Stroke Rehabilitation Ward Research Articles

Fatigue after Stroke: The Patient's Perspective

Background. Fatigue after stroke is common and distressing to patients. Aims. Our aims were to explore patients' perceptions of post-stroke fatigue, including the causes of fatigue and the factors that alleviate fatigue, in a mixed methods study. Results. We interviewed 15 patients who had had a stroke and were inpatients on stroke rehabilitation wards. A substantial proportion of patients reported that their fatigue started at the time of their stroke. Various different factors were reported to improve fatigue, including exercise, good sleep, rehabilitation and rest. Fatigue influences patients' sense of “control” after their stroke. Conclusion. Our results are consistent with the possibility that poststroke fatigue might be triggered by factors that occur at the time of the stroke (e.g., the stroke lesion itself, or admission to hospital) and then exacerbated by poor sleep and boredom. These factors should be considered when developing complex interventions to improve post-stroke fatigue.

Early rehabilitation management after stroke: What do stroke patients prefer?

Stroke rehabilitation is moving towards more intense therapy models that incorporate technologies such as robotics and computer games. It is unclear how acceptable these changes will be to stroke survivors, as little is known about which aspects of rehabilitation programmes are currently valued. Discrete choice experiments are a potential approach to assessing patient preferences, as they reveal the characteristics of programmes that are most important to consumers. A discrete choice experiment was presented as a face-to-face interview to assess the priorities and preferences of stroke survivors (n=50, mean age 72 years) for alternative rehabilitation service configurations. The discrete choice experiment was presented to the participants while they were on the stroke rehabilitation ward (approximately 3-4 weeks following stroke). Participants were highly focused on recovery and expressed strong preferences for therapy delivered one-to-one, but they did not favour very high intensity programmes (6 hours per day). While the attitudinal statements indicated high levels of agreement for programmes to incorporate the latest technology, the results from the discrete choice experiment indicated that participants were averse to computer-delivered therapy. Whilst rehabilitation therapy is highly valued, stroke survivors exhibited stronger preferences for low-intensity programmes and rest periods. High-intensity therapy protocols or approaches dependent on new technologies will require careful introduction to achieve uptake and acceptability.

Support after stroke.

There is strong evidence for early supported discharge after a stroke. This service development project used an interdisciplinary journal club to promote communication and identify the role of the nurse in an early supported discharge team. The team members were able to evaluate journal findings against the practice of their own team, which had been established after the closure of a stroke rehabilitation ward.

Frequency of nocturnal hypoxia in clinically stable patients during stroke rehabilitation

Objective: Sleep disordered breathing is common in patients with cerebrovascular disease. Nocturnal hypoxia may lead to daytime tiredness and cognitive impairment, thus affecting progress. This study assessed the prevalence of nocturnal hypoxia during rehabilitation from stroke. Design: Prospective observational trial. Setting: The stroke rehabilitation wards of the North Staffordshire Hospital, UK and of Kreiskrankenhaus Grevenbroich, Germany. Subjects: Adult patients on a stroke rehabilitation ward, 10 days to 3 months (mean 32 days, SD18) after stroke onset (n = 160). Age and local environment-matched controls (n = 156) without a history of stroke were recruited from the community at both centres. Main measures: Pulse oximetry was performed overnight on the day of enrolment from 21:00 to 09:00. The baseline awake oxygen saturation, the mean nocturnal oxygen saturation, the lowest nocturnal oxygen saturation and the 4% Oxygen Desaturation Index were calculated for each participant. Results: The mean baseline awake oxygen saturation of stroke patients was at 95.3% (SD 1.7), 0.5% lower than that of controls (P = 0.005, independent t-test). The group means of the mean nocturnal oxygen saturation for stroke patients were 0.5% lower (at 93.8% SD 2.2) than controls (P = 0.03, independent t-test). The mean lowest nocturnal oxygen saturation was at 79.4% (SD 9.9), 5.9% lower than that of the controls (P<0.001, independent t-test). Considerably more stroke patients (n = 67, 42%) than controls (n = 24, 15%) had ≥10 desaturations below the baseline per hour (P<0.001 chi-square test). Conclusion: Clinically stable stroke patients enrolled in rehabilitation programmes have lower oxygen saturation and more nocturnal desaturations than non-stroke controls.

Incidence and frequency of screening for nutritional risk in hospital inpatients in East Cheshire NHS Trust

Background: The NICE guideline for adult nutrition support recommends that all hospital inpatients are screened for risk of malnutrition ‘on admission’ and that screening is repeated weekly (NICE, 2006). Malnutrition screening using the Malnutrition Universal Screening Tool (MUST) tool (BAPEN, 2003) was introduced to East Cheshire NHS Trust on 1 March 2008 following training of ward nursing staff in using the tool. The aim of this audit was to evaluate whether East Cheshire NHS Trust is meeting the NICE guideline for screening of malnutrition risk.Methods: An audit was conducted including 301 inpatients over a 1‐week period in June 2008. The main outcomes included the presence of a MUST score, date of MUST score relative to date of admission, weekly screening of inpatients where relevant, correct completion of MUST tool and referral to the dietetic service if the patient was at high risk of malnutrition. Correct completion of the MUST form was assessed by checking that each section of the form had been completed. The audit team chose 48 h as the cut‐off for screening ‘on admission’. Data were collected by the allocated ward dietitian or dietetic assistant and recorded on a data collection sheet. All outcome data were recorded from the MUST screening paperwork completed by nursing staff, except date of admission, which was recorded in nursing or medical admission documentation. Data analysis calculating frequencies, mean values and percentages were carried out using Microsoft Excel 2003 (Microsoft Corp., Redmond, WA, USA).Results: Ninety‐three inpatients (31%) had a MUST score recorded. Only 24 (8%) were screened within 48 h of admission. There was variation across specialities as to the rate of screening achieved. No patients on general surgical wards were screened, but at least 50% patients were screened on respiratory, diabetes/stroke and cardiology wards, the intensive care unit and stroke rehabilitation ward. Of those patients screened for malnutrition, 39 out of 93 (42%) had a score of two or more, indicating that they were at high risk of malnutrition. The care plan for people identified as being at high risk is to refer to the dietetic department; however, only 26 out of 39 (67%) were referred, meaning that one‐third of patients with a score of two or more were not referred. One hundred and fifty‐three patients were admitted to hospital for more than 1 week. Only 5% (eight of 153) of these patients were MUST screened weekly. Individual patients were not re‐screened to check accuracy of the data on the form. Of the 93 MUST forms completed, 25 (27%) were completed incorrectly. The most common error on 18 out of 93 forms was information missing from completion of stage 1, which is the calculation of body mass index. This is likely to be related to lack of correct weighing equipment on some wards (e.g. hoist scales). Lack of nursing time and screening forms not being included in admission documentation may also have contributed to the low screening rate.Discussion: The audit shows that, although malnutrition screening for inpatients has commenced in East Cheshire, the NHS trust is not yet compliant with recommendations in the NICE Guideline for Adult Nutrition Support (NICE, 2006). From 1 March 2008, all referrals made to the dietetic department are required to include a MUST score to encourage nursing staff to complete the screen. It is recommended that the MUST form is also incorporated into nursing assessment documents and that MUST training be included in mandatory training for nursing staff; this has been shown to contribute to increased screening rates in other hospital trusts (Wong and Gandy, 2008).Conclusions: Screening inpatients for malnutrition has been introduced using MUST in East Cheshire. However, screening does not currently meet NICE guideline recommendations.References BAPEN (2003) Malnutrition Universal Screening Tool. Available at http://www.bapen.org.uk/must_tool.html (accessed on 19th May 2008).NICE (2006) Nutrition Support for Adults Oral Nutrition Support, Enteral Tube Feeding and Parenteral Nutrition. Available at http://www.nice.org.uk/nicemedia/pdf/cg032fullguideline.pdf (accessed on 19th May 2008).Wong, S. &amp; Gandy, J. (2008). An audit to evaluate the effect of staff training on the use of Malnutrition Universal Screening Tool. J. Hum. Nutr. Diet.21, 405–406.

Screening for cognitive deficits after stroke: a comparison of three screening tools

Objective: To assess the concurrent validity of three screening tests for focal cognitive impairments after stroke. Design: Comparison of results from the screening tests with those from a more comprehensive neuropsychological battery. Setting: Stroke rehabilitation wards of a general hospital and a rehabilitation hospital. Subjects: Forty-nine stroke patients (25—91 years, 35% women). Measures: Screening tests were the Cognistat, the Screening Instrument for Neuropsychological Impairments in Stroke (SINS) and the Clock Drawing Test. Health professionals, blind to the results of the reference method, did the screening. Reference method was a neuropsychological assessment based on the Norwegian Basic Neuropsychological Assessment, classifying the patients as `impaired' or `not impaired' within the following cognitive domains: language, visuospatial function, attention and neglect, apraxia, speed in unaffected arm, and memory. Results: The best sensitivity (95% confidence interval) was achieved for language problems by Cognistat, naming (80%, 44—98); for visuospatial dysfunction, attention deficits and reduced speed, all by SINS visuocognitive (82%, 60—95, 72%, 39—94, and 78%, 56—93, respectively); and for memory problems by Cognistat memory (69%, 52—87). The data were insufficient to assess any subtest for apraxia. Sensitivity in detecting deficits in any domain was 82% (71—94) for the Cognistat composite score, 71% (57—85) for the SINS composite score, and 63% (49—78) for the most sensitive score of the Clock Drawing Test. Conclusion: The Cognistat and the SINS may be used as screening instruments for cognitive deficits after stroke, but cannot replace a neuropsychological assessment. The Clock Drawing Test added little to the detection of cognitive deficits.

Effects of Mobilization and Tactile Stimulation on Recovery of the Hemiplegic Upper Limb: A Series of Replicated Single-System Studies

Hunter SM, Crome P, Sim J, Pomeroy VM. Effects of mobilization and tactile stimulation on recovery of the hemiplegic upper limb: a series of replicated single-system studies. Objective To explore the effects on motor function and impairment of mobilization and tactile stimulation for the paretic arm and hand after stroke. Design Replicated single-system series, ABA design. Setting The stroke rehabilitation ward of a community hospital in the United Kingdom. Participants Consecutive sample, men and women (N=6) with stroke (left or right), within 3 months of onset. Intervention Sixty minutes of daily mobilization and tactile stimulation to the paretic arm and hand for 6 weeks in addition to the usual rehabilitation program. Main Outcome Measures Focal disability (Action Research Arm Test [ARAT]) and motor impairment (Motricity Index arm section). Results All participants showed visual change in 1 or more of trend, level, or slope between baseline and intervention phases for both the ARAT and the Motricity Index. The visual analysis was confirmed through statistical testing ( c statistic and/or Mann-Whitney U test) for 5 of 6 participants (statistical analysis was precluded for 1 participant). No further improvements were made on intervention withdrawal. Conclusions This study shows proof of concept for using mobilization and tactile stimulation to improve motor recovery after severe paresis, justifying conducting dose-finding studies as a precursor to multicenter phase III clinical trials.

Patient narratives: The potential for “patient-centred” interprofessional learning?

The central theme of the paper is concerned with the educational potential that patient narratives may hold for improving patient-centred interprofessional care. It follows the processes of a research project that was required to provide an educational intervention in a multiprofessionally-staffed stroke rehabilitation ward. It discusses the evolution of the project, focusing on the ways in which patient narratives were constructed, the purposes they served, and the responses of professionals to the narratives in subsequent workshops. Along the way, the paper reflects on the responses of patients that problematise the notion of “patient-centred” care. Together with the responses of professionals to the narratives, the paper raises questions about the obstacles to and possibilities for such care.

A pilot randomized controlled trial of a daily muscle stretch regime to prevent contractures in the arm after stroke

To evaluate the feasibility and effects of daily stretch positioning for prevention of contractures in stroke patients without arm function. Randomized controlled pilot study. Stroke rehabilitation ward, U.K. Twenty-five subjects drawn from an initial pool of 126 presenting with loss of arm function, all within four weeks of stroke. In addition to usual care, subjects in the experimental group (n=13) were prescribed two 30-min stretches for wrist and finger flexors and two 30-min stretches targeting shoulder adductors and internal rotators, per day for up to 12 weeks post stroke. Stretches were carried out by therapists and nursing staff. Passive range of wrist extension and shoulder external rotation to standard force or to pain at four, eight and twelve weeks after stroke. Compliance was variable. Frequency of positioning was fair from four to eight weeks post stroke but declined after that. Mean (SD) frequency of stretch positions completed between four and eight weeks was 36.5 (13.0) for the wrist, 31.2 (14.1) for the shoulder, out of 56 prescribed. There were no significant effects of treatment. By eight weeks post stroke the mean range of wrist extension and shoulder external rotation lost on the affected side in both groups was approximately 30 degrees. The stretch treatment was not well tolerated over many weeks. Statistical power was low due to the large degree of variability of range of motion and small sample size. The regime tested cannot be recommended as a workable treatment to prevent contractures.

Comparison of Bobath based and movement science based treatment for stroke: a randomised controlled trial

Objectives: Bobath based (BB) and movement science based (MSB) physiotherapy interventions are widely used for patients after stroke. There is little evidence to suggest which is most effective. This single-blind...

Improving patient and carer communication, multidisciplinary team working and goal-setting in stroke rehabilitation

To determine the extent to which three forms of multidisciplinary team (MDT) care in stroke rehabilitation meet the standards set by the United Kingdom National Service Framework (NSF). Consecutive assessment of the three forms of care was completed. The study included three groups of 25 stroke inpatients on the stroke rehabilitation ward. (1) A standard weekly MDT meeting using a standard form for documentation; (2) a standard MDT meeting using a newly devised form; and (3) a novel MDT ward round using the new form, and attended by doctors. MDT ward rounds result in significantly better consideration of patients' needs (median 7 per patient compared with 0 and 5 in phases one and two), enhanced SMART (specific, measurable, achievable, realistic and time framed) goal-setting (median 3 per patient compared to 1 in phases one and two); greater patient involvement (12 patients compared to 0 and 4 in phases one and two); and improved team working (measured using the team climate inventory) than do MDT meetings. In the present study, standard weekly MDT meetings did not meet the standards set for MDT care by the NSF. The use of a MDT ward round allows these standards to be achieved.

Plasma homocysteine level and functional outcome of patients with ischemic stroke

Mizrahi EH, Fleissig Y, Arad M, Adunsky A. Plasma homocysteine level and functional outcome of patients with ischemic stroke. Objective To investigate the possible relationships between total plasma homocysteine level (tHcy) and functional outcome of stroke patients as evaluated by the FIM instrument. Design Retrospective chart analysis. Settingm Inpatient stroke rehabilitation ward of a university-affiliated referral hospital. Participants Consecutive patients (N=113) presenting with acute ischemic stroke. Patients were divided into 2 groups according to their tHcy levels (≤15μmol/L, >15μmol/L) and into 3 groups according to their FIM scores (low, ≤40; moderate, 41–80; high, >80). Interventions Not applicable. Main outcome measures The tHcy level was determined shortly after stroke onset by a high performance liquid chromatography method with fluorescence detection. Functional outcome was measured by the FIM instrument at admission and discharge. The tHcy level and FIM scores were obtained for all patients. Data outcomes were analyzed by t tests, 1-way analysis of variance, Mann-Whitney U, and Fisher exact tests, as well as by the 2 ordered polytomous logistic regression model. Results The 2 tHcy groups were similar in demographic, stroke, and comorbidity characteristics, differing only by higher frequency of hypertension in those with a tHcy greater than 15μmol/L (51.7% vs 80.8%, respectively, P=.01). Compared with patients who had tHcy levels at 15μmol/L or lower and were discharged from rehabilitation being in the highest FIM score group (>80), higher tHcy levels were not associated with a discharge FIM score of less than 40 (odds ratio [OR]=.77; 95% confidence interval [CI], 0.13–4.65; P=.77) or with a better functional outcome FIM score between 40 and 80 (OR=3.71; 95% CI, 0.73–18.99; P=.11). Conclusions Our findings suggest that determination of tHcy level does not correlate with functional outcome in patients presenting for rehabilitation after acute ischemic stroke.

Reading to stroke unit patients: Perceived impact and potential of an innovative arts based therapy

Objective. This study investigated the delivery of an arts based intervention to stroke patients and sought users' and professionals' views of any perceived benefits.Setting. The study was undertaken on the stroke rehabilitation ward of a London teaching hospital.Design. Semi-structured interviews were carried out with 21 patients, 3 health care professionals and 5 reading service personnel. Observation sessions were carried out weekly for the 10-month duration of the project. Data were analysed using the Framework method.Intervention. The reading service, run by Interact, a registered charity, aims to entertain, stimulate and engage patients. Readers are professional actors trained to work specifically with stroke patients. Interact provide a selection of reading materials or alternatively patients provide their own material.Results. Participants' accounts suggested that the service met its aim of providing entertainment and stimulation. Additionally, there was some evidence that taking part in the reading service was associated with participants' emotional well being, the processes of adjusting to hospitalisation and to their engagement in rehabilitation therapies. Hospital staff acknowledged the service benefited patients with regard to spiritual, emotional/psychological needs. However they maintained that the service, as entertainment rather than therapy, was of minor importance.Conclusion. This arts based intervention was welcomed by patients and seemed to address some needs not met in the current configuration of care. These findings suggest that interventions such as the reading service point to ways in which it is possible to enhance the rehabilitation environment and perhaps facilitate better outcomes for stroke patients.

Validation of a fall risk index in stroke rehabilitation

A fall risk index has previously been developed to identify fall-prone individuals in stroke rehabilitation. The purpose of this study was to validate the predictive accuracy of the index. The validation sample (n = 158) consisted of patients admitted to a specialized geriatric stroke rehabilitation ward. The index was scored for each subject, and the relationship between the score and falls was assessed. The index was then remodeled and cross-validated in the sample from which it was derived (model fit sample, n = 135). The total index score (0-11) was significantly connected with the time to first fall (hazard ratio, 1.22; confidence interval [CI], 1.03-1.44). However, the classification of subjects into groups with low, intermediate, and high risk of falling could not be correlated with the time to first fall. A remodeled index contained 3 of the separate original index items. Its relationship to fall risk in the model fit sample was (hazard ratio, 1.82; CI, 1.38-2.40). The fall risk index showed some correlation with the fall risk among patients in stroke rehabilitation, but the results indicate that it should be modified to reach acceptable accuracy. A remodeled index showed a higher association with fall risk.

Patterns of hemiparesis recovery in lacunar and partial anterior circulation infarct stroke syndromes.

To investigate patterns of hemiparesis recovery in lacunar (LACI) and partial anterior circulation infarct (PACI) stroke syndromes. Prospective observational study. District general hospital and stroke rehabilitation ward. Forty-seven patients (25 LACI and 22 PACI) with a first-ever stroke causing a hemiplegia. Average age 76.4 years (range 59-88). Outcome measures assessed disability (Barthel Index), limb power (Motricity Index) and mobility (Rivermead Mobility Index) at baseline and 3, 6, 9, 12, 16 and 24 weeks post stroke onset. The time to maximum recovery, time to 50% recovery and area under the recovery curve was determined for each of the outcome measures. There were no statistical differences between these recovery parameters between the PACI and LACI stroke syndromes. Classification of hemiplegic stroke into PACI or LACI syndromes does not distinguish distinctive recovery patterns.

Interference between gait and cognitive tasks in a rehabilitating neurological population

OBJECTIVESTo quantify the extent of interference between gait and cognitive tasks after brain injury; to investigate whether such interference is common to various cognitive tasks, or confined to specific cognitive...

Communicating with people with stroke and aphasia: understanding through sensation without words.

To illuminate the phenomena of 'communicating with people with stroke and aphasia without words', 10 care providers particularly successful at communicating with stroke and aphasia patients who were working at a stroke rehabilitation ward narrated their experiences of communicating with such patients. A phenomenological hermeneutic approach, inspired by Ricoeur's philosophy, was used in the analysis. Two main themes were found: facilitating openness and being in wordless communication. The care providers sensed the feelings of the patients and experienced similar feelings themselves, thus, the communication is guided by the shared feelings between the care provider and the patient, i.e. communion. For this 'communication through sensation' to take place, the following factors were found to be necessary: creative closeness in combination with protective distance; striving for satisfaction and against exhaustion and desperation; meeting the patient halfway to gain understanding; exhibiting attention and accessibility to the patient; and trust and confidence for both care providers and patients. The findings were interpreted and discussed in the light of works by Levinas, Lögstrup and Stern.

Quality of care on a stroke rehabilitation ward

Quality of care on a stroke rehabilitation ward

Building a relationship: communications and relationships between staff and stroke patients on a rehabilitation ward.

Communications among staff and patients on a stroke rehabilitation ward form the focus of this article, which reports on some aspects of a larger study using a grounded theory approach. Tape-recorded interviews were transcribed and analysed concurrently according to recommendations for the approach. A main theme entitled building a relationship was identified, and this process was found to occur in a context varying from participative at one end of a continuum to hierarchical at the other. Building a relationship was found to be influenced by role, personal qualities and organizational context. Appropriate relationships between role-holders were subject to negotiation, leading to a resulting congruence or incongruence between participants' expectations of each other and their roles. Personal qualities were brought into play in the process, with patients' views of staff and staff views of patients both being influential. Some of these views seemed to parallel what has been described in earlier literature as 'the sick role' and the labelling of patients as 'good' or 'bad'. Responses to personal qualities led to nurses ascribing meaning to patients' behaviour in terms of adjustment to their stroke, giving time to them to help them to adjust, and withdrawal and handing over to other staff if this strategy failed. Organizational context also had an influence on building a relationship, with time constraints being identified particularly by nurses, and the need to fit in the most essential aspects of care. Place was also important, in that nurses were confined to the ward as a work location, whereas other therapists and doctors worked in other places and sometimes had the facility to take patients off the ward to concentrate on therapy. The findings are discussed against the background of related literature and the conclusion is drawn that the crucial role of nurses in rehabilitation is not recognized and valued, and that shortages of resources-especially suitably qualified and trained nursing staff-are a negative influence on building the relationships which are vital to successful rehabilitation.

Network

I am a staff nurse working on a stroke rehabilitation ward for the elderly. I am interested in finding a post-stroke depression assessment tool suitable for the older patient, especially those with dysphasic problems. I would appreciate any information on this subject.