Age and Ageing (1979), 8, Supplement
REHABILITATION OF THE STROKE PATIENT P. J. R. NICHOLS
DEFINITION OF REHABILITATION
REHABILITATION IN THE ACUTE STAGE
About half of patients with a stroke will die within the first few weeks. Thus the immediate care of the patient with stroke depends on the severity of the condition and upon the immediate acute care. During this phase physiotherapy is directed towards: (a) passive movements of all limb joints of the affected side to prevent contra ctures; (b) prevention of deformity by the use of a bed cage, foot boards, axillary pillows, palmar wrist splint. Great care and gentleness are required to prevent over-stretching and soft tissue damage. As spasticity intervenes there is continuing need for skill and experience if soft tissue injury is to be avoided. If the patient is dying then unwarranted disturbance should be avoided, but if there is a reasonable chance of recovery it is essential to avoid delay in 67
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Rehabilitation is usually defined as implying the restoration of patients to their fullest physical, mental and social capability. In practice the word is used as a comprehensive term referring to the physical management of disability. In many conditions maintenance and preservation of function is of most importance during a period of inactivity or immobilization. This phase is followed, as recovery ensues, by a period of active re-establishment of function and utilization of residual capability. For those with irrevocable loss of function alternative techniques must be invoked to regain optimum function and aids and appliances introduced to substitute for loss of capacity. It is important to distinguish between the problems of rehabilitation of temporary disability and permanent disability. Those with temporary disability require intensive rehabilitation directed towards the physical disability. This will start early and be directed according to the clinical diagnosis and clinical condition. The aim is rapid return of function and early resettlement at home. For those with a chronic disability the aims and techniques of rehabilitation are different. Maintenance and support are the keystones. Repeated clinical, functional and social assessments are necessary. The main aim is social resettlement and maintenance of the social situation (Nichols 1974). Of course some patients with chronic disabilities need periods of intermittent rehabilitation and this should always be directed towards overcoming some intervening temporary change in the overall pattern of disability. A stroke should be considered initially as a 'temporary disability' and then, when the level of residual deficit becomes evident, as a chronic disability. The timing of the change of the approach is very important.
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diminution of power diminution of sensation spasticity visual field defects speech impairment impaired perception of body image impaired concentration (Hurwitz 1969) Each of these factors will have repercussions upon the pati ent's functional ability and rehabilitation programme. The individual factors have to be put in the overall context of: (a) the underlying lesion—progressive degeneration, etc.; (b) the patient's general condition—age, complicating factors; (c) social and environmental factors—housing, family available to care for the patient, social and educational background. The critical period for rehabilitation seems to be the first six to twelve weeks after the cerebrovascular accident, which is the phase of the greatest and fastest recovery. There are almost as many 'stroke rehabilitation regimes' as there are rehabilitation departments, each pursued with enthusiasm if not evangelism! The failure of any one particular treatment or regime to outstretch all others indicates their non-specificity. It is likely therefore that the rehabilitation period should attempt to impose a habit upon the patient for the more important exercise routines, e.g. shoulder mobilizing and finger exercising, walking, speech and writing practice. As far as possible, the patient's own motivation must be stimulated so that formal exercises are supplemented and incorporated into creative and social activities. Active exercises are frequently prescribed
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active prevention of unnecessary stiffness and deformity. The length of time the patient needs to be kept strictly bedfast will vary with the cause and severity of the lesion, but should be minimal. As recovery begins so active rehabilitation is introduced. Many centres spend much time training patients in sitting, balancing—the so-called 'bed edge exercises'—but this practice is now challenged by many therapists who advocate early walking training as soon as the patient's general clinical condition allows. Although there are no truly comparative studies, current practice leads towards introducing purposive activities as early as possible, and re-establishing understood and remembered patterns of movement. Of those who survive the first few weeks a further 10 per cent will die within the next two months. Of the survivors, about one-third will not achieve independence and twothirds will become independent with or without help. Muscle power, muscle control and muscle tone all contribute to physical disability. Motor defect alone is seldom a real bar to functional recovery: a patient with hemiparesis from poliomyelitis may have complete independence, and a patient with an arm and a leg amputated on one side, although clearly handicapped, can achieve considerable functional skill. Hemiplegia then is not necessarily a severe disability unless loss of motor power is associated with sensory deficit, speech impairment or impairment of cerebration. The characteristics of the neurological lesion are:
Rehabilitation of the Stroke Patient
69
almost in perpetuity for the treatment of paretic limbs after cerebrovascular accident and such patients contribute one of the largest single groups referred for physical treatment, but their effect is more likely to be achieved through (a) improvement and coordination, and (b) prevention of contractures (Lenman 1959). Many patients are unnecessarily attending departments intermittently when they could be better occupied attending social clubs or day centres, where general activities would combine exercises with interest and entertainment. This would free the hospital physiotherapy departments to give more intensive treatment to the earlier and more acute problems. SPASTICITY
WALKING AIDS
Most hemiplegics will require a walking aid for some weeks or months, and the elderly hemiplegic will often be unable to give up such an aid. Initially the best aids are 'quadruped' or 'tripod' sticks with a wide spread. Braces, calipers and splints
In the early stages a back splint to brace the knee is a useful aid for walking training. About 50 per cent of stroke patients need some immobilization and support of the ankle because of instability. A boot with a 'T-strap' may suffice, but the more unstable will need a double iron and drop-foot stop. Toe-raising springs have little value, the spring accentuates the spasticity and usually only serves to distort the shoe. There is often a problem in controlling the equino varus spastic lower leg. The type
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Much of the long-term management of the hemiplegic is the management of spasticity. In the early stages reduction of the spasticity will enable the therapist to encourage voluntary exercise and functional activities. The use of ice, the use of relaxation techniques and much of the proprioceptive neuromuscular facilitation techniques are directed towards this end. The use of drugs such as diazepam/valium and baclophen/ lioresal will often enable the physiotherapist to achieve more active function and reduce uncomfortable nocturnal spasm. The sustained stretching of spastic muscle during 8-9 h sleep is more likely to be effective in the prevention of deformity, than a few minutes of stretching two or three times a day. Thus adequate night doses of valium and the use of a lightweight splint with some dorsiflexion of the ankle is more value in preventing contractures of the calf muscles than intermittent attendance at a physiotherapy department. Injection of alcohol (40-45 per cent) into the muscle belly at or near motor points will usually give some temporary relief (Cockin et al. 1971). More accurate injection in the motor nerves with small quantities of 2 per cent aqueous phenol will usually convert a spastic muscle into a flaccid one (Copp & Keenan 1972). The presence of continuing pain or discomfort, or persistent interference with active function in an otherwise well-established patient should be an indication for considering surgical procedures to produce a more permanent reduction in the spasticity. The patient should continue to have periods of prone lying each day in order to prevent the development of hip flexion contractures and to continue with a bed footboard at night to prevent footdrop.
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Walking training Much time is spent in walking training and most of it is wasted. The spastic gait is always ugly and awkward looking. If the patient covers the ground well and walking is stable, it matters little if the leg is circumducted and there is some degree of foot drop. It is more important to teach him to use extensor spasm than to overcome it, e.g. step up stairs off the affected leg and step down on the affected leg, taking one step at a time. Evaluation of walking potential must include all those factors which are related to the motor aspects of walking, including: sitting and standing balance, visual-spatial perception; weakness or spasticity in the appropriate muscle groups; competence in walking in different conditions (levels, slopes, rough ground, steps); contractures of the hips, knees and ankles; the general status (cardiac, respiratory, urinary, as well as neurological)—energy expenditure is probably high. LONG-TERM MANAGEMENT: SURGERY
Surgical operations aimed at rebalancing muscle power in the presence of spasticity are often doomed to failure. Distinction must be made between spastic deformity and structural contracture. The spastic deformity disappears in sleep and can be relieved by positioning or a slow passive stretch. No surgical procedures will improve weak hip abduction, and no surgical procedure will restore normal gait, for hemiplegia is a dis-
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of short leg brace is determined by the severity of the spasticity. If it is mild, with no clonus, simple splints are usable, but usually the spasticity is too great and any stretching of the muscle increases it further. Thus the lower leg braces usually need to be holding braces, maintaining the foot and ankle in a functionally optimum position. However, if the foot is not dorsiflexed there will be a tendency for the knee to hyperextend during stance phase (if weightbearing occurs) because of the tight heel cord. The solution is to get the ankle correctly positioned and 'stop' the caliper. If dorsiflexion can be achieved without increasing spasm then this is an advantage. A wedged heel raise will prevent hyperextension of the knee. Full leg bracing is only rarely needed for the hemiplegic who remains frail or very weak. In such patients the weight and complexity of the caliper usually leads to rejection by the patient, even the more modern so-called 'cosmetic caliper'. In all instances, it is essential that the shoes fit properly. They should have a good heel to hold the foot down and the shoe needs to be able to be widely opened so that inserting the foot does not stimulate a full Babinski response. Furthermore, the shoe needs a firm sole plate which cannot be deformed by the caliper. Finally, the brace must be firmly attached to the shoe. It is virtually impossible for the average elderly hemiplegic to put on a conventional below-knee caliper and it is totally impossible for them to manage a full length caliper. This means that calipers and braces must be very simple, or be accepted as therapeutic training devices to be put on for walking exercises by the physiotherapist. New rigid plastics, e.g. polypropylene, have made it possible to produce aesthetically acceptable lightweight foot drop splints. Their manufacture entails very careful casting for a plastic moulded splint is only as good as the cast allows it to be.
Rehabilitation of the Stroke Patient
71
order in which imperfect motor control is inherent. Thus reconstructive procedures aim at reducing deformity and improving standing and walking stability, but are largely reserved for the young. LONG-TERM MANAGEMENT OF THE ARM
WHEELCHAIR USE
Recovery is invariably greater in the leg than in the arm and thus concentration on walking re-education dominates the first phase of active rehabilitation. But some will not achieve independent walking and will require a wheelchair—about one infiveof survivors. Unfortunately, the coordination required to propel a single-hand control wheelchair is considerable, and few elderly hemiplegics manage. Some younger hemiplegics can become very skilful with single-hand control chairs, but of these only a few can achieve outdoor mobility involving any slopes or rough ground. Most elderly hemiplegics are not going to achieve a high level of activity and will be better served by providing a wheelchair early in their disability. Many of them can manage to control the chair in their own environment by combined activity of one hand and one foot, the arm providing
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The spastic arm is a much more difficult problem to manage and its chances of recovery are slim. The spastic adducted shoulder can be mobilized by a combination of passive and active movements, particularly while in the warm treatment pool, or after injection of local anaesthetic and hydrocortisone if pain is a predominant feature. Ice packs may be followed by several hours of reduced spasticity, during which time active and passive movements can be achieved. There are many varieties of slings and wrist splints. Pulley exercises combining active and passive movements can be carried out at home as part of the regular daily routine. At all stages it is important to prevent, and if present to treat, oedema of the hands and fingers. Gravitational drainage, the use of the high sling, passive exercises, will all have this object in the early stages. Stiffness will inevitably develop in the presence of persistent oedema. Hand splints to assist extension of wrist and fingers are devilish devices. They have to be complex and large, both to overcome the powerful flexion spasticity, and to pull the fingers in the correct direction. Most splints seem only to hyperextend and sublux the metacarpophalangeal joints. There are a few procedures which will improve the upper limb. Relaxation of the entire flexor muscle mass of the forearm with phenol or alcohol will often improve the appearance of the hand and facilitate the use of splints, since splintage of a flail hand is easier than splintage of a spastic one. Similarly injection of the biceps and brachialis relieves the flexor spasm of the elbow and prevents the ugly reflex action of the elbow, which so often occurs during walking. Most recovery will occur early, and deformities which are present at three months will usually persist. Indeed, many authorities believe that if there is no voluntary control at three weeks there will be no useful recovery of function. Surgery can achieve permanent correction of such deformities but is usually reserved for the younger hemiplegics.
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the forward propulsion, albeit towards the opposite side, and the foot controlling the direction by acting as a brake and a pivot. This enables them to attain some limited mobility with little effort by themselves, and also enables relatives and friends to take them out into the community and maintain their morale. But self-propulsion is so difficult that a powered chair is often more appropriate. For some the appropriate outdoor powered vehicle adds a dimension to life. Attendant-controlled powered chairs can help the social situation. But provision of a wheelchair is a supplement to, not a substitute for, retraining in walking. RESULTS OF REHABILITATION
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Intensive rehabilitation is believed to achieve improved function in the majority of patients surviving the first few months after the acute cerebrovascular episode. About two-thirds of patients should achieve personal independence and one-third are likely to be fit for some independence. For one patient, rehabilitation potential may mean a change from the bed-bound state to ability to transfer to a wheelchair, and for another it may mean the ability to return to work in the community. The average length of time that patients stay in a rehabilitation unit in the United Kingdom is about six weeks. When referred to a rehabilitation unit about 50-60 per cent of patients with stroke achieve some useful level of work or contribution to housework. These units have the advantage of providing comprehensive physiotherapy and realistic occupational therapy, together with speech therapy, psychiatric advice when necessary, and a close liaison with social workers to plan early return home. Which contributes most to rehabilitation varies with the individual patient. But such units often have enthusiastic staff and high expectations which lead to commensurate performance by staff and patients. The enthusiastic consultant achieves a level of staff commitment and patient response unequalled by others in the same field. In rehabilitation excellent positive results are often achieved through personal or organizational charisma. No amount of physiotherapy or occupational therapy is a substitute for the activities of everyday life, and therefore all therapeutic activities should be as realistic as possible, and rehabilitation activities should be channelled into normal activities as quickly as possible. The longer the patient is away from his usual routine the more difficult it will be for him to return to them. But it is essential that the functional aims are realistic. An unrealistic optimism about a patient's performance and progress brings only discredit to the process of rehabilitation and its proponents. The successful rehabilitation of a hemiplegic patient depends largely upon his ability to adjust, comprehend and accept treatment, and this requires his active cooperation and participation. The psychological effects of brain damage involve impairment of perception; impairment of intellectual function, and changes in personality (Storey 1968). Loss of limb sensation or defects of coordination may hinder learning ability or the patient's understanding and awareness of himself, or his ability to perform integrated actions. The curious syndrome of 'neglect' of the left half of space which accompanies many instances of left hemiplegia is an important factor in rehabilitation. The affected patients appear to ignore the existence of objects which occur in their left visual field, not due to left hemianopia. Stimuli from the right side appear to suppress those from the left.
Rehabilitation of the Stroke Patient
73
NEED FOR RESEARCH AND EVALUATION
Perhaps the biggest problem of all in the rehabilitation of stroke patients both physically and in speech is the paucity of information derived from controlled evaluation (Royal College of Physicians 1974). From all the literature about the subject there is clearly an overwhelming impression that rehabilitation procedures—in the widest sense— produce some good results. But it is not enough to show that patients do well in these situations, it is necessary to see whether they do better than if they had been treated differently. If they do better, then it is essential to find out which features of the treatment contribute to the difference. To point this out is in no way to be critical of the therapists—physical, occupational or speech—but it is important in relation to the limited facilities which exist in rehabilitation, to attempt to analyse which aspects of care—medical, physical, social— contribute to which aspects of improvement. For example, the experiment in Oxfordshire to use a panel of amateur volunteers to help retrain aphasic patients is one which will be watched with interest. But as with most rehabilitation, the provisions are multiphasic, providing a mixture of specific and non-specific care, with a response which may well also be a mixture of specific and non-specific improvement, so that we cannot exactly say what is affecting what! This is particularly important when the numbers appearing to need care are so many, and the therapeutic professions spread so thinly. The critical requirement for competent evaluation of various rehabilitation measures is a clear-cut definition of the 'outcome measures' by which recovery can be adjudged. The clinical and functional outcome measures used in rehabilitation medicine are many and varied. The range is between two extremes of (1) death, an agreed uncontroversial outcome but rarely relevant in rehabilitation practice; or (2) the patient's attitude towards his disability; but measures of patient satisfaction are not really adequate to assess the real benefit of rehabilitation. Functional outcome of rehabilitation is usually
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Other features of brain damage which tend to carry a poor rehabilitation prognosis include apraxia, agnosia and perseveration. The presence of these disturbances of coordination is an indication that physical therapy and rehabilitation are likely to be unavailing. At best, training will take considerably longer than in the absence of such signs. Indeed, speech therapy, re-education of balance, and deliberate training to understand the sensory deficits are probably the most important part of rehabilitation. One further indication of cerebral damage which has a poor prognosis is the persistence of emotional lability. Rapidly changing emotions, temper outbursts, attacks of inappropriate crying or laughing, are all indications of loss of brain tissue. Although the premorbid personality will determine the emotional reaction of the patient with a major illness, it is the patient's ability to change which is important and much more clinical and psychological data are needed to establish clear guidelines for the clinician and therapist. There is a relatively small amount of literature devoted to the assessment of mental status in specific clinical conditions. But there is diminished intellectual adaptability and ability to retain instructions with increasing age, and there is clear evidence that cerebrovascular disease of any kind brings concomitant intellectual damage (Adams & Hurwitz 1963).
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recorded in terms of time off work, hospital attendance, activities of daily living (ADL), social activities, all of these are related to psychological, social and cultural factors. For example, the recent report on rehabilitation after myocardial infarction (Royal College of Physicians 1975) stated that after discharge from hospital return to work is the most important milestone on a patient's way to full recovery; but it went on to define the causes of delay in return to work as being mainly concerned with factors unrelated to the infarct, such as psychological, social, economic, the patient's age and occupation. Return to work is such a complex activity, depending upon the person's work record and the availability of work, that it is unwise to treat employability as a main criterion for recovery. In most instances of stroke, because of the age factor, return to work is not an appropriate 'outcome measure'. Conventionally, activities of daily living are often invoked as 'outcome measures'. These are for the occupational therapists what the muscle charts are for physiotherapists. Clearly, the routine tests given in the OT department are an excellent check list of a patient's current capability in those circumstances (i.e. the hospital OT department). They are a record of what the patient can do. Katz et al. (1970) have shown that mobility and confinement to the house are major considerations in planning long-term care. Dependence or independence in going to the toilet is a useful indication of over-all performance, dividing people into groups that required significantly different amounts of assistance, and differentiating between those who did and who did not require admission to long-stay institutions. These parameters are admittedly more dependent upon the person's ability to respond to the environmental situation than reflecting directly the effects of specific rehabilitation. In effect the problem is to decide which components or categories are relevant and can be combined into an index of disability or performance in ADL. The fundamental problem in defining outcome measures is the multiplicity of factors involved. In many systems of measuring dependence or independence, the various scores in the ADL index are summed into a unified index after applying appropriate weightings. Developing the weighting system is a formidable problem and the unified index or rating is rarely of value in following change, although it may help in identifying a general level of need. As yet there is little information available regarding the correlation between various activities of daily living, and between ADL and other outcome measures. But applying numbers implies some unjustifiable assumptions: that you can accurately quantify the numerical relationship between descriptive grades; and that you can accurately quantify the relative importance of various activities. ADL indices endow these activities with a scientific accolade to which they are not entitled (Nichols 1976). And when all these assessments and evaluation have been carried out there are many factors over which we have no control. The factors which go towards make-up of physical and social wellbeing of a chronically disabled person are similar to those assessed for the elderly and include: income, adequate clothing, nutrition, housing, warmth, availability of appropriate toilet and bathroom facilities, and social contacts. In the final analysis many (indeed most) problems of rehabilitation of the elderly stroke patient are social. In a recent survey we have carried out under the sponsorship of the Social Affairs Directorate of the European Economic Commission (Wycliffe-Noble, van Nuland & Nichols 1977), we were able to demonstrate that the recommended architectural
Rehabilitation of the Stroke Patient
75
standards for accommodation for the elderly and disabled leave much to be desired. For example, in the kitchen most elderly people prefer to work at a conventional kitchen table rather than specially designed work surfaces and most specially built accommodation does not allow for this. As regards wheelchair housing we found that half the housebound were not assessed before allocation of dwelling and there was little attempt to match needs with design. SUMMARY
REFERENCES
ADAMS, G. F. & HURWITZ, L. H. (1963) Lancet ii, 533. COCKEST, J., HAMILTON, E. A., NICHOLS, P. J. R. & PRICE, D. A. (1971) Brit. J. din. Pract. 25,73.
COPP, E. P. & KEENAN, J. (1972) Rheum, phys. Med. ii, 287. HURWITZ, L. H . (1969) Brit. med. J. 3, 699. KATZ, S., D O W N , T . D., CASH, H . R. & GROTZ, R. C. (1970) Gerontologist 10, 20.
LEHMAN, J. (1959) J. Neurol. Neurosurg. PtycUat. 22, 182. MATTHEWS, W. B. (1970) Practical Neurology. Oxford: Blackwell. NICHOLS, P. J. R. (1974) Brit. J. occup. Ther. 37, 7, 113. NICHOLS, P. J. R. (1976) Brit. J. occup. Ther. 39, 6. ROYAL COLLEGE OF PHYSICIANS (1974) Report of the Geriatrics Working Group on Strokes. London: RCP. ROYAL COLLEGE OF PHYSICIANS (1975) Report of the Joint Working Party of the RCP and British Cardiac Society: Cardiac Rehabilitation. London: RCP. STOREY, P. B. (1968) Physiotherapy 54, 54. WYCLIFFE-NOBLE, C , VAN NULAND, N . J. M . & NICHOLS, P. J. R. (1977) Housing for the Disabled:
A Survey of Adjustable and Non-adjustable Equipment in Kitchens. Jointly subsidized by the
Social Studies Commission of the EEC and the National Fund for Research into Crippling Diseases. Obtainable from C. Wycliffe-Noble, William & Mary House, French Street, Sunbury-on-Thames.
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There is no better summary of rehabilitation of strokes than in Bryan Matthews' book Practical Neurology (1970). Treatment must still be based on the long-recognized principles of mobilization, proper hydration and feeding, and the prevention of infection. There is simply no virtue at all in the patient's staying immobile in bed. An accurate prognosis is hard to give. Early return of movement is a good sign while adverse signs are extensive sensory loss, prolonged flaccidity and previous strokes. Dysphasia may prove a major disability, even if a good recovery from paralysis has occurred. Patients certainly improve while having speech therapy, but as the natural tendency is to improvement, it is difficult to be certain of any indisputable effect. The patient's attitude of mind will greatly affect the degree of functional recovery, and it is always necessary to remember that rehabilitation measures cannot succeed in those patients who are not motivated to improve—and persuasion, explanation and cajolery have little effect.
REHABILITATION OF THE STROKE PATIENT P. J. R. NICHOLS
DEFINITION OF REHABILITATION
REHABILITATION IN THE ACUTE STAGE
About half of patients with a stroke will die within the first few weeks. Thus the immediate care of the patient with stroke depends on the severity of the condition and upon the immediate acute care. During this phase physiotherapy is directed towards: (a) passive movements of all limb joints of the affected side to prevent contra ctures; (b) prevention of deformity by the use of a bed cage, foot boards, axillary pillows, palmar wrist splint. Great care and gentleness are required to prevent over-stretching and soft tissue damage. As spasticity intervenes there is continuing need for skill and experience if soft tissue injury is to be avoided. If the patient is dying then unwarranted disturbance should be avoided, but if there is a reasonable chance of recovery it is essential to avoid delay in 67
Downloaded from http://ageing.oxfordjournals.org/ at Monash University on April 10, 2016
Rehabilitation is usually defined as implying the restoration of patients to their fullest physical, mental and social capability. In practice the word is used as a comprehensive term referring to the physical management of disability. In many conditions maintenance and preservation of function is of most importance during a period of inactivity or immobilization. This phase is followed, as recovery ensues, by a period of active re-establishment of function and utilization of residual capability. For those with irrevocable loss of function alternative techniques must be invoked to regain optimum function and aids and appliances introduced to substitute for loss of capacity. It is important to distinguish between the problems of rehabilitation of temporary disability and permanent disability. Those with temporary disability require intensive rehabilitation directed towards the physical disability. This will start early and be directed according to the clinical diagnosis and clinical condition. The aim is rapid return of function and early resettlement at home. For those with a chronic disability the aims and techniques of rehabilitation are different. Maintenance and support are the keystones. Repeated clinical, functional and social assessments are necessary. The main aim is social resettlement and maintenance of the social situation (Nichols 1974). Of course some patients with chronic disabilities need periods of intermittent rehabilitation and this should always be directed towards overcoming some intervening temporary change in the overall pattern of disability. A stroke should be considered initially as a 'temporary disability' and then, when the level of residual deficit becomes evident, as a chronic disability. The timing of the change of the approach is very important.
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diminution of power diminution of sensation spasticity visual field defects speech impairment impaired perception of body image impaired concentration (Hurwitz 1969) Each of these factors will have repercussions upon the pati ent's functional ability and rehabilitation programme. The individual factors have to be put in the overall context of: (a) the underlying lesion—progressive degeneration, etc.; (b) the patient's general condition—age, complicating factors; (c) social and environmental factors—housing, family available to care for the patient, social and educational background. The critical period for rehabilitation seems to be the first six to twelve weeks after the cerebrovascular accident, which is the phase of the greatest and fastest recovery. There are almost as many 'stroke rehabilitation regimes' as there are rehabilitation departments, each pursued with enthusiasm if not evangelism! The failure of any one particular treatment or regime to outstretch all others indicates their non-specificity. It is likely therefore that the rehabilitation period should attempt to impose a habit upon the patient for the more important exercise routines, e.g. shoulder mobilizing and finger exercising, walking, speech and writing practice. As far as possible, the patient's own motivation must be stimulated so that formal exercises are supplemented and incorporated into creative and social activities. Active exercises are frequently prescribed
Downloaded from http://ageing.oxfordjournals.org/ at Monash University on April 10, 2016
active prevention of unnecessary stiffness and deformity. The length of time the patient needs to be kept strictly bedfast will vary with the cause and severity of the lesion, but should be minimal. As recovery begins so active rehabilitation is introduced. Many centres spend much time training patients in sitting, balancing—the so-called 'bed edge exercises'—but this practice is now challenged by many therapists who advocate early walking training as soon as the patient's general clinical condition allows. Although there are no truly comparative studies, current practice leads towards introducing purposive activities as early as possible, and re-establishing understood and remembered patterns of movement. Of those who survive the first few weeks a further 10 per cent will die within the next two months. Of the survivors, about one-third will not achieve independence and twothirds will become independent with or without help. Muscle power, muscle control and muscle tone all contribute to physical disability. Motor defect alone is seldom a real bar to functional recovery: a patient with hemiparesis from poliomyelitis may have complete independence, and a patient with an arm and a leg amputated on one side, although clearly handicapped, can achieve considerable functional skill. Hemiplegia then is not necessarily a severe disability unless loss of motor power is associated with sensory deficit, speech impairment or impairment of cerebration. The characteristics of the neurological lesion are:
Rehabilitation of the Stroke Patient
69
almost in perpetuity for the treatment of paretic limbs after cerebrovascular accident and such patients contribute one of the largest single groups referred for physical treatment, but their effect is more likely to be achieved through (a) improvement and coordination, and (b) prevention of contractures (Lenman 1959). Many patients are unnecessarily attending departments intermittently when they could be better occupied attending social clubs or day centres, where general activities would combine exercises with interest and entertainment. This would free the hospital physiotherapy departments to give more intensive treatment to the earlier and more acute problems. SPASTICITY
WALKING AIDS
Most hemiplegics will require a walking aid for some weeks or months, and the elderly hemiplegic will often be unable to give up such an aid. Initially the best aids are 'quadruped' or 'tripod' sticks with a wide spread. Braces, calipers and splints
In the early stages a back splint to brace the knee is a useful aid for walking training. About 50 per cent of stroke patients need some immobilization and support of the ankle because of instability. A boot with a 'T-strap' may suffice, but the more unstable will need a double iron and drop-foot stop. Toe-raising springs have little value, the spring accentuates the spasticity and usually only serves to distort the shoe. There is often a problem in controlling the equino varus spastic lower leg. The type
Downloaded from http://ageing.oxfordjournals.org/ at Monash University on April 10, 2016
Much of the long-term management of the hemiplegic is the management of spasticity. In the early stages reduction of the spasticity will enable the therapist to encourage voluntary exercise and functional activities. The use of ice, the use of relaxation techniques and much of the proprioceptive neuromuscular facilitation techniques are directed towards this end. The use of drugs such as diazepam/valium and baclophen/ lioresal will often enable the physiotherapist to achieve more active function and reduce uncomfortable nocturnal spasm. The sustained stretching of spastic muscle during 8-9 h sleep is more likely to be effective in the prevention of deformity, than a few minutes of stretching two or three times a day. Thus adequate night doses of valium and the use of a lightweight splint with some dorsiflexion of the ankle is more value in preventing contractures of the calf muscles than intermittent attendance at a physiotherapy department. Injection of alcohol (40-45 per cent) into the muscle belly at or near motor points will usually give some temporary relief (Cockin et al. 1971). More accurate injection in the motor nerves with small quantities of 2 per cent aqueous phenol will usually convert a spastic muscle into a flaccid one (Copp & Keenan 1972). The presence of continuing pain or discomfort, or persistent interference with active function in an otherwise well-established patient should be an indication for considering surgical procedures to produce a more permanent reduction in the spasticity. The patient should continue to have periods of prone lying each day in order to prevent the development of hip flexion contractures and to continue with a bed footboard at night to prevent footdrop.
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Walking training Much time is spent in walking training and most of it is wasted. The spastic gait is always ugly and awkward looking. If the patient covers the ground well and walking is stable, it matters little if the leg is circumducted and there is some degree of foot drop. It is more important to teach him to use extensor spasm than to overcome it, e.g. step up stairs off the affected leg and step down on the affected leg, taking one step at a time. Evaluation of walking potential must include all those factors which are related to the motor aspects of walking, including: sitting and standing balance, visual-spatial perception; weakness or spasticity in the appropriate muscle groups; competence in walking in different conditions (levels, slopes, rough ground, steps); contractures of the hips, knees and ankles; the general status (cardiac, respiratory, urinary, as well as neurological)—energy expenditure is probably high. LONG-TERM MANAGEMENT: SURGERY
Surgical operations aimed at rebalancing muscle power in the presence of spasticity are often doomed to failure. Distinction must be made between spastic deformity and structural contracture. The spastic deformity disappears in sleep and can be relieved by positioning or a slow passive stretch. No surgical procedures will improve weak hip abduction, and no surgical procedure will restore normal gait, for hemiplegia is a dis-
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of short leg brace is determined by the severity of the spasticity. If it is mild, with no clonus, simple splints are usable, but usually the spasticity is too great and any stretching of the muscle increases it further. Thus the lower leg braces usually need to be holding braces, maintaining the foot and ankle in a functionally optimum position. However, if the foot is not dorsiflexed there will be a tendency for the knee to hyperextend during stance phase (if weightbearing occurs) because of the tight heel cord. The solution is to get the ankle correctly positioned and 'stop' the caliper. If dorsiflexion can be achieved without increasing spasm then this is an advantage. A wedged heel raise will prevent hyperextension of the knee. Full leg bracing is only rarely needed for the hemiplegic who remains frail or very weak. In such patients the weight and complexity of the caliper usually leads to rejection by the patient, even the more modern so-called 'cosmetic caliper'. In all instances, it is essential that the shoes fit properly. They should have a good heel to hold the foot down and the shoe needs to be able to be widely opened so that inserting the foot does not stimulate a full Babinski response. Furthermore, the shoe needs a firm sole plate which cannot be deformed by the caliper. Finally, the brace must be firmly attached to the shoe. It is virtually impossible for the average elderly hemiplegic to put on a conventional below-knee caliper and it is totally impossible for them to manage a full length caliper. This means that calipers and braces must be very simple, or be accepted as therapeutic training devices to be put on for walking exercises by the physiotherapist. New rigid plastics, e.g. polypropylene, have made it possible to produce aesthetically acceptable lightweight foot drop splints. Their manufacture entails very careful casting for a plastic moulded splint is only as good as the cast allows it to be.
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order in which imperfect motor control is inherent. Thus reconstructive procedures aim at reducing deformity and improving standing and walking stability, but are largely reserved for the young. LONG-TERM MANAGEMENT OF THE ARM
WHEELCHAIR USE
Recovery is invariably greater in the leg than in the arm and thus concentration on walking re-education dominates the first phase of active rehabilitation. But some will not achieve independent walking and will require a wheelchair—about one infiveof survivors. Unfortunately, the coordination required to propel a single-hand control wheelchair is considerable, and few elderly hemiplegics manage. Some younger hemiplegics can become very skilful with single-hand control chairs, but of these only a few can achieve outdoor mobility involving any slopes or rough ground. Most elderly hemiplegics are not going to achieve a high level of activity and will be better served by providing a wheelchair early in their disability. Many of them can manage to control the chair in their own environment by combined activity of one hand and one foot, the arm providing
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The spastic arm is a much more difficult problem to manage and its chances of recovery are slim. The spastic adducted shoulder can be mobilized by a combination of passive and active movements, particularly while in the warm treatment pool, or after injection of local anaesthetic and hydrocortisone if pain is a predominant feature. Ice packs may be followed by several hours of reduced spasticity, during which time active and passive movements can be achieved. There are many varieties of slings and wrist splints. Pulley exercises combining active and passive movements can be carried out at home as part of the regular daily routine. At all stages it is important to prevent, and if present to treat, oedema of the hands and fingers. Gravitational drainage, the use of the high sling, passive exercises, will all have this object in the early stages. Stiffness will inevitably develop in the presence of persistent oedema. Hand splints to assist extension of wrist and fingers are devilish devices. They have to be complex and large, both to overcome the powerful flexion spasticity, and to pull the fingers in the correct direction. Most splints seem only to hyperextend and sublux the metacarpophalangeal joints. There are a few procedures which will improve the upper limb. Relaxation of the entire flexor muscle mass of the forearm with phenol or alcohol will often improve the appearance of the hand and facilitate the use of splints, since splintage of a flail hand is easier than splintage of a spastic one. Similarly injection of the biceps and brachialis relieves the flexor spasm of the elbow and prevents the ugly reflex action of the elbow, which so often occurs during walking. Most recovery will occur early, and deformities which are present at three months will usually persist. Indeed, many authorities believe that if there is no voluntary control at three weeks there will be no useful recovery of function. Surgery can achieve permanent correction of such deformities but is usually reserved for the younger hemiplegics.
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the forward propulsion, albeit towards the opposite side, and the foot controlling the direction by acting as a brake and a pivot. This enables them to attain some limited mobility with little effort by themselves, and also enables relatives and friends to take them out into the community and maintain their morale. But self-propulsion is so difficult that a powered chair is often more appropriate. For some the appropriate outdoor powered vehicle adds a dimension to life. Attendant-controlled powered chairs can help the social situation. But provision of a wheelchair is a supplement to, not a substitute for, retraining in walking. RESULTS OF REHABILITATION
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Intensive rehabilitation is believed to achieve improved function in the majority of patients surviving the first few months after the acute cerebrovascular episode. About two-thirds of patients should achieve personal independence and one-third are likely to be fit for some independence. For one patient, rehabilitation potential may mean a change from the bed-bound state to ability to transfer to a wheelchair, and for another it may mean the ability to return to work in the community. The average length of time that patients stay in a rehabilitation unit in the United Kingdom is about six weeks. When referred to a rehabilitation unit about 50-60 per cent of patients with stroke achieve some useful level of work or contribution to housework. These units have the advantage of providing comprehensive physiotherapy and realistic occupational therapy, together with speech therapy, psychiatric advice when necessary, and a close liaison with social workers to plan early return home. Which contributes most to rehabilitation varies with the individual patient. But such units often have enthusiastic staff and high expectations which lead to commensurate performance by staff and patients. The enthusiastic consultant achieves a level of staff commitment and patient response unequalled by others in the same field. In rehabilitation excellent positive results are often achieved through personal or organizational charisma. No amount of physiotherapy or occupational therapy is a substitute for the activities of everyday life, and therefore all therapeutic activities should be as realistic as possible, and rehabilitation activities should be channelled into normal activities as quickly as possible. The longer the patient is away from his usual routine the more difficult it will be for him to return to them. But it is essential that the functional aims are realistic. An unrealistic optimism about a patient's performance and progress brings only discredit to the process of rehabilitation and its proponents. The successful rehabilitation of a hemiplegic patient depends largely upon his ability to adjust, comprehend and accept treatment, and this requires his active cooperation and participation. The psychological effects of brain damage involve impairment of perception; impairment of intellectual function, and changes in personality (Storey 1968). Loss of limb sensation or defects of coordination may hinder learning ability or the patient's understanding and awareness of himself, or his ability to perform integrated actions. The curious syndrome of 'neglect' of the left half of space which accompanies many instances of left hemiplegia is an important factor in rehabilitation. The affected patients appear to ignore the existence of objects which occur in their left visual field, not due to left hemianopia. Stimuli from the right side appear to suppress those from the left.
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NEED FOR RESEARCH AND EVALUATION
Perhaps the biggest problem of all in the rehabilitation of stroke patients both physically and in speech is the paucity of information derived from controlled evaluation (Royal College of Physicians 1974). From all the literature about the subject there is clearly an overwhelming impression that rehabilitation procedures—in the widest sense— produce some good results. But it is not enough to show that patients do well in these situations, it is necessary to see whether they do better than if they had been treated differently. If they do better, then it is essential to find out which features of the treatment contribute to the difference. To point this out is in no way to be critical of the therapists—physical, occupational or speech—but it is important in relation to the limited facilities which exist in rehabilitation, to attempt to analyse which aspects of care—medical, physical, social— contribute to which aspects of improvement. For example, the experiment in Oxfordshire to use a panel of amateur volunteers to help retrain aphasic patients is one which will be watched with interest. But as with most rehabilitation, the provisions are multiphasic, providing a mixture of specific and non-specific care, with a response which may well also be a mixture of specific and non-specific improvement, so that we cannot exactly say what is affecting what! This is particularly important when the numbers appearing to need care are so many, and the therapeutic professions spread so thinly. The critical requirement for competent evaluation of various rehabilitation measures is a clear-cut definition of the 'outcome measures' by which recovery can be adjudged. The clinical and functional outcome measures used in rehabilitation medicine are many and varied. The range is between two extremes of (1) death, an agreed uncontroversial outcome but rarely relevant in rehabilitation practice; or (2) the patient's attitude towards his disability; but measures of patient satisfaction are not really adequate to assess the real benefit of rehabilitation. Functional outcome of rehabilitation is usually
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Other features of brain damage which tend to carry a poor rehabilitation prognosis include apraxia, agnosia and perseveration. The presence of these disturbances of coordination is an indication that physical therapy and rehabilitation are likely to be unavailing. At best, training will take considerably longer than in the absence of such signs. Indeed, speech therapy, re-education of balance, and deliberate training to understand the sensory deficits are probably the most important part of rehabilitation. One further indication of cerebral damage which has a poor prognosis is the persistence of emotional lability. Rapidly changing emotions, temper outbursts, attacks of inappropriate crying or laughing, are all indications of loss of brain tissue. Although the premorbid personality will determine the emotional reaction of the patient with a major illness, it is the patient's ability to change which is important and much more clinical and psychological data are needed to establish clear guidelines for the clinician and therapist. There is a relatively small amount of literature devoted to the assessment of mental status in specific clinical conditions. But there is diminished intellectual adaptability and ability to retain instructions with increasing age, and there is clear evidence that cerebrovascular disease of any kind brings concomitant intellectual damage (Adams & Hurwitz 1963).
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recorded in terms of time off work, hospital attendance, activities of daily living (ADL), social activities, all of these are related to psychological, social and cultural factors. For example, the recent report on rehabilitation after myocardial infarction (Royal College of Physicians 1975) stated that after discharge from hospital return to work is the most important milestone on a patient's way to full recovery; but it went on to define the causes of delay in return to work as being mainly concerned with factors unrelated to the infarct, such as psychological, social, economic, the patient's age and occupation. Return to work is such a complex activity, depending upon the person's work record and the availability of work, that it is unwise to treat employability as a main criterion for recovery. In most instances of stroke, because of the age factor, return to work is not an appropriate 'outcome measure'. Conventionally, activities of daily living are often invoked as 'outcome measures'. These are for the occupational therapists what the muscle charts are for physiotherapists. Clearly, the routine tests given in the OT department are an excellent check list of a patient's current capability in those circumstances (i.e. the hospital OT department). They are a record of what the patient can do. Katz et al. (1970) have shown that mobility and confinement to the house are major considerations in planning long-term care. Dependence or independence in going to the toilet is a useful indication of over-all performance, dividing people into groups that required significantly different amounts of assistance, and differentiating between those who did and who did not require admission to long-stay institutions. These parameters are admittedly more dependent upon the person's ability to respond to the environmental situation than reflecting directly the effects of specific rehabilitation. In effect the problem is to decide which components or categories are relevant and can be combined into an index of disability or performance in ADL. The fundamental problem in defining outcome measures is the multiplicity of factors involved. In many systems of measuring dependence or independence, the various scores in the ADL index are summed into a unified index after applying appropriate weightings. Developing the weighting system is a formidable problem and the unified index or rating is rarely of value in following change, although it may help in identifying a general level of need. As yet there is little information available regarding the correlation between various activities of daily living, and between ADL and other outcome measures. But applying numbers implies some unjustifiable assumptions: that you can accurately quantify the numerical relationship between descriptive grades; and that you can accurately quantify the relative importance of various activities. ADL indices endow these activities with a scientific accolade to which they are not entitled (Nichols 1976). And when all these assessments and evaluation have been carried out there are many factors over which we have no control. The factors which go towards make-up of physical and social wellbeing of a chronically disabled person are similar to those assessed for the elderly and include: income, adequate clothing, nutrition, housing, warmth, availability of appropriate toilet and bathroom facilities, and social contacts. In the final analysis many (indeed most) problems of rehabilitation of the elderly stroke patient are social. In a recent survey we have carried out under the sponsorship of the Social Affairs Directorate of the European Economic Commission (Wycliffe-Noble, van Nuland & Nichols 1977), we were able to demonstrate that the recommended architectural
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standards for accommodation for the elderly and disabled leave much to be desired. For example, in the kitchen most elderly people prefer to work at a conventional kitchen table rather than specially designed work surfaces and most specially built accommodation does not allow for this. As regards wheelchair housing we found that half the housebound were not assessed before allocation of dwelling and there was little attempt to match needs with design. SUMMARY
REFERENCES
ADAMS, G. F. & HURWITZ, L. H. (1963) Lancet ii, 533. COCKEST, J., HAMILTON, E. A., NICHOLS, P. J. R. & PRICE, D. A. (1971) Brit. J. din. Pract. 25,73.
COPP, E. P. & KEENAN, J. (1972) Rheum, phys. Med. ii, 287. HURWITZ, L. H . (1969) Brit. med. J. 3, 699. KATZ, S., D O W N , T . D., CASH, H . R. & GROTZ, R. C. (1970) Gerontologist 10, 20.
LEHMAN, J. (1959) J. Neurol. Neurosurg. PtycUat. 22, 182. MATTHEWS, W. B. (1970) Practical Neurology. Oxford: Blackwell. NICHOLS, P. J. R. (1974) Brit. J. occup. Ther. 37, 7, 113. NICHOLS, P. J. R. (1976) Brit. J. occup. Ther. 39, 6. ROYAL COLLEGE OF PHYSICIANS (1974) Report of the Geriatrics Working Group on Strokes. London: RCP. ROYAL COLLEGE OF PHYSICIANS (1975) Report of the Joint Working Party of the RCP and British Cardiac Society: Cardiac Rehabilitation. London: RCP. STOREY, P. B. (1968) Physiotherapy 54, 54. WYCLIFFE-NOBLE, C , VAN NULAND, N . J. M . & NICHOLS, P. J. R. (1977) Housing for the Disabled:
A Survey of Adjustable and Non-adjustable Equipment in Kitchens. Jointly subsidized by the
Social Studies Commission of the EEC and the National Fund for Research into Crippling Diseases. Obtainable from C. Wycliffe-Noble, William & Mary House, French Street, Sunbury-on-Thames.
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There is no better summary of rehabilitation of strokes than in Bryan Matthews' book Practical Neurology (1970). Treatment must still be based on the long-recognized principles of mobilization, proper hydration and feeding, and the prevention of infection. There is simply no virtue at all in the patient's staying immobile in bed. An accurate prognosis is hard to give. Early return of movement is a good sign while adverse signs are extensive sensory loss, prolonged flaccidity and previous strokes. Dysphasia may prove a major disability, even if a good recovery from paralysis has occurred. Patients certainly improve while having speech therapy, but as the natural tendency is to improvement, it is difficult to be certain of any indisputable effect. The patient's attitude of mind will greatly affect the degree of functional recovery, and it is always necessary to remember that rehabilitation measures cannot succeed in those patients who are not motivated to improve—and persuasion, explanation and cajolery have little effect.
