Physical therapy during stroke rehabilitation for people with different walking abilities
ABSTRACT Latham NK, Jette DU, Slavin M, Richards LG, Procino A, Smout RJ, Horn SD. Physical therapy during stroke rehabilitation for people with different walking abilities.
To describe how physical therapy (PT) activities during post-stroke inpatient rehabilitation vary by admission walking ability and over time.
Observational cohort study.
Six inpatient rehabilitation hospitals in the United States.
People receiving post-stroke PT (N=715) who were classified as walking at admission.
Percentage of time spent in 11 activities, percentage of patients who participated in each activity, and the FIM instrument scores.
The majority of PT time was spent in gait activities. Even people with the most limited mobility spent 25% to 38% of PT time in gait activities during the first 6-hour treatment block. Treatment progression was evident, and a shift to more advanced activities occurred over time (eg, less bed mobility and more advanced gait). However, even in the final 6-hour block, a small proportion of time was spent on community mobility activities (1.2%-5.2%), and most people received no community mobility training.
PT activities focused on specific functional tasks at the ability level of each individual patient and provided higher-level activities as patients improved their function. However, although there is increasing recognition that the environment influences task performance, little time was spent in community mobility activities before discharge.
- [Show abstract] [Hide abstract]
ABSTRACT: Apoplectic stroke is a dramatic complication of the car- diovascular system's diseases and it has become one of the most distressing health problems of contemporary societies. Often it results in handicap, postapoplectic dementia, depression and high death rate. Around 70% of survivors have difficulties in walking, while the re- maining 30% suffer from acute motor impairment and require constant medical attention. Therefore, restora- tion or, at least, improvement of locomotion is the ma- in goal of rehabilitation of the cerebral hemorrhage su- rvivors. Studies on gait pathologies provide valuable clues for planning physiotherapy that would minimize or eliminate the given dysfunction. The aim of this stu- dy was qualitative and quantitative evaluation of gait in cerebral hemorrhage survivors with the right- or the left-sided hemiparesis. 25 patients (17 with the right-si- ded and 8 with the left-sided hemiparesis) were subjec- ted to functional evaluation of the paretic lower limb, gait evaluation (gait efficiency and gait ability) and wal- king distance assessment. Correlation between the neurological and locomotor status of the patients was evaluated. The analysis showed a statistically signifi- cant correlation between the examined traits. It also in- dicates a necessity for performing neurological and functional evaluation of patients after stroke and moni- toring of the rehabilitation progress. Lack of improve- ment may indicate that the rehabilitation scheme ne- eds to be altered, especially in the first months after the stroke. The final effect of rehabilitation depends, to a large extent, on the choice of appropriate physiothera- peutic strategy.
- [Show abstract] [Hide abstract]
ABSTRACT: This thesis is based on the findings of the FuPro-Stroke study (the Stroke section of the Functional Prognostification and disability study on neurological disorders), which is a multicentre, prospective cohort study among patients with stroke, who were included during inpatient rehabilitation. The aim of the research reported on in the present thesis was to investigate the long-term prognosis of chronic stroke outcome up to 3 years after onset. Poor mobility status is a key concern in chronic stroke patients, especially since it may lead to ADL dependence and affect social reintegration. We found that mobility at one-year post stroke could be predicted by functional status, sitting balance, time between stroke onset and measurement, and age. We also investigated determinants that could predict decline in mobility status in chronic stroke patients. Inactivity in terms of instrumental activities of daily living (IADL), cognitive problems, fatigue and depressive symptoms at one year post stroke were the main predictors for deterioration in mobility. Community ambulation is an important outcome for stroke patients and we found that this variable was closely related to gait speed. The optimal cut-off point for community ambulation was 0.66 m/s. Balance, endurance and the use of an assistive walking device were determinants that confounded the relation between community ambulation and gait speed. The effectiveness of training programmes focusing on lower limb strengthening, cardio-respiratory fitness or gait-oriented tasks, in terms of the outcome of gait, gait-related activities and health-related quality of life (HRQoL) after stroke were also investigated. Twenty-one high quality RCTs were included, five of which focused on lower limb strengthening, two on cardio-respiratory fitness training and 14 on gait-oriented training. After conducting a meta-analysis we suggested that gait-oriented training is the most successful method to improve walking competency after stroke. Depression and fatigue are both well-known sequels after stroke. At three years post stroke, 19% of the patients showed depressive symptoms. Depression was best predicted by one-year IADL activity and fatigue. It was also shown that 68%, 74% and 58% of the patients experienced fatigue at 6, 12 and 36 months post stroke, respectively. Fatigue was significantly related to IADL and HRQoL, but not to ADL. Depression and motor impairment were important confounders in the relationship between fatigue and IADL and HRQoL. Since the number of stroke patients is rising and it is a chronic disease, it is important that appropriate care is provided to suit the needs of all these patients. We suggest in our study that 33% of the patients perceived at least one unmet care demand at three years after stroke. Younger age, motor impairment, fatigue and depressive symptoms were significantly related to the presence of unmet demands. These results suggest that our health care system is as yet not fully meeting the demands of patients with chronic stroke. Our advise is that the focus of care and research should be on improving our understanding of the course of functional recovery by monitoring patients over time, introducing innovative intervention strategies and exploring the underlying mechanisms of functional improvement after stroke.
- [Show abstract] [Hide abstract]
ABSTRACT: Horn SD, DeJong G, Smout RJ, Gassaway J, James R, Conroy B. Stroke rehabilitation patients, practice, and outcomes: is earlier and more aggressive therapy better? To examine associations of patient characteristics, rehabilitation therapies, neurotropic medications, nutritional support, and timing of initiation of rehabilitation with functional outcomes and discharge destination for inpatient stroke rehabilitation patients. Prospective observational cohort study. Five U.S. inpatient rehabilitation facilities. Post-stroke rehabilitation patients (N=830; age, >18 y) with moderate or severe strokes, from the Post-Stroke Rehabilitation Outcomes Project database. Not applicable. Discharge total, motor, and cognitive FIM scores and discharge destination. Controlling for patient differences, various activities and interventions were associated with better outcomes including earlier initiation of rehabilitation, more time spent per day in higher-level rehabilitation activities such as gait, upper-extremity control, and problem solving, use of newer psychiatric medications, and enteral feeding. Several findings part with conventional practice, such as starting gait training in the first 3 hours of physical therapy, even for low-level patients, was associated with better outcomes. Specific therapy activities and interventions are associated with better outcomes. Earlier rehabilitation admission, higher-level activities early in the rehabilitation process, tube feeding, and newer medications are associated with better stroke rehabilitation outcomes.Archives of Physical Medicine and Rehabilitation 01/2006; 86(12 Suppl 2):S101-S114. DOI:10.1016/j.apmr.2005.09.016 · 2.44 Impact Factor