage may be prevented or minimised if appropriate
treatments are initiated. The patient should also be assessed on admission for their needs in relation
to moving and handling and risk of developing pressure sores. In terms of prompt assessment and
types of treatment, health care provision is dependent on a number of factors (e.g. local adaptations
of the NSF, availability and training of staff etc), all of which impact on practice.
According to NCGS (2002) patients should be reassessed at appropriate intervals. The CSP's CoreStandards (CSP, 2000) suggest that a professional evaluation of a patient should be carried out using
standardised measurement instruments to facilitate a more systematic approach and to enable
progress to be monitored. In todays climate of evidence-based practice all physiotherapists should
advocate the use of valid, reliable and clinically sensitive outcome measures as a benchmark for goal
setting, treatment decisions and effective practice (CSP, 2004).
Goal Setting Physiotherapeutic management involves a problem solving approach to stroke care, in
order to set short and long terms goals (where appropriate) which may contribute to the process of
rehabilitation (CSP, 2002). Goal setting refers to the identification of, and agreement on, a targetthat the patient, therapist or team will work towards over a specific period of time (Intercollegiate
Working Party, 2000). Research evidence has demonstrated that using goals improves rehabilitation
outcome provided that significant patient involvement occurs and that both short and long-term
goals are developed. Unfortunately, the research base used has been taken from non-stroke studies,
most of which involved small sample sizes and usually in the context of outpatient rehabilitation.
(Wade, 1999). Also different definitions have been used and practice varies according to therapist
skills (NCGS, 2004). Therefore, the extent to which these studies can be generalised to stroke is
uncertain.
According to Ashburn et al, (2000) the process of goal setting itself may highlight several differences
in expectations between patients and physiotherapists. Therefore, rehabilitation should always be
placed in the context of the patients own activities and beliefs. This may be done by incorporating
goals that are meaningful to the patient and aimed at promoting independent movement for daily
functioning, thus achieving the best possible quality of life and social participation. Nevertheless, an
understanding of the term is not always shared by patients and carers (Lawler et al, 1999).
Independent walking is often an important ultimate goal, requiring several stages of recovery.
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Initially, patients may display poor trunk control and are unable to bear weight on the affected
extremity. Care must be taken to set goals which are challenging but achievable (CSP, 2002).
Physiotherapeutic management should focus on posture, trunk control, and weight transfer. A short-
term goal may include being able to sit out during meal times, with a view to a long-term goal of
eating in the dining room with other patients (Wade, 2000).
Outcome measures - There is much debate about the selection of appropriate outcome measures
for routine clinical use and various instruments are available according to whether a measure of
impairment (e.g. Rivermead Motor Assessment), disability (e.g. Barthel Index), or activity limitations
and participation restrictions (e.g. London Handicap Scale) is required. A recent survey found that
22% of therapists are not measuring outcomes and that many are using measures not tested for
reliability and validity (Lennon et al, 2001). The reasons why remain unclear. According to the CSP
(2001b) the measurement instrument should be appropriate to the treatment intervention and
relevant to the patient. To measure mobility for example, the Rivermead Mobility Index (RMI) or the
updated version (MRMI) may be selected. Used correctly both are sensitive enough to provide an
objective measurement, from which the amount of assistance required for mobility can be
calculated (Johnson & Selfe, 2004). This information can be relayed and utilised within the MDT.
Prevention of complications and the physiotherapist
Airway, breathing and circulation (ABC) - As with any other medical conditions, the treatment during
the acute phase begins with the management of ABC in order to prevent and reduce medical
complications. Physiotherapeutic management focuses on chest care. Therefore, if active
rehabilitation is not possible (e.g. impaired consciousness), passive rehabilitation is performed to
minimise the risk of bronchopneumonia, a major cause of death among stroke patients (Hilker2003). For example the physiotherapist will aim to maximise the patients position such as side lying
or supported high sitting (if tolerable) to help improve oxygen saturation and maintain blood
pressure, thereby limiting further neurological damage (Blood pressure Acute Stroke Collaboration-
BASC, 2004, Balla, 2000, Chatterton, 2000).
Early intervention - Physiotherapists should be aware that many patients may have had impaired
physical fitness prior to their stroke. Due to age, for example, many will have experienced a decline
in cardio respiratory fitness and muscle function (Harridge 2000, Malbut-Shennan 2000). There is the
wide range of options available for treatment of both primary and secondary conditions, the
selection of which should be tailored to the individual and centered on evidence-based practice
(CSP, 2002).
Rehabilitation is aimed at decreasing the consequences of the illness and helping relearn skills that
are lost when part of the brain is damaged. The provision of physiotherapy is a major component of
rehabilitation and should commence within 24 hours or as soon as the patient is medically stable
(NSF, 2001). The reality is however that only 56% of patients are seen within this time frame (Rudd
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et al, 2001). Paucity of evidence regarding reasons remains unclear. However, there is very little
evidence to support the NSF recommendations in this regard (CSP, 2002).
Early physiotherapeutic intervention in the acute phase centers on mobilisation for the prevention
of secondary co-impairments e.g. pressure ulcers, deep vein thrombosis and musculoskeletalproblems such as contractures and shoulder pain. Exercises may be carried out in bed or on a chair,
in order to maintain muscle length and tone (Carr, 2000, Dean, 2000).
Post- stroke shoulder pain - is common (although the aetiology is uncertain) and is associated with
poor recovery of arm function. How and when shoulder pain is measured results in different
prevalence estimates. However, 80% of patients may be affected within the first year after stroke
(Hanger et al, 2000). Physiotherapeutic management utilises a range of measures to prevent
shoulder pain. These may include, correct positioning (avoiding the use of overhead arm slings,
which may encourage uncontrolled abduction) and the use of foam supports (CSP, 2001). Incorrecthandling has been found to be a contributing factor of shoulder pain (Dean et al, 2000). Therefore,
the physiotherapist should educate other members of the team (including carers) in correct handling
techniques. If the shoulder pain is already established according to RCP & CSP (2002)
physiotherapeutic management may include high-intensity transcutaneous electrical nerve
stimulation (TENS). However, research as to the benefits of TENS in this situation is lacking. Patients
should be assessed for pain on a regular basis, as it is a common secondary impairment and if not
addressed, may hinder rehabilitation and long-term functional recovery (RCP & CSP, 2002).
Treatment strategies and the physiotherapist
Approaches - In terms of rehabilitation different approaches focus on the modification of
impairment and improvement in function within everyday activities. A number of different
physiotherapy approaches (e.g. Bobath approach, Motor Re-learning approach, Brunnstrom, Rood,
Proprioceptive Neuromuscular Facilitation etc) have been developed based on different ideas about
how people recover after a stroke. The Bobath approach is used by 90% of the physiotherapists in
the UK (SIGN, 2004), which is a problem-solving approach to the assessment and treatment of
individuals with disturbances of function, movement and tone. However, previous studies found that
physiotherapists favour the Motor Relearning Programme, which focuses on task-orientated
strategies, (Carr & Shepherd, 1998, Davidson, 2000).
Several studies (e.g. Pomeroy & Tallis, 2000) have investigated the effectiveness of the different
approaches and have found no differences between the approaches in terms of improvement in
functional ability. However, others (e.g. Carr & Shepperd, 1998) have found that the Motor Re-
learning Programme was more beneficial in terms of improved motor function and reduced stay in
hospital as compared with the Bobath programme after the first three months of stroke. It must be
pointed out that evaluating treatment approaches is extremely difficult as there are so many
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confounding factors (e.g. patient characteristics, physiotherapist skills etc). According to Lennon
(2001) many physiotherapists follow a more eclectic approach based around each patient's assessed
needs and this is the position adopted in the NCGS (2004).
Regardless of considerable research efforts on multiple treatment modalities, there is still no singlerehabilitation intervention demonstrated unequivocally to aid recovery (Pollock, 2004). Emerging
evidence suggests that providing the opportunity to practice functional activities (task-specific
training) may result in improved outcomes (Pollock et al, 2004). As an example physiotherapeutic
management aimed at promoting the recovery of postural control (balance during the maintenance
of a posture, restoration of a posture or movement between postures) to enable the patient to sit
upright, will begin in supine with facilitated movement. As the patients core stability progresses (to
unsupported sitting, through to transferring between the bed and a chair, to standing up), care
should be taken that quality is not substituted for quantity.
Intensity of therapy - Despite it being suggested that patients should receive as much physiotherapy
as can be given (CPS, 2002). Only a few trial have been conducted to test this (e.g. Langhorne et al,
2002; Partridge, 2000, Van der Lee & Snels, 2001 and Kwakkel et al, 1999) and no firm conclusion
can be made due to confounding factors (e.g. the services providing extra therapy were also those
whom had additional and more qualified staff and whom were better organised). Many studies were
found to methodologically flawed (e.g. small numbers of participants, selection bias etc). After a
review of the literature Scottish Intercollegiate Guidelines Network-SIGN (2004) revealed a
moderate positive benefit of intense therapy for the fittest 10% of stroke patients. However, no firm
conclusion could be made regarding the benefit to the other 90%. In reality people in the acute
phases often suffer from fatigue and may not respond well physically to intense therapy, although
psychologically they may feel that it is beneficial (Partridge, 2000).
The latest guidance suggests that therapy should be provided on a needs basis according to how
much the patient is willing or able to tolerate. Nevertheless, It is currently not known whether there
is a minimum point at below which there is no benefit at all. Therefore, once the physiotherapist has
helped the patient to increase tolerance, physiotherapeutic management may go on to include gait
re-education.
Gait Disorders - The physiotherapist should offer gait re-education, which has been found to be
beneficial in improving the patients walking ability (e.g. Green et al, 2002). There is some concern
that walking aids encourage patients to favour the unaffected limb. What little research there is,
suggests that they do not, although these studies have utilised small sample sizes (e.g. Tyson &
Ashburn, 1994; Laufer et al 2001). Patients safety is paramount and as such may require equipment
such as walking frames and walking sticks to increase their standing stability and ensure safety.
Therefore, physiotherapeutic management should be based on clinical judgment in consultation
with the patient and reassess periodically.
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A focused training programme such as treadmill training has been found to be beneficial in the
treatment of gait disorders. Several studies show that patients not walking independently between
30 days and three months after stroke may benefit from treadmill training (Moseley et al 2004).
However, this should only be considered as an addition to conventional therapy and treated actively
in accordance with the patients wishes (NCGS, 2004). It should also be recognised that, standard
treadmills are unable to provide bodyweight support and so their value is limited.
Falls -Risk of falling remains a long-term problem for stroke patients and they may become
increasingly susceptible to more serious injury from which rehabilitation is difficult (e.g. fractured
neck of femur). A careful appropriate assessment will help identify those at greatest risk and
implementation of handling strategies by all members of the team is once again paramount (Warlow
et al, 2001).
Physiotherapist as educator- Research suggests that patients and carers have little understanding of
stroke, risk factors, consequences and types of support available (Forester et al, 2001) Lack of
knowledge may result in failure to comply with secondary prevention and also lead to poorer long
term psychosocial outcomes (OMahony et al, 1997). Information in the form of leaflets, videos etc
are not as effective as education plus information (Johnson & Pearson, 2000). Physiotherapists are in
a position to provide both. However, future research is required to examine different types of
education (CSP, 2002).
Physiotherapeutic management post discharge - Early discharge has the potential to reduce the
risk of distress associated with prolonged hospital stay (Rodgers et al, 1997). However, hospital
services should have a protocol and local guidelines for discharge, in order to establish (prior to
discharge) whether there is a specialist stroke rehabilitation team in the community or the patient is
able to transfer safely and attend a day care centre (Roderick, 2001). A stroke care co-ordinator is
recommended (NSF, 2002) in order to bridge hospital and community based services, taking on the
responsibilities for care plans, secondary prevention measures, aiding patients etc. The
physiotherapist should provide a full assessment and liaise with the co-ordinator prior to discharge
in order to ascertain the individuals requirements and pre-empt any problems.
The physiotherapist working closely with the occupational therapist will help to determine what
equipment and adaptations could increase safety and independence (NCCS, 2004). Carers should
receive all necessary equipment and training in moving and handling, to be able to position and
transfer the patient safely in the home environment. Ideally, procedures (and funding) should be in
place to enable re-assessment to check existing aids, appliances and identify and provide new
requirements.
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The timely and appropriate provision of aids and/or appliances is one of the crucial aspects of stroke
care. However, many patients experience multiple waiting lists for essential equipment and
adaptations. An investigation of five main equipment services by the Audit Commission (2000) found
that there was under investment, low priority afforded by senior managers and geographic
variations in people eligible to receive services. There was also variations in the range and quantity
of equipment provided, the time spent waiting for its delivery, and in the number of staff trained.
This may result in delay from hospital discharge, which impacts on all services including
physiotherapy.
There is now considerable evidence to suggest that stroke sufferers require a longer period of
support and contact than the few months currently provided by hospital departments (Rudd &
Wolfe, 2002). After stroke, patients continually decline and if this decline can be prevented or
reversed by longer-term stroke rehabilitation, this may prevent re-admission to hospital and thereby
be cost effective (NCGS, 2004).
The NSF (2002) recommendation that rehabilitation should continue until maximum recovery has
been achieved is a step forward. However, exactly who will decide this maximum recovery remains a
mystery. The physiotherapist should assess any patient with disability at six months or later after
stroke for further targeted rehabilitation where appropriate (NCGS, 2004). Whilst at the same time,
physiotherapists should encourage independence. One problem is that there is little evidence for
specific recommendations for appropriate longer-term physiotherapy provision (CSP, 2002).
Conclusion
Ongoing physiotherapeutic management of stroke patients is a dynamic process, incorporating
evidence based practice (e.g. issued in the National Clinical Guidelines for Stroke Patients, 2004) and
responding to the changes in the health service (e.g. as a result of the National Service Framework
for Older People, 2002). Stroke is still a major health problem. However, it has been reliably
established that organised multidisciplinary stroke care, such as typically provided in a stroke unit,
reduces mortality and institutionalisation compared to care provided in a general medical ward. In
spite of this evidence the NSF targets have not been met and more stroke units are required.
Physiotherapeutic management sits well within a MDT to maximise assessment, treatment andgeneral rehabilitation. Together they can provide holistic health care, preventing deaths and
minimising physical (and psychological) disability. However, this is the ideal and only beneficial if the
MDT is efficient. Resource limitations (finances, time, staffing levels etc) have a major impact upon
the type and efficiency of services provided, resulting in wide variations geographically. Clearly
physiotherapeutic practices may be constrained even within a dedicated stroke unit. In addition
there is a shortage of physiotherapists in dedicated stroke units and general rehabilitation units
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(NSSOA, 2004). More units and resources are required in order to both save lives and minimise the
risk of further strokes (which would be cost effective).
Physiotherapeutic practices themselves focus on evidence-based guidance such as that of the NCGS
(2004) and as such, is therefore continually evolving. Physiotherapists must keep up to date in orderto maximise the benefits of therapeutic management for the patient and be able to critically
appraise studies in order to incorporate new knowledge into clinical practice. As part of
physiotherapeutic management physiotherapists are required to disseminate information to other
team members, patients and carers. However, often provisions for training/education are minimal,
again often due to lack of resources.
An increase in awareness and use of clinical guidelines can go some way to standardizing care. The
problem arises in that physiotherapists are dealing with individuals each with unique circumstances
and clinical presentations (this may explain some of the methodological flaws identified in studies,such as confounding factors, small sample sizes etc). Evidence based practice and guidance therefore
can never be applied to all situations or patients. Clinical judgment (e.g. such as in the choice of
treatment for a particular patient) has to remain the cornerstone of effective therapy, utilizing
evidence-based practice where applicable.
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