Rehabilitation After Stroke
By: Dr. Angela Mc Namara
Rehabilitation Medicine Specialist
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Rehabilitation After Stroke By: Dr. Angela Mc Namara |
Stroke is one of the major causes of death and disability in the developed world. Rehabilitation is an important part of its management, yet rehabilitation services are haphazard.
Some advances have been made in the area of prevention, most significant of which is the early diagnosis and treatment of hypertension. Arteriosclerosis resulting in carotid artery disease also requires early diagnosis as surgical treatment can prevent an impending stroke taking place.
The consequences of severe stroke to the patient and family is well known. Rapidly advancing technology is focusing on more accurate diagnosis and treatment and this is resulting in greater interest being directed towards rehabilitation and its outcome.
The main aim of rehabilitation is to enable stroke victims to reach their maximum level of function and live the best life possible within the limits imposed by their impairment. Institutional care is avoided if at all possible. For those who require full nursing care it is estimated that the cost for one person is in the region of £30,000 per year.
The yearly incidence of stroke is estimated at 2 in 1,000 of the population. Dublin, therefore, has more than 2,000 new stroke patients a year. As public health, medical and social advances continue to extend life expectancy, we can expect an increase in the size of the community at risk of stroke in the future. It is now and will continue to be a major public health issue requiring our increased and focused attention.
Some strokes are transient and full recovery will take place within 24 hours. Those with disability will be referred to rehabilitation. This is best done by a team of experts. The majority of patients survive but the outlook for each individual is variable. It is generally accepted that about one third will recover fully, on third will have some degree of impairment and disability and one third will be completely dependent.
Different models on the best way to manage stroke have been reported. Stroke units have been advocated in many countries. In Ireland such a development is difficult to develop in the present general hospital system with such demands on the acute beds.
Local circumstances and constraints influence the design of rehabilitation services. A pragmatic approach is to ensure that good rehabilitation practice begins on the day of the stroke, regardless of where the patient is housed, and then appropriate patients are moved to a stroke rehabilitation unit as soon as possible thereafter.
In 1989 a Comprehensive Stroke Programme was introduced at St. Vincent's Hospital, Dublin, based on a model from the USA. It works satisfactorily and is possibly the best model for the public hospital service in Ireland.
Characteristic features of stroke programmes include:
At St. Vincent's the team is co-chaired by consultants in both geriatric Medicine and Rehabilitation Medicine.
St. Vincent's programme emphasises early intervention by a team of specialists from Medicine, Surgery, Nursing, Physiotherapy, Occupational Therapy, Speech Therapy, Medical Social Work. Dietitian and other specialists. The family and carers are also important participants in the rehabilitation of the patient. Working together the team aims to assist the stroke victim achieve their maximum potential as soon as possible and avoid secondary complications.
Good rehabilitation depends on the implementation of some basic principles and these include a full evaluation of the patient's potential. The physician's role in assessment and treatment is crucial. It is important to remember that the effort involved in rehabilitation for the patient after a stroke can be compared to Olympic effort for a normal person. Elderly patients may have a number of medical problems that are relevant. Their frailty and low effort tolerance will affect outcome. Treatment must begin early, be systematic, and built up in stages to include the types of treatment specific to the damage suffered.
Motivation is a major factor and may take some time to assess. Here the support of the family and carers is central. If motivation is poor, rehabilitation measures may not succeed. Depression is a common feature and must be identified and treated.
Two-thirds of the patients with stroke are over the age of 60 and therefore the largest numbers fall into the older age group. Rehabilitation facilities for those who are over 65 are generally more developed in Ireland with a number of options for secondary rehabilitation available. For those who are younger the services are quite limited.
The National Rehabilitation Hospital in Rochestown Avenue, Dun Laoghaire is the main option. It is a large in-patient unit that offers comprehensive secondary rehabilitation. There is a great demand on the beds and some stroke victims wait a long time for admission. Frequently the individual will already have been discharged from the general hospital before gaining entry.
There are a number of out-patient facilities available, such as St. Anthony's in Herbert Avenue, that offer a limited service for stroke.
Major development is needed in the field of rehabilitation to bring services for stroke in line with other developed European countries.
A key deficiency is the almost complete absence of consultants in the speciality of rehabilitation medicine in the general hospitals in this country where the majority of stroke rehabilitation takes place.
Ireland is unique in Europe having a National Rehabilitation Board (NRB). This is a statutory authority responsible for rehabilitation. In the recent past the NRB suggested to the Minister of Health the need to look at Rehabilitation Medicine in this country. In 1993 Mr. Brendan Howlin, the then Minister, set up the "National Advisory Committee on Medical Rehabilitation" (NACMR). This has representatives from all the relevant specialties in medicine and surgery, as well as representatives from the Department of Health, Comhairle Na n'Ospideal and the NRB. This committee is chaired by Professor Barry Bresnihan, St. Vincent's Hospital, Dublin. One of its main roles is to undertake a detailed assessment of existing Medical Rehabilitation facilities throughout the Republic of Ireland. The report of this committee is due in the near future and it is hoped that any recommendations will be acted upon and that the significant developments in the area of Rehabilitation Medicine will follow in the near future.
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