Rehabilitation research: the
impact on your life after stroke
Helen Rodgers
Professor of Stroke Care
Newcastle 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”
Oxford English Dictionary 1599
‘A stroke of God’s hand’
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
Patient, carer and
public knowledge,
values and input
Professional knowledge,
Judgement, values and
expertise
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
Design
Randomised 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
Repetitive
movements
Muscle
strengthening
‘Approaches’
Focused
training
Treadmill
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
Bus
Dial–A–Ride
Driving
Shop mobility
Scooter
Voluntary car
Wheelchair use
Passenger car
Taxi
• Mean 6 sessions
(23%)
(17%)
(13%)
(10%)
(8%)
(8%)
(6%)
(9%)
(4%)
(4%)
Results – comparison of groups
Four months
Control
n = 82
Intervention
n = 86
Comparison
Yes I get out as
30 (37%)
much as I want to
56 (65%)
RR = 1.78
(95% CI 1.29
to 2.46)
Journeys
Median (mean)
15 (22)
38 (43)
Mann-Whitney
p<0.001
EADL mobility
section Median
6
9
Mann-Whitney
p<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
‘USUAL CARE’
Stroke unit setting
V
Structured, competency
based, with assessment
of carer skills
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