Comparison of Stroke Rehabilitation Guidelines Essay

Stroke is considered to be the third cause of death and disability for millions of people in developed countries (1). Stroke is the clinical manifestation of a wide range of pathologies, with different etiologies and prognoses, and many risk factors. Stroke is defined as a syndrome characterized by rapidly developing clinical symptoms and/or signs of focal loss of cerebral function, in which symptoms last more than 24 hours or lead to death, with no apparent cause other than that it is a vascular origin. Stroke victims who survive the first attack may have persisting impairments such as cognitive impairments, upper and lower limb impairments and speech disabilities. The United Kingdom’s prevalence of stroke in the population is estimated to be 47 per 10000 making stroke the most common cause of adult physical disability (1; 2; 3). In the United State the Veterans Health Administration (VHA) estimated that 15000 veterans are in hospitals with a diagnosis of stroke every year (4). Comparison of Stroke Rehabilitation Guidelines Essay Paper

Stroke rehabilitation is a main factor in helping stroke survivors to regain their functional ability when medical and surgical interventions are limited (5). Physical therapy plays a major role in stroke rehabilitation. Physical therapists choose the duration and type of therapy given and provide education for stroke patients. Stroke rehabilitation aims at giving the patients the ability to regain maximum and full potential in functional activities and restoration of motor control (6; 7; 8; 5). Three main factors in rehabilitation contribute to the speed and quality of recovery. These factors are: treatment session duration and frequency, type of treatment approach used for rehabilitation, and providing education about the condition for patients during and after therapy (2; 3; 7; 8; 9). Comparison of Stroke Rehabilitation Guidelines Essay Paper

Physical therapy rehabilitation for stroke patients is designed to impact the disabilities and impairments associated with post stroke conditions. Rehabilitation is mainly aimed at limiting any deterioration of impairments and maximizing the functional level for patients suffering from stroke. To be able to deliver this, physical therapists should follow a certain set of guidelines which will insure better outcomes and avoid unnecessary practices that could prolong and delay optimum gain of function (6; 7). Comparison of Stroke Rehabilitation Guidelines Essay Paper

It is unclear whether physical therapists in Kuwait follow any specific guidelines in stroke rehabilitation. Therefore, it would be plausible to learn more about current local rehabilitation procedures. This may help in the further development of local rehabilitation procedures and practice guidelines, optimization of treatment and rehabilitation management, improvement in stroke patient’s health and quality of life, and minimization of conflicted rehabilitation practices that prolong therapy which in turn affect and burden the health system with increased number of patients (6; 8; 10; 11). We hypothesize that physical therapist in Kuwait rehabilitation do not follow stroke rehabilitation guidelines and science based practices in stroke rehabilitation. Therefore the aims of this study are to:Comparison of Stroke Rehabilitation Guidelines Essay Paper

Explore if stroke rehabilitation in Kuwait follow general guidelines of stroke rehabilitation regarding frequency of treatment sessions and duration of each session.

Investigate if physical therapists specializing in the field of neuroscience in Kuwait follow general guidelines of stroke rehabilitation regarding their treatment approaches.

Identify if education is being provided for stroke patients about their condition during and after rehabilitation.

Literature Review:

Stroke is defined as a syndrome in which clinical symptoms and/or signs of cerebral function loss develop rapidly, and last for more than 24 hours or result in death. Stroke can be classified according to the cause, which is either ischemic or hemorrhagic. Ischemic strokes account for 85% of all strokes, while 15% account for hemorrhagic strokes. Over 10% of patients who had a first stroke will have a second one within a year, and the risk of recurrence within 5 years is 15-42% (1).Comparison of Stroke Rehabilitation Guidelines Essay Paper

There are a wide range of conditions that lead to stroke, such as hypertension and diabetes. Each year, 5.45 million deaths are attributed to stroke, and over 9 million survive. Survivors often experience a wide range of persisting impairments. Common impairments include Physical disability, cognitive impairment, Lower limb impairments, and speech difficulties (1).Comparison of Stroke Rehabilitation Guidelines Essay Paper

Rehabilitation is an important part after survival from a stroke. Rehabilitation was defined in the New Zealand guideline for management of stroke as ‘a problem-solving and educational process aimed at reducing the disability and handicap experienced by someone as a result of disease, always within the limitations imposed by both available resources and the underlying disease’ (12). It’s of utmost importance that the stroke patient understands, and receives education concerning his/her condition and what limitations may persist, even after rehabilitation (12).Comparison of Stroke Rehabilitation Guidelines Essay Paper

Reker D. M. et al, researched whether adherence to post stroke guidelines was associated with greater patient satisfaction. They used a prospective inception cohort study design for new stroke admissions, including post-acute care, and they made follow-up interviews at 6 months after the stroke injury. Two hundred and eighty eight patients were included in the study, from eleven Veterans Affairs medical centers (VAMCs). The main outcome measures used in this study were: 1) compliance with the Agency for Healthcare Research and Quality (AHRQ), 2) patient satisfaction with care provided, and 3) stroke-specific instruments. Results have shown that, for every 10% percent increase in guidelines compliance, the average value of patient satisfaction increases by 1.5 points for the mean overall satisfaction score, which ranges from 4 to 39, and includes items for hospital satisfaction, home satisfaction, and overall satisfaction. The study concluded that compliance to AHRQ guidelines is significantly associated with patient satisfaction (7). Comparison of Stroke Rehabilitation Guidelines Essay Paper

Several comparisons between Stroke Rehabilitation Protocols/ guidelines have been performed. This is beneficial in establishing the best treatment, with regards to dosing, intensity, duration, as well as efficiency and efficacy of interventions. A study by McNaughton H, et al examined the practice and outcomes of stroke rehabilitation between New Zealand and the United States facilities. This study used a Prospective observational cohort design and included 1161 participants from six United States (U.S.) Rehabilitation facilities and 130 participants from one New Zealand rehabilitation facility, all above the age of 18 years. In this study, New Zealand patients were older than the United States patients. However, the severity of initial stroke was higher for the U.S. patients. Despite that fact, patients in the U.S. were discharged earlier. They also had more intensive therapy, represented in higher durations spent with physical therapy and occupational therapy professionals. Also, U.S therapists tended to spend less time on assessment and non-functional activities, while focusing more on active management of patients. Results showed that, U.S. participants had better outcomes represented by changes in Functional Independence Measure FIM scores and fewer discharges to institutional care (13.2% vs. 21.5%). This study illustrates that duration and intensity of therapy can be adjusted to gain a better outcome. Also, it is important to know which activities are being done in the treatment session, and find out if they contribute to a better outcome of rehabilitation (10). Comparison of Stroke Rehabilitation Guidelines Essay Paper

Horn et al. investigated the effect of specific rehabilitation therapies in stroke rehabilitation on outcomes, taking into account the differences between patients. In this study, they wanted to examine the associations between patient characteristics, rehabilitation therapies, neurotropic medication, nutritional support, and time of starting therapy with functional outcomes and discharge destination for stroke inpatients. Discharge total, motor, and cognitive FIM (functional independence measure) scores and discharge destinations were registered for 830 patients with moderate or severe strokes from five U.S. inpatient rehabilitation facilities. Results showed that earlier initiation of rehabilitation, time spent in higher-level rehabilitation activities, such as upper-extremity control, gait and problem solving, usage of newer psychiatric medications, and gastric feeding, were all associated with better outcomes. The study also illustrated that a variety of Physical Therapy, Occupational Therapy, and Speech Language Pathology activities were correlated with higher or lower FIM scores. On one hand, more minutes spent per day on PT gait activities, OT upper-extremity control activities and home management, and SLP problem solving activities were associated significantly with higher FIM scores. On the other hand, more minutes spent per day on PT bed mobility and sitting, OT bed mobility, and SLP auditory comprehension and orientation were consistently associated with lower FIM scores (11). Comparison of Stroke Rehabilitation Guidelines Essay Paper

One study described Physical Therapy intervention for stroke patients in inpatient facilities within the U.S. (13). Six rehabilitation facilities in the U.S. included 972 subjects with stroke injury. Variables studied were time spent in therapy, and content and activities that were used in rehabilitation. The mean duration of stay in the inpatient facilities was 18.7 days, and received PT was on an average of 13.6 days. Patient spent 57.15 minutes on average for Physical therapy treatment every day. Activities of gait, transferring, and pre-functional activities, which include strengthening exercises, balance training, and motor learning, were the most performed interventions. Also, therapists included activities that incorporated different functions into one functional activity. This study implicated that a focus of physical therapist when providing treatment is optimizing functional activities, as they were the most frequent activities performed. However, activities to remediate impairments and to compensate for lost functions were also included in the treatment sessions (13) . Comparison of Stroke Rehabilitation Guidelines Essay Paper

Brocklehurst et al. investigated the use of physical therapy, occupational therapy, and speech therapy for patients suffering from stroke, as they mentioned that those interventions formed the basis of stroke rehabilitation. The study included 135 stroke patients from five general and one geriatric hospital, in South Manchester. Of the 135 subjects, 107 received PT, 35 received OT, and 19 received speech therapy. Results were obtained after measuring the rate of change in function over a one year period. Patients, who had more severe disabilities, and the worst prognosis, were more likely to get physical therapy treatment. Factors that determine type and specificity of physical therapy to stroke rehabilitation were also examined. Some of the factors were extent of disability, and disability-associated morbidities, such as fecal incontinence, spasticity, sensory loss and dysphasia. Even though the most disabled received the most physical therapy treatment, they showed the least improvement in function even after six months of therapy. This study also concluded that patients, whose progress was poorest, received more physical therapy (5). Comparison of Stroke Rehabilitation Guidelines Essay Paper

Hsiu-Chen Huang et al. investigated the impact of timing and dose of rehabilitation delivery on the functional recovery of patients suffering from stroke. In this study, a retrospective review of medical charts was done for 76 patients who were admitted to a regional hospital for a first-ever stroke. Patients had multidisciplinary rehabilitation programs, including PT, OT, and a continuous rehabilitation for at least three months. The main outcome measure for this study was the Barthel index, taken at initial assessment, one month, three months, six months and one year after stroke. Results of this study showed that there is a dose-dependent effect of rehabilitation on functional outcome improvements of stroke patients. Also, earlier delivery of rehabilitation is associated with lasting effects on functional recovery up to one year post-stroke (14). Comparison of Stroke Rehabilitation Guidelines Essay Paper

It is unclear whether physical therapists follow evidence based practice many countries of the world including Kuwait. There is no doubt the era of evidence based practice is upon us for many reasons including better treatment outcomes, patient satisfaction, reimbursement amongst others. In one survey study, conducted by Iles and Davidson, examination of physical therapists’ current practice in Australia was undertaken. This study found that there are several barriers in the way of evidence-based practice. Those barriers included time to stay up to date, access to journals, access to summaries of evidence that are easy to understand, and lack of personal skills in looking for and evaluating research evidence (15).

Salbach et al. examined the determinants of research use in clinical decision making among physical therapists treating post-stroke patients. Two hundred and sixty three physical therapists from the state of Ontario, Canada, responded to a survey questionnaire, containing items for evaluating practitioner and organizational characteristics and perception of research believed to be influencing evidence-based practice. The survey also contained the frequency of using research evidence in clinical decision making in a typical month. Results showed that, only a small percentage of therapists (13.33%) reported using research in clinical decision making six times a month or more. However, most therapists (52.9%) reported using research 2-5 times a month, while 33.8% used research 0-1 time per month. In this study, research use was associated with the academic preparation in the principles of Evidence-Based Practice (EBP), research participation, service as a clinical instructor, being self-effective in implementing EBP, attitude towards research, perceived organizational support of research use, and access to bibliographic databases at work. This study concluded that a third of therapists rarely apply research evidence in clinical decision making. Suggested interventions to promote research use included education in the principles of EBP, EBP self-efficacy, having a positive attitude towards research, and involvement in research (8). Comparison of Stroke Rehabilitation Guidelines Essay Paper