Post on 24-Jun-2018
Stroke Patients Rehabilitation 1
Submitted in partial fulfilment of the BA (Hons) Professional practice
(NURSING/MIDWIFERY), Faculty of Health and Well Being, Sheffield Hallam
University.
September, 2012
Word Count: 7946
Stroke Patients Rehabilitation 2
Acknowledgements
I would like to thank my professors at Sheffield Hallam University, who have been
essential in supporting me through this research, encouraging me through the problems
I faced and motivating me through the process.
Stroke Patients Rehabilitation 3
Table of Contents
Acknowledgements..................................................................................................................................2
Table of Contents.....................................................................................................................................3
Abstract......................................................................................................................................................5
Chapter I: Introduction..............................................................................................................................6
1.1. Background....................................................................................................................................6
1.2. Introduction....................................................................................................................................7
1.3. Research Motivation.....................................................................................................................8
Chapter II: Literature Review..................................................................................................................9
2.1. Introduction....................................................................................................................................9
2.2. Symptoms of a stroke.................................................................................................................11
2.3. Prevention of stroke....................................................................................................................13
2.4. Rehabilitation...............................................................................................................................15
2.4.1. Goals of Rehabilitation........................................................................................................15
2.4.2. Types of Rehabilitation........................................................................................................16
2.5. Rehabilitation after Stroke..........................................................................................................16
2.6. Various methods of rehabilitation..............................................................................................17
2.6.1. Relieve spasticity.................................................................................................................17
2.6.2. Exercises to regain mobility................................................................................................18
2.6.3. Stem cells..............................................................................................................................18
2.7. Specialized Professionals in Rehabilitation after Stroke........................................................18
2.7.1. Doctors..................................................................................................................................18
2.7.2. Rehabilitation Nurses..........................................................................................................19
2.8. Rehabilitation of Stroke Patients at Home...............................................................................21
Chapter III: Methodology.......................................................................................................................25
3.1. Introduction..................................................................................................................................25
3.2. Research Design.........................................................................................................................26
3.3. Aim of Research..........................................................................................................................27
Stroke Patients Rehabilitation 4
3.4. Ethical Consideration..................................................................................................................28
Chapter IV: Result..................................................................................................................................29
4.1. Outcomes of patients..................................................................................................................31
4.1.1 Mortality..................................................................................................................................31
4.1.2 Death or requiring institutional care....................................................................................32
4.1.3 Death or dependency...........................................................................................................32
4.1.4 Activities of daily living (ADLs)............................................................................................33
4.1.5. Subjective state of health....................................................................................................33
4.1.6. Patient satisfaction...............................................................................................................33
4.2. Outcomes of caregivers.........................................................................................................34
4.2.1. Mood......................................................................................................................................34
4.2.2 Satisfaction of caregivers.....................................................................................................34
4.3. Discharge.....................................................................................................................................34
4.4. Connection with Past..................................................................................................................35
4.5. Interpretation of results...............................................................................................................36
Chapter Five: Conclusion......................................................................................................................39
References..............................................................................................................................................41
Appendices..............................................................................................................................................44
Appendix I............................................................................................................................................44
Appendix II...........................................................................................................................................45
Appendix III..........................................................................................................................................47
Stroke Patients Rehabilitation 5
Abstract
This paper presents a research on comparing stroke patients that have been
rehabilitated at homes and hospitals and the factors behind the differences if any. The
research mainly focuses on the rehabilitation techniques and the different roles of
specialists in this field. The methodology is based on the patients that have been
introduced to ADA and how they have been able to rehabilitate at homes after their
treatment and the efforts done by the hospitals to ensure minimum readmissions of the
patients.
Stroke Patients Rehabilitation 6
Chapter I: Introduction
1.1. Background
Stroke to a disorder called sudden cerebral circulation, which alters the function
of a particular brain region. These are disorders that have in common a sudden onset,
which typically affect older people and, although they can also occur in young-and are
often the end result of the confluence of a number of personal, environmental, social,
etc., To we term the risk factors. Although the human brain signifies only 2% of the
weight of the body however it requires almost 20% of the flow to meet their needs (i.e.
energy intensive) and not otherwise available energy reserves (not groceries). These
conditions a constant supply of oxygen and nutrients, thus being very sensitive in the
absence of cerebral blood flow, in charge of providing the energy required for running.
For this reason the brain has a large amount of blood vessels and multiple mechanisms
to maintain constant the amount of circular blood for him and ensure proper delivery of
oxygen and nutrients, yet in bad circumstances. When blood vessels are injured by one
cause or another and the blood does not reach suitably (even small interruptions of
blood flow) cause the reduction or cancellation of the function of the brain affected. If
the irrigation decreases for longer than a few seconds, the cells in that area brain are
destroyed and cause permanent damage to that area the brain has security
mechanisms. There are many small connections between different brain arteries and if
the blood decreases progressive, these small connections increase in size and serve as
referral to blocked area. This is called collateral circulation. If there is sufficient collateral
circulation, a completely blocked artery may not cause deficiencies.
Stroke Patients Rehabilitation 7
1.2. Introduction
The family is the oldest social institution of humanity, where we form all it is the
place where we feel more protected, for children is an example and an ideal place for
learning. It has the responsibility to provide its members the opportunity to develop and
enrich their personality and function to meet the physical and emotional needs of its
members by establishing positive patterns of relationships. This should promote
socialization, learning and creativity.
The current population ages rapidly this leads to the emergence of diseases
caused by the passage of time and risk factors relating to the health-disease process.
That is why modern life requires of new knowledge to meet the new needs and
challenges of the future, as well as the disadvantages that may arise along the way.
The disease, individually designed, is a process that creates an imbalance not only in
the sick person, but covers larger areas. An individual in this state involves a family
while sick because recoveries include economic sectors, employment, relationships,
social and emotional.
Strokes predominate in the middle Ages and later life. They affect about 5% of
the population over 65 years and represent 9 and 10% respectively of total deaths,
occurring more than 90% of deaths in people 50 years or older, among which 50%
survive or Most left with a sequel. According to the World Health Organization (WHO),
strokes are "rapidly developing clinical signs of focal disturbance of cerebral function of
vascular origin and presumably more than 24 hours." This definition is included in most
cases of cerebral infarction, cerebral haemorrhage and subarachnoid haemorrhage, but
excluding those cases in which the recovery occurs within 24 hours.
Stroke Patients Rehabilitation 8
A stroke is the blockage of a blood vessel which interrupts the supply of oxygen to the
cells causing their death. The consequences of a stroke and the severity and extent of
the functions affected depends on where the blockage has occurred in the brain and
how great was the damage. Stroke was defined as ischemic or hemorrhagic, as caused
by a blockage in an artery or a laceration of the artery wall that causes bleeding in the
brain.
People at higher risk of having a stroke are those with high blood pressure, who
are sedentary, obese, who smoke, drink or have diabetes. High blood pressure (over
160/95 mm Hg.) is responsible for the largest number of strokes. Atherosclerosis
caused by high cholesterol or diabetes are at increased risk of stroke. Other factors
such as atria fibrillation in the heart by pumping deficiencies can form clots that can then
break off and travel to the brain as emboli. The abuse of drugs and other substances
are also at risk. Headaches or migraine are stroke risk. Genetic factors also by the
person's predisposition and stress.
1.3. Research Motivation
I have chosen rehabilitation and early discharge is to find out the best way to
rehabilitate stroke patients as we receive many patients that cannot cope at home and
therefore are admitted to nursing homes after hospital discharge.
Stroke Patients Rehabilitation 9
Chapter II: Literature Review
2.1. Introduction
A cerebrovascular accident (CVA), formerly stroke (CVA) and sometimes called
brain attack, is a deficit neurological origin sudden vascular caused by infarction or
haemorrhage in the brain . The term "accident" is used to emphasize the sudden
appearance or sudden onset of symptoms, although in fact this is actually a disease, its
causes are internal in nature (Warlow, 1996).
Symptoms can vary widely from one case to another depending on the type of
stroke ( ischemic or hemorrhagic ), the location and size of the brain lesion, which
explains a wide spectrum: no sign remarkable loss motor skills, sensory loss, speech
disorder, loss of sight, loss of consciousness, death. These symptoms, if they occur
very rapidly (within minutes), can disappear immediately or within a few hours (called to
TIA) or otherwise persist longer. Stroke whose symptoms persist are called strokes
made. In case of survival, the recovery process is still poorly understood, but a period of
spontaneous recovery from a few weeks to a few months, followed by a period of slower
evolution for several years, is recognized.
A previous review (Langhorne, 1999) focused on care systems that have been
established as a total care options during admission, i.e., services such as the "hospital
at home", which aims to prevent stroke patients entering the hospital. A second
approach has been to develop services that can accelerate the discharge of patients
already admitted to the hospital.
Stroke Patients Rehabilitation 10
In Western countries (Europe, U.S., etc.), 600 individual suffers from a stroke
each year (120,000 in France). 80% of them are ischemic and 20% haemorrhage
(Isard, 1992). Approximately the probability of ischemic stroke increases with age while
the probability of hemorrhagic stroke is independent of age (Mackay, 1995).
When nerve cells are deprived of oxygen, if only for a few minutes, they die, they
do not regenerate. Also, the more time between stroke and medical care are shorter,
the risk of serious squeal is shrinking (Barnes, Dobkin, & Bogousslavsky, 2005).
There are two forms of stroke: ischemic stroke - when there is a blockage of a
blood vessel that supplies blood to the brain, and hemorrhagic stroke - when an
ensangramiento in the brain and there around. The following sections describe these
forms of stroke detail.
2.2. Symptoms of a stroke
A stroke can cause paralysis or loss of consciousness. Sometimes it is detected by one
or more of the following signs (Burkman, 2010):
dizziness and sudden loss of balance;
a sudden numbness, loss of sensation or paralysis of the face, arm, leg or one
side of the body;
confusion, sudden difficulty speaking or understanding;
sudden loss of vision or blurred vision in one eye;
Sudden headache, exceptionally intense, sometimes accompanied by vomiting.
All cases, you must contact emergency services as soon as possible.
Stroke Patients Rehabilitation 11
It is essential to contact an emergency medical team as soon as possible after the
onset of stroke.
A stroke occurs suddenly and may have an immediate effect on speech and
movement. Some people have a blurred vision, while others experience sudden
confusion and loss of balance, have difficulty speaking or have a sudden severe
headache with no obvious reason. Stroke (stroke) is the third leading cause of death
in many countries and the leading cause of acquired disability in adults. Stroke is
primarily a disease of the elderly: 75% of patients over 65 years but 20% still have a
work at the time of the accident (Barnes, Dobkin, & Bogousslavsky, 2005).
Sudden paralysis or numbness on one side of the body, sudden difficulty in
speaking, loss of attention, very sudden decrease of vision in one eye, without an
immediate treatment, the lesions may become irreversible. Every minute counts in
this case (Burkman, 2010).
A stroke occurs when blood flow is interrupted in the brain due to a blockage by a
clot (it is ischemic stroke, which accounts for 80% of strokes) or the bursting of a
blood vessel (AVC colitis). Deprived of oxygen and nutrients, certain nerve cells are
damaged and others die.
The transient ischemic attack (TIA) is a precursor of stroke. It is caused by an
interruption of short duration, the flow of blood in a part of the brain. Signs appear
suddenly and disappear completely in a few minutes. AIT multiplies by 50 the risk of
stroke, says the SFNV.
Stroke Patients Rehabilitation 12
2.3. Prevention of stroke
Since strokes and heart attacks are caused by both atherosclerosis and high
blood pressure, methods to prevent or control cardiovascular disorders may help reduce
the risk of stroke. The three most important risk reducers are controlling high blood
pressure, quitting smoking and exercising properly. Smoking is the second leading
cause of stroke, but quitting smoking can reduce the risk of stroke to normal levels in
five years. Although reducing the levels of cholesterol, which protects against
atherosclerosis and ischemic stroke, the risk for hemorrhagic stroke slightly less
common, this is not an argument for keeping unhealthy levels. Everyone should reduce
their intake of saturated fat, maintain a healthy diet rich in fruits and vegetables, and
avoid being overweight and try to reduce stress. People with diabetes should try to
control the levels of blood sugar strictly (Hutton, 2005).
People whose diets are low in vitamin C have the same high risk for stroke as
people with hypertension. Although a protective role of vitamin supplements is not clear
yet, found that women with diets rich in fruits and vegetables reduced their risk of stroke
over women with diets low in these foods. A long-term study of men found that for every
three servings of fruits and vegetables in the diet, the risk of stroke was reduced (Kalra,
Evans, Perez, Knapp, Donaldson, Swift, 2000).
The accidents are caused by hemorrhagic rupture of a blood vessel, often
damaged or in poor condition at the origin and subjected to excessive blood pressure.
Tobacco and alcohol are factors particularly debilitating blood vessels.
Stroke Patients Rehabilitation 13
Depending on the location of the vessel, the bleeding may be meningitis due to
rupture of an aneurysm in the arterial subarachnoid spaces, cerebral intra (also called
intraparenchymal) and may be associated with ventricular flood. The hematoma formed
rapidly, showing signs of focal neurological onset in relation to structures destroyed or
compressed by the lesion. Moreover, it is edema around the hematoma, which
increases the compression of the brain in the skull, causing or aggravating a intracranial
hypertension (intracranial hypertension). The hematoma may rupture in a cerebral
ventricle. Sometimes during hemorrhagic there is also a release of calcium ions which
induce a vaso-spasm causing sudden ischemic attacks.
The ischemic is due to occlusion of a cerebral artery or to the brain (carotid or
vertebral arteries). The brain is partially deprived of oxygen and glucose. This occlusion
causes myocardial stroke (also called a softening of the brain). The mechanism of this
occlusion is often either an atherosclerotic obstruction or clot (local training or
embolism, in this case, usually of cardiac origin). However, other causes may exist:
tearing the wall of the artery (dissection), compression by a tumour. The deficit for a
defined territory of the brain: it is said systematized.
The ischemic cerebral infarction may be complicated by secondary bleeding at
the lesion: it is then a question of hemorrhagic softening. The cerebral thrombophlebitis
is an occlusion of a cerebral vein (not an artery). It is much rarer. The brain gap is a
complication of hypertension and is characterized by multiple small areas affected by
cerebral infarction.
Stroke Patients Rehabilitation 14
Hypertension is the main risk factor for stroke. In a healthy person, the blood
pressure should be below 140/90 mm Hg. If hypertension is (> 14/9), the pressure at
which the blood vessels are constantly subjected becomes too high and the cerebral
vessels have an increased risk of rupture, causing a brain haemorrhage.
2.4. Rehabilitation
Rehabilitation increases the chances of a successful recovery after a stroke. The
first few days after a stroke are very critical. During this time, the brain may swell,
causing more brain damage. In rare cases, this could cause death (Law & MacDermid,
2007).
Rehabilitation begins as soon as the patient is medically stable. This usually
takes place several days after the stroke. For rehabilitation to be successful, it is
important that the patient and family cooperate and show enthusiasm. Although
therapies are programmed only a few times a week, patient and family should do
therapeutic exercises every day. Although rehabilitation has improved in the last 20 to
30 years, the victims of sometimes strokes cannot return to the condition they were in
before the spill. It is important to continue working with skill and techniques discouraged
(Carey, 2012).
2.4.1. Goals of Rehabilitation
There are two main goals of rehabilitation (Levine, 2010):
a. Strengthen and re-educate the patient to help him improve.
b. Instruct the patient to lead a life as normal as possible within the limits of their
condition.
Stroke Patients Rehabilitation 15
2.4.2. Types of Rehabilitation
Rehabilitation is a combination of three types of therapy (Gresham, Duncan, & Stason,
2004):
a. Physical Therapy: strengthens muscles and improves the ability to walk patient.
b. Speech therapy: re-instruct the patient in all that relates to speech. This includes how
to speak, understand, read, write, solve problems, and so on.
c. Occupational therapy: teaches patients different "tricks" that help to lead a life as
normal as possible.
2.5. Rehabilitation after Stroke
Rehabilitation is a set of physical exercises or cognitive therapies to help stroke
victims regain neurological function and recover their deficits. The goal of therapy after
stroke is better to adapt to her new life and regain maximum independence.
Rehabilitation is a key step recovery after stroke and should be customized to the
fullest. The most important advances are made in the months after your stroke. This is
why it is crucial to begin the rehabilitation exercises as soon as possible. Rehabilitation
is usually divided into three phases: acute phases, sub acute and chronic. During each
phase, patients focus on different skills working with different therapists (Dunn, Lewis,
Vetter, Guy, Hardman & Jones, 1994).
The first steps involve promoting independent movement because many patients
are paralyzed or seriously weakened. Patients are instructed to change positions
frequently while they are lying in bed and passively or actively participate in exercises
scope to increase their mobility and strengthen their stroke-impaired limbs.
Stroke Patients Rehabilitation 16
(Rehabilitation exercises should help you regain maximum independence. Often
patients do not recover completely physical function and then work on alternative
methods to compensate for their disabilities (Carey, 2012).
The nurses and rehabilitation therapists help patients perform progressively more
complex and demanding, such as bathing, dressing, and using the toilet, and encourage
them to begin using their stroke-impaired limbs to perform these tasks. The first step in
the return to functional independence for stroke survivor is to begin to reacquire the
ability to perform these basic activities of daily living.
2.6. Various methods of rehabilitation
2.6.1. Relieve spasticity
There are different ways to assess your spasticity. We can estimate the mobility of your
arms and legs, your muscle activity, flexibility, etc.. Depending on your results,
therapists will establish an appropriate rehabilitation program, combining physical
exercise and medication. Stretching is a classic example of exercise can increase
flexibility and reduce muscle spasms. You may suggest braces to relax your leg, for
example.
2.6.2. Exercises to regain mobility
Many stroke victims are physically blocking them at home. Physical exercises will help
them regain mobility, strength and endurance, or improve their balance and
coordination. The progress can regain some independence and are also a source of
motivation and a good way to prevent another stroke.
Stroke Patients Rehabilitation 17
2.6.3. Stem cells
Stem cells are unspecialized cells. Their function in the body is not yet determined, it is
possible to use them to replace damaged cells or other tissues, and resume their duties
in certain areas of the brain. Therapy with stem cells is therefore to guide the healing of
the body. This solution remains controversial, but is nevertheless used during
amputations, transplants or to treat certain cancers such as leukaemia. Research is
now trying to use stem cells in neurological diseases such as Alzheimer's or
Parkinson's.
2.7. Specialized Professionals in Rehabilitation after Stroke
Rehabilitation after a stroke mainly involves a number of physicians,
rehabilitation nurses, physical, occupational, recreational, speech and language,
vocational and mental health professionals (Challis, Darton, Johnson, Stone & Traske,
1991).
2.7.1. Doctors
Physicians have the primary responsibility for managing and coordinating long-
term care of stroke survivors, including recommending rehabilitation programs that best
suit the needs of each patient. Doctors also are responsible for general care of the
health of a stroke survivor and advise how to prevent a second apoplectic attack, for
example, controlling high blood pressure or diabetes and eliminating risk factors such
as smoking, excessive weight a diet high in cholesterol, and high consumption of
alcohol (Donald, 1995).
Stroke Patients Rehabilitation 18
Physiotherapists you work the motor functions, in order to gain mobility or reduce your
pain and spasticity. We seek to develop your strength, regain mobility and endurance.
During rehabilitation exercises, you ability to walk; move your arms back a little spastic
limb control, etc. During the rehabilitation period, your brain works and how to master
rediscovered functions missing. Physical therapy is difficult and exhausting. On
average, patients undergoing therapy hour per day the chances of recovery are much
larger than rehabilitation is intensive. Nurses and caregivers will also explain how you
practice these exercises alone, so you can continue your therapy when you get home.
2.7.2. Rehabilitation Nurses
Nurses specializing in rehabilitation help survivors relearn how to perform basic
activities of daily living. They also educate survivors about the regular health care, for
example, how to follow a medication schedule, how to care for your skin, how to move
from bed to a wheelchair, and how to address the special needs of people with
diabetes. Rehabilitation nurses also work with survivors to reduce risk factors that can
cause a second stroke, and provide training for caregivers.
Pharmacist. Provides prescribed medications and can answer questions about
them.
The physiotherapist. If you have difficulty to move, you use an arm or leg, keep
your balance or coordinating your movements, your case is conifer a
physiotherapist. It will teach you techniques and special exercises to improve
muscle control, balance, movement and walking.
Stroke Patients Rehabilitation 19
The occupational therapist. An occupational therapist can help you learn to do
only the activities of daily life and learn new techniques that will be useful in
everyday life. This specialist can help you achieve your personal goals and to
make maximum use your mental and physical abilities.
The speech therapist. If you are experiencing difficulties with speech, language
comprehension, reading and writing, speech works with you. It will help you
speak or learn other ways to communicate. The therapist can also help you if you
have difficulty in swallowing.
Psychologist. If you have any problems with concentration or memory, or
emotional disorder, a psychologist can help.
The social worker. A social worker can help you and your family copes with
feelings of anger, sadness, depression, confusion and anxiety are common after
a stroke. These stakeholders also provide support in respect to community
services, finance of family, work and planning caption discharge from the
hospital.
The recreational therapist. A recreational therapist can help planning first new
hobby and discover new interests, or to learn new ways to indulge in your
favorite activities.
The dietitian. The dietitian can help you and the caregiver in planning healthy
meals first to let you control your weight and cholesterol, as well as to meet other
needs food or any problem when you swallow or eat.
Stroke Patients Rehabilitation 20
Other important factors are your rehabilitation your caregiver, your family and
friends. They can provide significant emotional support. Your caregiver and your family
can also help you continue your rehabilitation at home.
Even when you have completed your rehabilitation program, one or more members of
your health care team can continue to monitor your progress for a while. Some health
professionals do home visits, while others make you come to their office. Rehabilitation
services may also be available in hospitals, nursing homes, health centers and social
services and support groups in your area. Ask your rehabilitation team if these services
are available in your area.
2.8. Rehabilitation of Stroke Patients at Home
Rehabilitation at home allows greater flexibility so that patients can design their
own program of rehabilitation and follow a single path. Survivors of a stroke can
participate at a level of intensive therapy several hours a week or follow a less
demanding. These arrangements are often the most convenient for people who do not
have transportation or requiring treatment of a single type of rehabilitation therapist.
Patients dependent on Medicare program for rehabilitation must meet Medicare's
requirements to be "homebound" or "homebound" to qualify for these services, but for
now, the lack of transportation is not a valid reason for therapy at home. The major
disadvantage of rehabilitation programs at home is the lack of specialized equipment
(Challis, Darton, Johnson, Stone & Traske, 1991). However, performing the treatment at
home gives people the advantage of practicing skills and developing compensation
strategies within their own environment.
Stroke Patients Rehabilitation 21
Most patients need stroke rehabilitation to help them recover after leaving the
hospital. The stroke rehabilitation will help you regain the ability to take care of him.
When we talk about output is first returning home is imagined by the patient and by
caregivers. This is the goal for all. The output of the rehabilitation centre at home can
mean many things. It can, firstly, represent a conclusion for example healthcare team
centre. "This is the end of the physical cycle of care and stop supported. This phase is
much stronger than most of the time teams upstream and downstream of the outlet do
not know "and released once the patient and family will not return unless another stay
rehabilitation. It can be regarded as a sanction for the patient's status changes: in the
centre of rehabilitation he was sick, when it comes out it becomes "disabled." As if
nothing could hope the best for him and that somehow "it is not worth it remains long,
"he has reached the maximum recovery capabilities. There is often a gap between the
patient's ability in a protected environment and what it is capable home. The transition
between these two environments is often too brutal for the patient to his entourage
It is also a goal motivating rehabilitation: 'he works to return. “This transition can be
experienced by the patient as reassuring as it will go inside his home in a familiar
environment, familiar with his family where he has his habits. It will "get his life before
his cocoon ... family.” This is often a place to live for many years; this is its identity and
history. This output can finally be feared or sign of anxiety for the patient's family. Most
do not yet know what to expect or what they will face. Often families not imagine
disabilities of hemiplegic patients, using daily or they are going to need. Even to the
patient himself. It can be aware of their disability and understand to return without being
able to do as before the stroke. It should be this output should be a transition, a turning
Stroke Patients Rehabilitation 22
point. We should anticipate, prepare and continue home rehabilitation. This is a follow-
up care, which tends to be developed by AVC streams. The Rehabilitation is a process
that begins with the stabilization of the patient's condition after stroke until years later.
Whatever it is, the output to the home will only be possible under certain conditions
Rehabilitation after stroke (CVA) is effective. It aims to stimulate brain plasticity
processes, prevention of secondary complications and the best range returned to the
patient. It involves a team dedicated to the best structure in physical medicine and
rehabilitation. From the first days after stroke, it is to prevent the occurrence of
complications, including shoulder pain and musculotendinous retractions. Active
rehabilitation begins gradually according to the patient's condition and relies on a few
key principles: strong interaction sensitivity-motor-motor and cognition and the
importance of taking into account the individual from himself and from its environment;
exercises focused on the task to improve the selection of tasks with a purpose
meaningful to the patient, the repetition of the exercise to learning, the increasing
intensity of stimulation. And, as appropriate, rehabilitation improves grip, balance,
walking, or communication disorders visuospatial. The first months after stroke are
essential, but rehabilitation may be necessary beyond one year after the stroke and
recovery late it can be very useful.
After a stroke, you may need to learn new ways to think, talk and move you.
Rehabilitation after a stroke is a learning process in which a rehabilitation team works
closely with you and the people you care. Together, you set goals, make a plan and
participate in treatment that will give you the strength and confidence to live as
independently as possible.
Stroke Patients Rehabilitation 23
Rehabilitation begins when your doctor thinks that your condition is stable and you will
reap the maximum. Rehabilitation services are offered in different institutions and
contexts. Where you go will depend on what is available in your area and the type of
rehabilitation program that best suits your recovery needs. Rehabilitation services
offered in different locations can include:
Treatment programs inpatient in a hospital providing acute care, rehabilitation
centre or a centre for long-term care;
Outpatient programs in different types of institutions;
Home care with the help of agencies that provide this type of care
It should normally be directed by a physician to have access to rehabilitation services. If
you have not been directed to these services and you feel you need it, do not hesitate to
talk to your doctor.
Stroke Patients Rehabilitation 24
Chapter III: Methodology
3.1. Introduction
Chapter 3 includes an examination of the theoretical framework of the research
and the appropriateness for addressing the point of this study. Chapter 3 also includes
information regarding research design; qualitative tradition used; the role of the
researcher; questions and sub-questions; the context for the study; ethical protection of
participants; criteria for selecting participants; the justification of the data collected; how
and when the will be analyzed; and changes that were made from a prior exploratory
study to enhance this research study.
To ensure validity and reliability, this qualitative research utilized various
methods. A reflection of the various tools to be employed to ensure reliability of
research is included in this section. The research design was derived logically from the
problem statement by focusing on where and when a learning disability in reading could
develop.
Methodology is the philosophical source on which the study that was performed
and assessed which can guides to obtain the research aim. The common theories of
research approaches, research approach; data collection approaches and research
tools. This part will end with research limitation and the time structure of the research. A
methodology is one that continues to make the shares of an investigation. In simple
terms it is the guide indicating what we will do and how to act when you want to get
some kind of research. You can define a methodology and approach that allows
Stroke Patients Rehabilitation 25
observing a problem in a total, systematic, disciplined and with some discipline
(Panneerselvam, 2004).
3.2. Research Design
It is the structure to be followed in an investigation to exercise control of it to find reliable
results and its relation to the questions arising from the hypothesis. The problem
statement defined the initial scope of the investigation and made assumptions (or not
set due to wing nature of the study), the investigator must display the practical and
concrete way to answer the research questions, as well meet their objectives. This
involves selecting or developing one or more research designs and applies them to the
particular context of their study. The term design refers to the plan or strategy designed
to get the information you want. In the quantitative approach, the researcher uses his or
her designs to analyze the accuracy of the assumptions made in a particular context or
to provide evidence about the lines of research (if you do not have hypotheses) (Laurel,
2003).
The researcher searched the trials register of the Cochrane Stroke (Cochrane Stroke
Group's Trials Register), the latest of which was conducted by the Review Group
Coordinator in August 2004. Furthermore, additional information was obtained from the
trials. The researcher included all randomized, unconfined, who had compared the
procedures and high conventional care with alternative services, whose aim was to
accelerate the discharge of patients. Therefore, randomisation will have occurred
relatively early after hospital admission and before discharge.
Stroke Patients Rehabilitation 26
3.3. Aim of Research
The aim of this research is to compare the stroke patients that have been discharged
from hospital to those who are rehabilitated in the hospitals.
3.4. Qualitative Research
The qualitative research prevents quantification. Qualitative researchers are narrative
records of the phenomena being studied by techniques such as participant observation
and unstructured interviews (Thomas, 2003).
3.5. Quantitative Research
The quantitative research is one in which data are collected and analyzed
quantitative variables. The fundamentals of quantitative methodology can be found in
positivism that arises in the first third of the nineteenth century as a reaction to the
empiricism that was dedicated to collect data without introducing knowledge beyond the
field of observation (Thomas, 2003).
3.6. Reliability and Validity
To ensure reliability, I ensured that the data were collected from three quality
sources and that all data and conclusions were reported accurately and with integrity to
the meaning acquired from the individuals to the best of my ability. Validity was
established by using collection methods that were appropriate for this study to ensure
that the data sources and collection methods answered the main questions being asked
by this research study. The inquiry reflected the theory and research questions, and the
conclusions being drawn from the research were conducted based on triangulation.
Stroke Patients Rehabilitation 27
Validity was also accomplished by bracketing all personal experiences related to the
phenomena so that emphasis was placed on the information provided by the
participants of the study.
3.4. Ethical Consideration
When conducting a medical research it is important for the researchers to ensure that
the subjects being involved in the research are protected from any unethical
involvement. The data that is being provided by the hospital and reports should be kept
confidential and should not be used for any other purpose other than mentioned. It is my
duty as a researcher to respect the confidentiality of the patients and work ethically.
Also even after the conduction of the result the data will be kept securely and
confidentially and will not be used by the researcher further.
Stroke Patients Rehabilitation 28
Chapter IV: Result
Despite physical therapy, however, remains a degree of disability which limits the
autonomy of the patient and makes it very difficult to re- house. With the new type of
organization problems they are much reduced, because the patient is resigned after a
rehabilitation cycle complete. In view of the discharge can create however, a certain
degree of conflict with the patient that would prolong the hospital stay and relatives who
are afraid of not being able to cope with the problems of his return home. Now it is not
possible to tackle best these problems. The method we have adopted to solve this- ste
conflict situations is to take note of the problems of the whole family (Patient and family)
and look together for solutions possible, thus transforming the conflict into a common
problem to solve. This task of course it is not only the responsibility of the physician, but
is faced with a coordinated effort by the whole team physician.
Usually it is considered that the purpose of a hospitalization re-consists in formulating a
diagnosis and set appropriate treatment. This goal can go well for much acute
pathology, for example for a bronchopneumonia, so that the dismissal did not present
the particular problems. In the case of a patient with- task from a stroke, however, we
agreed that Our intervention is intended to enable him to return home and to be able to
undertake, with possible, its usual activities. In practice we deem mo that a shelter ends
in the best way when the patient is able to recover the maximum mo can function
compromised, he learned to compensate adequately the possible disability remaining
and was able to accept the damage is not editable. Based on this approach, the
Stroke Patients Rehabilitation 29
preparation of the return-to-home becomes the common goal that allows us to
overcome the initial conflict.
No doctor would be able alone to bear the problems related to reintegration.
Traditionally the search for solutions to these problems was entrusted given to the
social worker, but experience has shown layer that a delegation mechanism is not
sufficient for you. When the social worker operates without a connection closely with
other operators, its activity tends to be reduced to a paperwork that, even if necessary,
is too small to solve the many difficulties. We have gained the conviction it that the
problem must be addressed in a coordinated by the whole team physician, each
according to their skills, starting from the con- division of a common goal. To achieve
this project we gather systematically a discussion of the cases. When the clinical
condition of the patient are stabilized and the rehabilitation program is being advanced,
the treating team is able to predict with sufficient approximation the maximum level
recovery reached and the day on which pro- gram discharge. These conditions are
realising in variable times depending on the severity stroke, usually within sixty days
provided for estimate by the region for the post-hospital rehabilitation coetaneous of
these patients. The meeting takes place every week on Wednesdays, from 11.30 to
12.30, and involves the team physician for the team as described above. Every fourth
now is called a nuclear family. Considered random who are discharged every week 7:00
to 10:00 patients are convened only the families of the cases "Difficult" while you
prepare the other patients return home with the same care, but without use collegial
meeting. The presence of the patient encounter is of importing necessary and often his
condition allows them to participate only limited to working together. With its
Stroke Patients Rehabilitation 30
participation we want to mo emphasize the active role in decisions that concern and the
search for solutions. During the meeting, we explain how understanding the clinical
situation and the results achieved. Often parents express their anxieties and practical
difficulties of reorganization family. The internist, the physical therapist and social
worker, each according to their competence, provide the information requests, propose
solutions to the problems that arise and, when appropriate, initiate the necessary
paperwork to obtain aid specific. Group work that is being done is based the maximum
concreteness, every problem is addressed in operational terms and solutions looking for
in the realm of the possible, with the con- awareness that the residual disability often
associated cite with a very advanced age and the presence of multiple diseases, in any
case entails a load relevant care for family members
Analyzes Plan - The interpretation and analysis time results are shown in Tables (Table
01, Table 02, and Table 03 in Appendices).
4.1. Outcomes of patients
4.1.1 Mortality
Data were available for this outcome in the 11 trials. It was assumed that patients with
missing data were alive. Overall, there was no significant difference in mortality between
the services team and conventional ATA. To reduce mortality and functional squeal of
stroke, there is ample evidence that the measure is essential emergency hospitalization
in specialized stroke units, which can better meet the demands required by diagnostic
and therapeutic stroke:
Stroke Patients Rehabilitation 31
- Diagnosis of stroke itself, its type (cerebral haemorrhage, subarachnoid haemorrhage,
stroke, venous thrombosis etc ...) and its cause (atherosclerosis, cardiac embolism, a
disease of small cerebral arteries dissection etc ...), which requires access to
emergency MRI, arterial and cardiac explorations.
- Therapeutic requirements: general measures and prevention of complications, use of
antithrombotic aspirin for the vast majority of alteplase (tissue plasminogen activator in
recombinant form or rt-PA) for ischemic stroke within three hours of respecting cons-
indications (currently less than 5% of cerebral infarctions) any recourse to the surgery or
neuro-interventional radiology).
4.1.2 Death or requiring institutional care
Data were available for this outcome in nine trials. It was assumed that patients with
missing data were alive and at home. Overall, there was a significant reduction in the
odds of passed away patients requiring institutional care or long-term.
4.1.3 Death or dependency
Data were available for this outcome in 11 trials. It was assumed that patients with
missing data were alive and were independent. - Increase the number of stroke units
with access to MRI and cardiac exams so that they can all hospital emergency stroke
(currently in France, neurovascular units can accommodate only 10% of stroke) .
- Officially recognized among stroke units, intensive care units (ICU) neurovascular
addressing the seriously ill, unstable, which may require the use of neuro-interventional
radiology or neurosurgery. Recognize their status similar to cardiac ICU.
Stroke Patients Rehabilitation 32
- Make every effort within institutions to accelerate the circuit further examinations
required before thrombolytic.
- Start as soon as possible neurological rehabilitation.
- Develop a curriculum in vascular neurology.
4.1.4 Activities of daily living (ADLs)
Despite the methodological difficulties of studies on the effectiveness of rehabilitation
after stroke, the benefit is demonstrated, including hemiplegic and aphasia, and this
benefit is even more important that rehabilitation is early and intense time.
Rehabilitation (excluding acute phase) is for about 80% of survivors after stroke. It can
be done at home in case of disability and mild disability or specialized centre where
more severe squeal, which corresponds to approximately 20-25% of stroke
4.1.5. Subjective state of health
These data were available in 10 trials. Overall, there was no significant difference in
scores of subjective health status between the two groups. We found no significant
degree of heterogeneity.
4.1.6. Patient satisfaction
These data were available in five trials. Also, it was concluded that the patients will
- Continue as necessary for neurological rehabilitation intense and prolonged
- Increase the number of beds for neurological rehabilitation supports the aftermath of
stroke
Stroke Patients Rehabilitation 33
- Development of alternatives to hospitalization (home hospitalization rehabilitation, day
hospital etc ....)
- Continuation of secondary prevention.
4.2. Outcomes of caregivers
Subjective health status 2.1 - These data were available (in a variety of formats) in six
trials (613 caregivers). Overall, there was no significant difference in the scores or
heterogeneity.
4.2.1. Mood
These data were available in only two trials, with 58 caregivers. Overall, there was no
significant reduction in mood score of carers receiving services ATA, but there was
significant heterogeneity between trials.
4.2.2 Satisfaction of caregivers
These data were available (in a variety of formats) in four trials (279 caregivers).
Overall, no significant difference in the odds of those caregivers who received services
ATA expressed satisfaction with services (OR 1.56, 95% CI 0.87 to 2.81).
4.3. Discharge
Everything we do during hospitalization need to get well prepared for this moment. After
a variable period of four to eight-week it, the patient and his family are having to re-
examined the daily life in different conditions- if the previous. The patient usually goes
from the hospital after getting a recovery- persistent, but its level of autonomy is almost
always less than the previous one. Often need help or supervision for at least
performance of activities of daily living. The whole family must be reorganized: the
Stroke Patients Rehabilitation 34
patient, relatives and partners also that of the relatives not living that did not it occupied.
When we deliver the letter discharge, we take this opportunity to summarize- re the
history of the disease. We make sure that the patient can be appropriate, is capable of
talk to his friends and knows how to manage the life as a person with disability as
better. Explain clearly how to take therapies and we advise you of new reference chin to
the primary care physician for the management of pro- clinical problems. Of course the
actual situations are different for each patient, and there are situations more or less
problems. They range from the case of the patient who out completely self-sufficient, to
what only needs to check with the doctor physician, to what must continue treatment
with the help of local services. In fact the patient is discharged when it reaches the
maximum recovery possible for him or when it is not longer necessary to continue the
treatment, bearing in mind that a further improvement can take place in the phase
domiciliary both in spontaneously or continuing physiotherapy (Outpatient, day hospital
or at home). In selected cases we offer to patients and their family to participate in an
outpatient group to return to work everyday
4.4. Connection with Past
On 7 December 2004, the National Academy of Medicine recommended to consider
cerebrovascular accident (CVA) as a vital emergency and increase the number of
stroke units. Four years later, under the responsibility of neurologists, 80 units of the
140 needed to effectively treat 130 to 150 000 strokes annual open. Noting the major
breakthrough for public health posed Units Neuro-Vascular and aware that these
creations have meaning complemented by the development and structuring of post
hospital sectors, the National Academy of Medicine recommends:
Stroke Patients Rehabilitation 35
In accordance with Decree No. 2008-377 of 17 April 2008 on the implementation
conditions applicable to the activity follow-up care and rehabilitation, the development of
health care delivery in acute care and rehabilitation (SSR) specialized to accommodate
early, 40% of stroke patients requiring neurological rehabilitation. These structures must
have a personal and a technical platform for an intensive rehabilitation for patients who
need rehabilitation and suitable for all.
The development of the supply of shelters and reception centres in medico-social
structures. Such structures must have the means to support patients 'neurological'
disabled regardless of age (day care, home specialized care, foster care medical zed
residences for elderly dependents or nursing homes). In accordance with the circular of
2003, the development of health care delivery units in Long Term Care (LTC) for
patients with neurological disabilities, identifying beds for youth.
Reduction, from the stage of initial hospitalization, delays in administrative procedures,
either for orientation or medico-social aid awards. When returning home, the possibility
of early rehabilitation, if necessary, in partnership with the back support structures and
maintaining the home. Implementation, to promote coordination of care throughout the
journey of mobile multidisciplinary rehabilitation and / or networks around the
neurological disability acquired adult. These medical teams should include neurologists,
occupational therapists, psychologists, social workers and doctors trained in disability
and work closely with the physician. (Scheinberg, Koren, Bluestone & McDowell,
1986).
Stroke Patients Rehabilitation 36
4.5. Interpretation of results
The authors acknowledge that the interpretation of the characteristics of services and
patients creates the potential for post-hoc explanation of the results. However, as far as
possible be attempted to plan a priori analysis. While recognizing that the amount of
data available was limited, it seems possible to establish some general conclusions.
a. Most of the evidence of the benefit of ATA services comes from trials with ATA
multidisciplinary team whose work is coordinated through regular meetings.
b. The ATA multidisciplinary team comprised staff characteristic physical, occupational
and speech therapy and speech therapy, with the support of doctors, nurses and social
workers.
c. These services appear to be effective even when compared to a service-based
standard of care in a stroke unit.
d. Although no evidence could be found that the level of service (hospital or community)
influenced the results, all teams ATA reported here had a specialist interest in stroke or
rehabilitation.
e. All trials enrolled a selected subgroup (40% average) of stroke patients living in an
urban environment generally.
f. Most of the evidence for benefit of ATA seems to correspond to patients with
moderate disability (initial Barthel index> 9/20), although the cost - benefit is not clear
for this subgroup. For patients with more severe disabilities, substantial savings in bed
days may well be outweighed by the risk of poorer outcomes.
Stroke Patients Rehabilitation 37
In conclusion, ATA teams adequately resourced and well coordinated can offer an
additional option of effective service for a selected group of stroke patients and should
be considered, along with attention to organized inpatient (stroke unit) as part a
comprehensive service for the disease (Stroke Unit Trialists' Collaboration, 2001).
Stroke Patients Rehabilitation 38
Chapter Five: Conclusion
The selected stroke patients who received inpatient care of ATA service returned
home sooner than those who received conventional care. They also were more likely to
be independent and live at home six months after stroke, and to express satisfaction
with the services received. There was no observable adverse effect on the health or
subjective mood of patients or caregivers. Observable benefits ATA services largely
derived from trials where the services were provided by teams coordinated ATA and
enrolled patients with less severe disabilities.
About a week after a stroke, the condition of patient begins to change and initial
deficit may tend to alone improved. After the deficit improved, weakening and speech
difficulties are some of the remaining problems and can incapacitate in large scale
patient. Rehabilitation can help improve some of the damage caused by stroke (Harvey,
Macko, Stein, Zorowitz, & Winstein, 2008).
If it is true that the achievement of higher level of autonomy possible for the patient is
the purpose of each rehabilitative treatment, from the point of view both individual and
social a measure of the effectiveness of treatment is also made from the success of the
re- inclusion of the patient at home. Safe mind what depends on numerous factors
including non- strictly medical. Considering the new address that was given to
department with its transformation from a division of medicine inpatient post-acute
rehabilitation, we realized that it was necessary to make the change- that compared to
the traditional working style. We have identified and implemented some of them: - The
choice of rehabilitation at home as target primary. The orientation of all activities
Stroke Patients Rehabilitation 39
towards achievement of this objective, team work, the involvement of relatives, the
choice of appropriate organizational tools (the Physical medicine and social-medical
team, the meeting with patient and family, the group for re- insertion at home), choice
and prescription of assistive devices may necessary, the connection to local services In
our experience, these changes are proved useful to assist the reintegration of home
patients have improved their level of satisfaction relatives and have been a source of
gratification to all those who are engaged in the process of changes.
The conclusions of this review are based on a relatively small number of trials. More
research is needed to define the most important characteristics of effective services and
the balance cost ATA - benefits for different groups of patients and services. Further
research is needed to determine whether more generic ATA devices (for example,
services for a diverse population of elderly) get the same results as specific services for
stroke described here. Not been adequately evaluated the role of ATA services in rural
communities.
Stroke Patients Rehabilitation 40
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Stroke Patients Rehabilitation 43
Appendices
Appendix I
Table 1: Primary Analyses: Plan and Timings
Trial Death Institutional Care
Dependency Defined dependent
Length of Stay
Patient 1 6 weeks 6 weeks 6 weeks Barthel index <95/100
Initial hospital discharge
Patient 2 7 weeks 7 weeks 7 weeks Barthel index <95/100
Not used - only available for acute hospital
Patient 3 6 weeks 6 weeks 6 weeks Barthel index <95/100
Initial hospital discharge
Patient 4 6 weeks 6 weeks 6 weeks Barthel index <19/20
Initial hospital discharge
Patient 5 12 weeks
12 weeks 12 weeks Barthel index <19/20
Initial hospital discharge
Patient 6 12 weeks
12 weeks 12 weeks Barthel index <19/20
Initial hospital stay (acute and rehabilitation wards)
Patient 7 3 weeks 3 weeks 3 weeks Barthel index <95/100
Initial hospital stay
Patient 8 3 weeks 3 weeks 3 weeks Rankin score 3-5
Initial hospital stay
Patient 9 6 weeks 6 weeks 6 weeks Rankin score 3-5
Initial hospital stay
Patient 10
6 weeks 6 weeks 6 weeks Barthel index <95/100
Initial hospital stay
Patient 11
6 weeks 6 weeks 6 weeks Barthel index <95/100
Initial hospital stay
Stroke Patients Rehabilitation 44
Appendix II
Table 2: Plan of Secondary Analyses: Patient outcomes (P stands for Patients)
Trial Timing of
outcome
ADL score
Extended ADL
score
Subjective health
Mood Service satisfaction
Hospital Readmis
-sion
P 1 6 weeks
Barthel index (median, IQR)
Adelaide Activities Profile
SF-36 (General health perceptions)
SF-36 (mental health)
Satisfied with Rehabilitation Programme
6 weeks
P 2 7 weeks
Barthel index (median, SD imputed)
- SF-36 (general health perceptions)
SF-36 (mental health)
- -
P 3 - - - - - - -P 4 6
weeksBarthel index
Nottingham extended ADL
SF-36 (general health perceptions)
SF-36 (mental health)
Satisfied with outpatient rehabilitation
6 weeks
P 5 12 weeks
Barthel index
Rivermead ADL score
Nottingham Health Profile (score reversed)
Number abnormal on Hospital Anxiety and Depression Scale
Satisfied with care in general
12 weeks
P 6 12 weeks
Barthel index
Nottingham Extended ADL score
Euroquol scale (0-100)
Hospital Anxiety and Depression Scale (depression
- -
Stroke Patients Rehabilitation 45
subscore, reversed score)
P 7 3 weeks
Barthel index
Instrumental ADL (OARS) scale
SF-36 (general health perceptions)
SF-36 (mental health)
- -
P 8 3 month
- Nottingham Extended ADL score (median, IQR)
Dartmouth COOP chart overall health section (median, IQR; reversed scale)
Dartmouth COOP chart feelings section (median, IQR; reversed scale)
- 3 weeks
P 9 6 weeks
- Nottingham Extended ADL score (median, IQR)
General Health Questionnaire (reversed score)
MADRS score
Satisfied with care in general
-
P 10 8 weeks
- Frenchay Activities Index (median, IQR)
Sickness Impact Profile score (median, IQR)
- Satisfied with care received
6 weeks
P 11 12 weeks
- Social Frenchay Activity Index
Nottingham Health Profile (average of sum 1 & 2)
MADRS
- -
Stroke Patients Rehabilitation 46
Appendix III
Table 3: Plan of Secondary Analyses: Carer outcomes
Trial Timing of Outcome
Subjective Health
Mood Service Satisfaction
P 1 6 weeks SF-36 General Health Perceptions
SF-36 Mental Health
Satisfied with Rehabilitation Programme
P 2 - - - -P 3 - - - -P 4 6 weeks Caregiver strain
index (score reversed)
- Satisfied with outpatient services
P 5 12 weeks Caregiver strain index (score reversed)
- Satisfied with outpatient services
P 6 12 weeks Caregiver strain index (score reversed)
Hospital Anxiety and Depression Scale (depression subscore, reversed score)
-
P 7 - - - -P 8 3 weeks General Health
Questionnaire (median, range, score reversed)
- -
P 9 6 weeks General Health Questionnaire (score reversed)
- Satisfied with care in general
P 10 - - - -P11 12 weeks Caregiver
Burden Score- -