791

admission with overnight hospital stay that is usually necessary for intra-arterial studies. Because of the nature of

the phase-contrast technique, measurement of physiological variables, such as renal arterial blood velocity and total renal blood flow, should be possible in the future. We thank Mr M. E. Snell and Mr M. Thick for their assistance.

REFERENCES et al. Percutaneous transluminal angioplasty, the procedure of choice in the hypertensive

1. Greenstein SM, Verstandig A, McLean GK,

renal

allograft recipient

with renal artery stenosis.

Transplantation

1987; 43: 29-32. 2. Tilney NL, Rocha A, Strom TB, Kirkman RL. Renal artery stenosis in transplant patients. Ann Surg 1984; 199: 454-60. 3. Deane C, Cairns H, Walters H, et al. Diagnosis of renal transplant artery stenosis by color doppler ultrasonography. Transplant Proc 1990; 22: 1395. 4. Kim D, Edelman RR, Kent C, Porter DH, Skillman JJ. Abdominal aorta and renal artery stenosis: evaluation with MR angiography. Radiology 1990; 174: 727-31. 5. Pernicone JR, Siebert JE, Potchen JE, et al. Three dimensional phase contrast MR angiography in the head and neck. AJNR 1990; 11: 457-66. 6. Edelman RR, Hesselink JR, Newhouse J, Sartoris DJ. Clinical magnetic resonance imaging. Philadelphia: W. B. Saunders, 1990: 109-82.

STROKE OCTET Stroke: rehabilitation and long-term

care

DERICK T. WADE One third of patients who sustain a stroke will survive the acute event to be left with considerable residual disability. In

this article I will discuss the process and aims of rehabilitation, assessment, goal-setting, the role of the doctor, treatment and its organisation, and long-term care. Although disabled patients are more likely to have been admitted to hospital, the principles apply wherever the patient is managed.

I will start

underlying pathology and impairments and by the availability of resources, and (b) to help the person to make the best adaptation possible to any difference between roles achieved and roles desired. FOUR LEVELS OF ILLNESS

Pathology

What is rehabilitation?

Abnormality of structure or function affecting an organ or organ system. Impairment Symptoms and signs, the manifest abnormalities of function evident to an

by outlining the

Disability

rehabilitation occurs; details

are

framework within which given elsewhere.1-3

Four levels of illness

Any patient’s illness can be considered at four levels (see table). Most medical (hospital) attention is focused on pathology, but the four-level approach reminds us that, with time, attention should shift towards disability and handicap and simultaneously move from the patient to his environment.

End-point vs process It is important to distinguish between the end-point and the process of rehabilitation. The process is a reiterative one of problem solving, focusing on the disability. Components include assessment (identification and measurement of problems and analysis of the causes); planning (goalsetting) ; intervention; and evaluation or reassessment. There are two aspects of intervention. The most necessary is to provide care sufficient to maintain the status quo; many patients need hospital admission simply to receive appropriate nursing. However, the most important is to provide treatment-actions that cause or increase recovery from disability or in other ways reduce handicap.

Goals of rehabilitation The goals of rehabilitation are not always self-evident.4,5 I like the following defmition: rehabilitation should aim (a) to maximise the patient’s role fulfilment and his independence in his environment, all within the limitations imposed by the

external observer

Behavioural consequences, activities important to the patient that disrupted or prevented, altered interaction with environment

are

Handicap Social and societal consequences of disease, altered roles, and goals that can no longer be achieved

Assessment: first step The aims of assessment are to identify the main areas of the underlying causes (impairments, and if necessary diseases); prognostic factors relating to natural history and successful intervention; and, most important, the goals of the patient and the family. Assessment is best carried out with standardised simple measures, many of which can be used by any busy clinician.2Irecommend the motricity index and trunk control test for motor loss;6star cancellation for neglect;Frenchay aphasia screening test for aphasia ;8 Hodkinson mental test ;9 Barthel activities of daily living index Rivermead mobility index;"1 and measurement of the time taken to walk 10 metres. Other measures may be useful for specific purposes. Doctors should confine themselves to carrying out measurements that are relevant and useful at the time; further assessments can always be done later if necessary.

difficulty;

Prognosis In stroke the natural history and prognosis known12 and this knowledge can be used

are

well

to

plan

ADDRESS: Rivermead Rehabiltation Centre, Oxford OX1 4XD, UK (Dr D. T. Wade, MD)

792

interventions. Recovery is fastest in the first few weeks, slowing down thereafter but probably continuing for at least 6 months. Early stages mainly reflect resolution of oedema and reduction in impairments; later stages largely result from adaptation, achieving old ends by new means. The best single prognostic indicator is the presence of urinary incontinence shortly after stroke,13 which identifies patients who are likely to die or to need long-term care. Other indicators include severity of motor loss, loss of consciousness, and any combination of motor and cognitive deficits. Thus, as one would expect, the more severe the stroke the worse the outcome.12 A few specific prognostic indicators have been identified. For example, absence of any active hand grip at 3 weeks means that no useful function will return, and the inability to recognise non-speech sounds (eg, a telephone) soon after stroke is associated with severe long-term communicative disability. There is no evidence to guide selection of patients for specific interventions. Since we do not know what features predict a good or bad response to therapy, it is impossible to carry out triage on a rational basis. Statements such as "well motivated patients respond best" are at best opinions and at worst excuses for not

offering help. Goal

planning

Many difficulties in rehabilitation arise because too little attention is paid to planning goals-the setting of long-term aims, medium-term objectives, and short-term targets. These goals must be discussed and agreed upon by all relevant parties; if goals are not set, rehabilitation may be less effective and sometimes serious difficulties arise. Initially one must determine the patient’s long-term hopes and interests. The first big hurdle to be overcome in goal-setting is to use an agreed and easily understood tenninology;14 the second is to agree on a suitable timeframe, which will vary according to the time since the stroke. Aims (long-term goals) should be set in terms of handicap. There are four areas of practical importance. (a) Accommodation: where will the patient live and what physical adaptations will be needed? (b) Personal support: what help will be essential for the

patient? (c) Meaning of life: what roles will the patient be fulfilling within his/her own social setting? (d) Occupation of time: what will the patient be doing to occupy his/her free time? Aims will inevitably be vague soon after stroke when the future is uncertain, but there is often a pronounced discrepancy between those of the patient and family and those of the professional staff. It is a legitimate and sometimes essential objective of the team to modify the expectations of the patient and family. Social workers and clinical psychologists may have more to offer in the area of identifying and modifying unrealistic aims, but all staff must be involved if rehabilitiation is to succeed. Many of the difficulties ultimately faced in management of patients can be traced back to conflicts between the aims and objectives of different parties, or to a failure to understand and accept the need for certain targets.

Medical

input

Every rehabilitation team needs a leader to set communal goals for the whole rehabilitative effort; the team includes the patient and his family. In practice, this role tends to fall

the doctor, who usually has little other direct input and therefore no vested interest. An interested doctor brings knowledge about the natural history and prognosis of stroke; experience in diagnosing and managing associated conditions, and often skill in neurological assessment. A good leader will be a good negotiator, someone who is aware of the aspirations and sensitivities of others; goals cannot be to

imposed. Whether leader or not, the doctor will often be best placed predict the outcome, and this information is essential to guide the therapeutic team, patient, and family towards goals. Moreover, the doctor can often gain access to to

resources.

Intervention I will not discuss therapeutic techniques in any detail, but I do wish to emphasise that there is no evidence to support any specific strategy. What little information there is supports a pragmatic, functional (behavioural) approach; adherence to unscientific theories (eg, Bobath) is to be avoided. One should not advocate function at all costs, but there must always be convincing reasons for not "going for independence". For example, wheelchairs and walking aids should be given as soon as possible. There is no evidence to guide the rational use of impairment-specific interventions such as baclofen for spasticity (which I use very rarely); orthopaedic operations (which I have not used in 5 years); and ankle-foot orthoses (foot-drop splints, which we use regularly in my unit). Mood disturbances are common after stroke, but there are no good treatment guidelines. Depression is difficult to identify and is probably overdiagnosed;15 it is often confused with emotionalism, which usually improves with time but can be alleviated specifically with amitriptyline. Depression may also be confused with the state of misery. Depression should be diagnosed only if the symptoms include consistent and constant social withdrawal together with somatic complaints lasting at least 2 weeks. Initial interventions include increased social stimulation, relief of pain and other symptoms, and maximisation of independence; antidepressants can be

prescribed cautiously.

Organisation of rehabilitation Well-organised stroke rehabilitation services are cost effective: the patient’s independence is increased, so there is less need for therapists and hospital stays are shorter.’6 The challenge is to institute community-based disability services that not only improve stroke outcome but also help other patients with neurological disability .17 For example, it seems that community physiotherapy leads to a better outcome at less cost than outpatient attendance at a geriatric day hospital.18 The important components are early accurate assessment by experienced therapists; early involvement of occupational therapists;19 and a functional approach with early mobilisation.

Long-term care About 40% of patients surviving stroke for 6 months will require help with one or more activities of daily living such as bathing, dressing, feeding, and mobility. Many will receive that help from their families, but some depend on homecare services. More important, many patients have a greatly reduced level of social interaction and are often unable to get about in the community. Day care services can

793

% of stroke survivors are unable to live in the open community and need long-term nursing care, usually because of a combination of inadequate social support and severe disability, often including dementia. Routine follow-up by a physiotherapist every 3-6 months may help reverse or slow down the long-term decline in mobility seen after stroke."

provide a lifeline. About 10

REFERENCES 1. Wade DT. Neurological rehabilitation. In: Kennard C, ed. Recent advances in clinical neurology, 6: 133-56. Edinburgh: Churchill

Livingstone, 1990. 2. Wade DT. Measurement in neurological rehabilitation. Oxford: Oxford University Press, 1992. 3. McGrath JR, Davis AM. Rehabilitation: where are we going and how do we

get there? Clin Rehab (in press).

4. Watts FN, Bennett DH. The concept of rehabilitation. In: Watts FN, Bennett DH, eds. Theory and practice of rehabilitation. Chichester: Wiley, 1991: 3-14. 5. Shephard G. Psychiatric rehabilitation for the 1990s. In: Watts FN, Bennett DH, eds. Theory and practice of rehabilitation. Chichester: Wiley, 1991: XIII-XLVIII. 6. Collin C, Wade DT. Assessing motor impairment after stroke: a pilot reliability study. J Neurol Neurosurg Psychiatry 1990; 53: 576-79. 7. Halligan PW, Marshall JC, Wade DT. Visuospatial neglect: underlying factors and test sensitivity. Lancet 1989; ii: 908-11.

8.

Enderby PM, Wood VA, Wade DT, Langton-Hewer R. The Frenchay aphasia screening test: a short simple test for aphasia appropriate for non-specialists. Int Rehab Med 1986; 8: 166-70.

9. Hodkinson HM. Evaluation of a mental test score for assessment of mental impairment in the elderly. Age Ageing 1972; 1: 233-38. 10. Collin C, Wade DT, Davis S, Home V. The Barthel ADL index: a reliability study. Int Disab Studies 1988; 10: 61-63. 11. Collen FM, Wade DT, Robb GF, Bradshaw CM. The Rivermead mobility index: a further development of the Rivermead motor assessment. Int Disab Studies 1991; 13: 50-54. 12. Wade DT, Langton Hewer R. Rehabilitiation after stroke. In: Toole JF, ed. Handbook of clinical neurology, 11. Amsterdam: Elsevier, 1989: 233-54. 13. Barer DH. Continence after stroke: useful predictor or goal of therapy? Age Ageing 1989; 18: 183-91. 14. Davis AM, Davis S, Moss N, et al. First step towards an interdisciplinary approach to rehabilitation. Clin Rehab (in press). 15. House A. Depression after stroke. Br Med J 1987; 294: 76-78. 16. Indredavik B, Bakke F, Solberg R, Rokseth R, Haahein LL, Holme I. Benefit of a stroke unit: a randomised controlled trial. Stroke 1991; 22: 1026-31. 17. Wade DT. Designing district disability services: the Oxford experience. Clin Rehab 1990; 4: 147-58. 18. Young JB, Forster A. The Bradford community service trial: eight week results. Clin Rehab 1991; 5: 283-92. 19. Smith ME, Garraway WM, Smith DL, Akhtar AJ. Therapy impact on functional outcome in a controlled trial of stroke rehabilitation. Arch Phys Med Rehab 1982; 63: 21-24. 20. Wade DT, Collen FM, Robb GF, Warlow CP. Physiotherapy intervention late after stroke and mobility. Br Med J 1992; 304: 609-13.

Stroke services MARTIN DENNIS What is

a

stroke service? I like

to

define it

as

an

organisation that delivers effective interventions to stroke patients and their carers (table I). Some might argue that primary prevention should be included, but there would be so much overlap with strategies to prevent coronary heart disease that it would be wasteful to set up parallel schemes. In the UK, very few health districts have a coordinated stroke policy or serviced General practitioners (with their

supporting community services), general medical, geriatric, neurological, and rehabilitation services carry out many of TABLE I-FUNCTIONS OF A COMPREHENSIVE STROKE SERVICE

Prompt and accurate diagnosis in patients with stroke (and conditions that mimic stroke), whether admitted to hospital or not Detailed assessment: To identify the cause of the stroke; To identify coexisting or complicating conditions--eg, heart failure, atrial fibrillation, dementia, arthritis; To defme the patients’ impairments, resulting disabilities, and handicaps--eg, swallowing difficulties; To examine the patients’ social background (ie, the context in which the stroke has occurred and to which patients will have to return). Effective and appropriate medical or surgical treatment for the stroke and associated medical conditions. Prevention and treatment of complications and provision of terminal care when necessary. Provision of training (eg, physiotherapy, occupational therapy, speech therapy) and of adjustments to the patient’s environment to minimise disability and handicap and maximise autonomy. Resettlement of patients at home or, if this is not possible, arrangements for institutional care. Follow-up to detect and manage late complications (eg, emotional problems) and to reduce the risk of further vascular events

(secondary prevention). Education of staff and others involved in patients’ Research.

care.

the functions of a stroke service, but inevitably in a rather haphazard fashion. Some important functions are neglected and delivery of services is often uneven. In other countries (eg, Italy and the Netherlands) stroke patients are cared for by a single group of specialists, usually neurologists, which, theoretically, should make for better organisation. However, certain functions may still be neglected if the specialists have a narrow view of their role or if the necessary facilities are simply not available. Good quality acute medical care is often not matched by the same quality of nursing care, facilities for rehabilitation, or long-term care, especially for those unable to pay.

Structure of

a

stroke service

Several models for stroke services have been described and a few have been evaluated. Stroke "units" have received special attention but are far from homogeneous. Some care only for patients in the very early period2 after a stroke whereas others only accept patients for rehabilitation;3 some consist of a multidisciplinary stroke team to manage patients wherever they are in the hospital.4,5 In general, I believe that such models represent no more than single components of a stroke service; unless they are part of a coordinated strategy they may reduce continuity of care. Moreover, such models usually neglect patients who are not admitted to hospital; in the UK, for example, up to 45 % of all stroke patients are not admitted’ and a figure of 15% was reported in one study from Italy.7 Missing components may include a home assessment service, a stroke clinic, a day hospital, a family support worker, or nursing home facilities. ADDRESS Department of Clinical Neurosciences, Western General Hospital, Crewe Road, Edinburgh EH4 2XU, UK (Dr M.

Dennis, MD)

Stroke: rehabilitation and long-term care.

791 admission with overnight hospital stay that is usually necessary for intra-arterial studies. Because of the nature of the phase-contrast techniq...
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