Rehabilitation research: the impact on your life after stroke

Helen RodgersProfessor of Stroke CareNewcastle University

Acknowledgements

• Stroke Unit Trialists Collaboration

• Early Supported Discharge Trialists

• Professor Anne Forster

• Professor Peter Langhorne

• Professor Tony Rudd

• Professor Marion Walker

“to get over a strong attack of apoplexy is impossible, over a weak one is not easy”

‘A stroke of God’s hand’

Oxford English Dictionary 1599

Treatment

• Put to bed with head well raised• Bleed freely (1-2 pints)• Apply warm mustard poultices• Open bowels quickly and freely• Throw up a turpentine clyster• Cut off the hair• Apply rags of vinegar (or gin)

and water• 8-10 leeches on temple opposite

paralysed side

King’s Fund Forum

Consensus and controversy in stroke

The treatment of stroke

June 27, 28 and 29, 1988

Regent’s College, Inner Circle

Regent Park, London NW1

Problems in rehabilitation

• shortage of therapy

• long unoccupied periods

• failure to recognise and respond to mood disturbance

• delegation of care to inadequately trained medical staff

• confusion by too many people involved

Problems in rehabilitation

• misunderstandings and rivalries between professionals

• breakdown in communication between professionals, patients and carers

• insufficient appreciation of the impact of stroke on the family

• ill prepared discharge

Cornerstones of stroke care

• TIA clinic

• stroke unit

• early supported discharge

• long term support

Planning stroke services

• incidence

• outcome

• prevalence

• Oxford Community Stroke Register

• OXVASC Study

• South London Stroke Register

Stroke is an emergency

Features of stroke unit care

• Consultant doctor specialising in stroke care

• Links with patient and carer organisations

• Weekly meeting of all professionals

• Good information for patients about stroke

• Staff provided with up-to-date training

Early Supported Discharge

The case against hospital rehabilitation

• artificial environment

• promotion of dependence

• boring

• risk of infection

• poor nutrition

• emphasis on physical recovery

• isolation

The case for community rehabilitation

• Home is the most appropriate environment• Involvement and empowerment of patients

and carers• More emphasis on psychological and social

issues• Less isolation• Cheaper

The case against community rehabilitation

• carer stress

• may not be co-ordinated or timely

• intrusive

• travelling

• primary care work load

Absolute outcomes(additional events per 100 patients treated)

Alive (6-12 months) 1 (2-4) Not significant

Living at home 5 (1-9)P = 0.02

Independent 6 (1 – 10)P = 0.02

Early supported discharge

• improved satisfaction with services

• no impact on mood

• no adverse effect on carer mood or health

Economics of ESD services

• Length of stay reduced by 8 (5-11) days

• ESD is slightly cheaper

How should community stroke care be organised and

provided?

Outpatient Service Trialists

To assess the effects of therapy based rehabilitation services targeted towards stroke patients resident in the community within one year of stroke onset.

• 14 trials• heterogeneous interventions• including 1617 patients

Lancet 2004

Outpatient Service Trialists

“Patients receiving rehabilitation at home within one year of stroke onset are more likely to have a better outcome, in terms of independence and achievement of maximum level of function in all aspects of daily life.”

Developing services

Evidence

Professional knowledge,Judgement, values and expertise

Patient, carer and public knowledge, values and input

NICE: stroke quality standard

• 45 minutes of each therapy

• minimum 5 days per week

• level to meet rehabilitation goals

• as long as continuing to benefit

Nutrition

Swallowing

FOOD Trial

• food supplements• early tube feeding• PEG feeding

A Very Early Rehabilitation Trial (AVERT) - Phase III clinical trial

DesignRandomised controlled trial of very early rehabilitation

versus standard care.

Features• blinded assessment • intention to treat analysis • multi-centre• large (n = 2104)* largest stroke rehab study • multi-disciplinary rehabilitation focused intervention

Physiotherapy after stroke

‘Approaches’

Focused training

Muscle strengthening

Treadmill

Repetitive movements

Constraint induced movement

Van Peppen, Clin Rehab 2004

Task orientated

rehabilitation is best

Rehabilitation goals

Aerobic exercise

Mental Practice

Video Games

Outdoor Mobility Programme

• 42% of patients don’t get out of the house as much as they would like after stroke

• lack of information• physical limitations• fear of falling

Mobility Interventions

• Walking (23%)• Bus (17%)• Dial–A–Ride (13%)• Driving (10%)• Shop mobility (8%)• Scooter (8%)• Voluntary car (6%)• Wheelchair use (9%)• Passenger car (4%)• Taxi (4%)

• Mean 6 sessions

Results – comparison of groups

Four months Controln = 82

Interventionn = 86

Comparison

Yes I get out as much as I want to

30 (37%) 56 (65%) RR = 1.78(95% CI 1.29to 2.46)

JourneysMedian (mean)

15 (22) 38 (43) Mann-Whitneyp<0.001

EADL mobility section Median

6 9 Mann-Whitneyp<0.05

University of Nottingham

• Depression

• Anxiety

• Emotionalism

• Memory

• Concentration

Fatigue

Stroke family support workers

• improve outcome for patients with mild/moderate disability

• improve satisfaction with some aspects of service provision

Evaluating effect of a training programme for caregivers

TRAINING PROGRAMME

Stroke unit setting

Structured, competency based, with assessment

of carer skills

V

‘USUAL CARE’

Stroke unit setting

Information and advice available from MDT

High quality research leads to service improvement .......

...... and some surprises

Advances in stroke care

• there have been significant improvements in stroke care

• important and unacceptable gaps remain in service provision