Comparison of Stroke Rehabilitation Guidelines

Stroke is considered to be the third cause of death and disability for millions of people in developed countries (1). Stroke is the clinical manifestation of a wide range of pathologies, with different etiologies and prognoses, and many risk factors. Stroke is defined as a syndrome characterized by rapidly developing clinical symptoms and/or signs of focal loss of cerebral function, in which symptoms last more than 24 hours or lead to death, with no apparent cause other than that it is a vascular origin. Stroke victims who survive the first attack may have persisting impairments such as cognitive impairments, upper and lower limb impairments and speech disabilities. The United Kingdom’s prevalence of stroke in the population is estimated to be 47 per 10000 making stroke the most common cause of adult physical disability (1; 2; 3). In the United State the Veterans Health Administration (VHA) estimated that 15000 veterans are in hospitals with a diagnosis of stroke every year (4).

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Stroke rehabilitation is a main factor in helping stroke survivors to regain their functional ability when medical and surgical interventions are limited (5). Physical therapy plays a major role in stroke rehabilitation. Physical therapists choose the duration and type of therapy given and provide education for stroke patients. Stroke rehabilitation aims at giving the patients the ability to regain maximum and full potential in functional activities and restoration of motor control (6; 7; 8; 5). Three main factors in rehabilitation contribute to the speed and quality of recovery. These factors are: treatment session duration and frequency, type of treatment approach used for rehabilitation, and providing education about the condition for patients during and after therapy (2; 3; 7; 8; 9).

Physical therapy rehabilitation for stroke patients is designed to impact the disabilities and impairments associated with post stroke conditions. Rehabilitation is mainly aimed at limiting any deterioration of impairments and maximizing the functional level for patients suffering from stroke. To be able to deliver this, physical therapists should follow a certain set of guidelines which will insure better outcomes and avoid unnecessary practices that could prolong and delay optimum gain of function (6; 7).

It is unclear whether physical therapists in Kuwait follow any specific guidelines in stroke rehabilitation. Therefore, it would be plausible to learn more about current local rehabilitation procedures. This may help in the further development of local rehabilitation procedures and practice guidelines, optimization of treatment and rehabilitation management, improvement in stroke patient’s health and quality of life, and minimization of conflicted rehabilitation practices that prolong therapy which in turn affect and burden the health system with increased number of patients (6; 8; 10; 11). We hypothesize that physical therapist in Kuwait rehabilitation do not follow stroke rehabilitation guidelines and science based practices in stroke rehabilitation. Therefore the aims of this study are to:

Explore if stroke rehabilitation in Kuwait follow general guidelines of stroke rehabilitation regarding frequency of treatment sessions and duration of each session.

Investigate if physical therapists specializing in the field of neuroscience in Kuwait follow general guidelines of stroke rehabilitation regarding their treatment approaches.

Identify if education is being provided for stroke patients about their condition during and after rehabilitation.

Literature Review:

Stroke is defined as a syndrome in which clinical symptoms and/or signs of cerebral function loss develop rapidly, and last for more than 24 hours or result in death. Stroke can be classified according to the cause, which is either ischemic or hemorrhagic. Ischemic strokes account for 85% of all strokes, while 15% account for hemorrhagic strokes. Over 10% of patients who had a first stroke will have a second one within a year, and the risk of recurrence within 5 years is 15-42% (1).

There are a wide range of conditions that lead to stroke, such as hypertension and diabetes. Each year, 5.45 million deaths are attributed to stroke, and over 9 million survive. Survivors often experience a wide range of persisting impairments. Common impairments include Physical disability, cognitive impairment, Lower limb impairments, and speech difficulties (1).

Rehabilitation is an important part after survival from a stroke. Rehabilitation was defined in the New Zealand guideline for management of stroke as ‘a problem-solving and educational process aimed at reducing the disability and handicap experienced by someone as a result of disease, always within the limitations imposed by both available resources and the underlying disease’ (12). It’s of utmost importance that the stroke patient understands, and receives education concerning his/her condition and what limitations may persist, even after rehabilitation (12).

Reker D. M. et al, researched whether adherence to post stroke guidelines was associated with greater patient satisfaction. They used a prospective inception cohort study design for new stroke admissions, including post-acute care, and they made follow-up interviews at 6 months after the stroke injury. Two hundred and eighty eight patients were included in the study, from eleven Veterans Affairs medical centers (VAMCs). The main outcome measures used in this study were: 1) compliance with the Agency for Healthcare Research and Quality (AHRQ), 2) patient satisfaction with care provided, and 3) stroke-specific instruments. Results have shown that, for every 10% percent increase in guidelines compliance, the average value of patient satisfaction increases by 1.5 points for the mean overall satisfaction score, which ranges from 4 to 39, and includes items for hospital satisfaction, home satisfaction, and overall satisfaction. The study concluded that compliance to AHRQ guidelines is significantly associated with patient satisfaction (7).

Several comparisons between Stroke Rehabilitation Protocols/ guidelines have been performed. This is beneficial in establishing the best treatment, with regards to dosing, intensity, duration, as well as efficiency and efficacy of interventions. A study by McNaughton H, et al examined the practice and outcomes of stroke rehabilitation between New Zealand and the United States facilities. This study used a Prospective observational cohort design and included 1161 participants from six United States (U.S.) Rehabilitation facilities and 130 participants from one New Zealand rehabilitation facility, all above the age of 18 years. In this study, New Zealand patients were older than the United States patients. However, the severity of initial stroke was higher for the U.S. patients. Despite that fact, patients in the U.S. were discharged earlier. They also had more intensive therapy, represented in higher durations spent with physical therapy and occupational therapy professionals. Also, U.S therapists tended to spend less time on assessment and non-functional activities, while focusing more on active management of patients. Results showed that, U.S. participants had better outcomes represented by changes in Functional Independence Measure FIM scores and fewer discharges to institutional care (13.2% vs. 21.5%). This study illustrates that duration and intensity of therapy can be adjusted to gain a better outcome. Also, it is important to know which activities are being done in the treatment session, and find out if they contribute to a better outcome of rehabilitation (10).

Horn et al. investigated the effect of specific rehabilitation therapies in stroke rehabilitation on outcomes, taking into account the differences between patients. In this study, they wanted to examine the associations between patient characteristics, rehabilitation therapies, neurotropic medication, nutritional support, and time of starting therapy with functional outcomes and discharge destination for stroke inpatients. Discharge total, motor, and cognitive FIM (functional independence measure) scores and discharge destinations were registered for 830 patients with moderate or severe strokes from five U.S. inpatient rehabilitation facilities. Results showed that earlier initiation of rehabilitation, time spent in higher-level rehabilitation activities, such as upper-extremity control, gait and problem solving, usage of newer psychiatric medications, and gastric feeding, were all associated with better outcomes. The study also illustrated that a variety of Physical Therapy, Occupational Therapy, and Speech Language Pathology activities were correlated with higher or lower FIM scores. On one hand, more minutes spent per day on PT gait activities, OT upper-extremity control activities and home management, and SLP problem solving activities were associated significantly with higher FIM scores. On the other hand, more minutes spent per day on PT bed mobility and sitting, OT bed mobility, and SLP auditory comprehension and orientation were consistently associated with lower FIM scores (11).

One study described Physical Therapy intervention for stroke patients in inpatient facilities within the U.S. (13). Six rehabilitation facilities in the U.S. included 972 subjects with stroke injury. Variables studied were time spent in therapy, and content and activities that were used in rehabilitation. The mean duration of stay in the inpatient facilities was 18.7 days, and received PT was on an average of 13.6 days. Patient spent 57.15 minutes on average for Physical therapy treatment every day. Activities of gait, transferring, and pre-functional activities, which include strengthening exercises, balance training, and motor learning, were the most performed interventions. Also, therapists included activities that incorporated different functions into one functional activity. This study implicated that a focus of physical therapist when providing treatment is optimizing functional activities, as they were the most frequent activities performed. However, activities to remediate impairments and to compensate for lost functions were also included in the treatment sessions (13).

Brocklehurst et al. investigated the use of physical therapy, occupational therapy, and speech therapy for patients suffering from stroke, as they mentioned that those interventions formed the basis of stroke rehabilitation. The study included 135 stroke patients from five general and one geriatric hospital, in South Manchester. Of the 135 subjects, 107 received PT, 35 received OT, and 19 received speech therapy. Results were obtained after measuring the rate of change in function over a one year period. Patients, who had more severe disabilities, and the worst prognosis, were more likely to get physical therapy treatment. Factors that determine type and specificity of physical therapy to stroke rehabilitation were also examined. Some of the factors were extent of disability, and disability-associated morbidities, such as fecal incontinence, spasticity, sensory loss and dysphasia. Even though the most disabled received the most physical therapy treatment, they showed the least improvement in function even after six months of therapy. This study also concluded that patients, whose progress was poorest, received more physical therapy (5).

Hsiu-Chen Huang et al. investigated the impact of timing and dose of rehabilitation delivery on the functional recovery of patients suffering from stroke. In this study, a retrospective review of medical charts was done for 76 patients who were admitted to a regional hospital for a first-ever stroke. Patients had multidisciplinary rehabilitation programs, including PT, OT, and a continuous rehabilitation for at least three months. The main outcome measure for this study was the Barthel index, taken at initial assessment, one month, three months, six months and one year after stroke. Results of this study showed that there is a dose-dependent effect of rehabilitation on functional outcome improvements of stroke patients. Also, earlier delivery of rehabilitation is associated with lasting effects on functional recovery up to one year post-stroke (14).

It is unclear whether physical therapists follow evidence based practice many countries of the world including Kuwait. There is no doubt the era of evidence based practice is upon us for many reasons including better treatment outcomes, patient satisfaction, reimbursement amongst others. In one survey study, conducted by Iles and Davidson, examination of physical therapists’ current practice in Australia was undertaken. This study found that there are several barriers in the way of evidence-based practice. Those barriers included time to stay up to date, access to journals, access to summaries of evidence that are easy to understand, and lack of personal skills in looking for and evaluating research evidence (15).

Salbach et al. examined the determinants of research use in clinical decision making among physical therapists treating post-stroke patients. Two hundred and sixty three physical therapists from the state of Ontario, Canada, responded to a survey questionnaire, containing items for evaluating practitioner and organizational characteristics and perception of research believed to be influencing evidence-based practice. The survey also contained the frequency of using research evidence in clinical decision making in a typical month. Results showed that, only a small percentage of therapists (13.33%) reported using research in clinical decision making six times a month or more. However, most therapists (52.9%) reported using research 2-5 times a month, while 33.8% used research 0-1 time per month. In this study, research use was associated with the academic preparation in the principles of Evidence-Based Practice (EBP), research participation, service as a clinical instructor, being self-effective in implementing EBP, attitude towards research, perceived organizational support of research use, and access to bibliographic databases at work. This study concluded that a third of therapists rarely apply research evidence in clinical decision making. Suggested interventions to promote research use included education in the principles of EBP, EBP self-efficacy, having a positive attitude towards research, and involvement in research (8).

A study by Ogiwara, made a comparison between the bases of treatment between Japanese physical therapists, and Swedish therapists. They investigated the reasons why the Japanese choose certain approaches of treatment when handling stroke patients, and then compared the results with those of Swedish therapists. Swedish therapists attributed their choice of treatment to hands-on experience and participation in practical courses, in which various techniques are taught. Bobath’s approach was the only method that was commonly continued to be used after graduation in both countries. Results have illustrated that Swedish therapists were more interested in new methods of treatment (91%), whereas only 77% of Japanese therapists had an interest. Implication of their results might mean that Japanese therapists are interested in their treatment approach, and also show that introducing new approaches of treatments takes a longer time in comparison to Sweden. Additionally, Swedish therapists tend to make a combination of treatment approaches, while Japanese physical therapists tend to follow only one particular approach. Several reasons were speculated for addressing the differences in treatment protocols, some of which were: 1) diversity of cultures, 2) diversity of health the care system, 3) availability of equipment and space needed to follow a certain new approach, 4) belief of efficacy of a certain approach and 5) the language barrier imposed on Japanese therapist, and availability of translated literature. This study showed that there are several barriers and differences encountered when the need of application of new approaches is desired (9).

Wachters-Kaufmann et al. conducted a study regarding the conferring of information for stroke patients and caregivers. Their study investigated how information was provided to patients and caregivers and how they actually preferred to be informed. The actual and desired information correspond in terms of content, frequency, and method of presentations well as the actual and desired information. The study was done in the North of the Netherlands and the stroke unit of University hospital Groningen. The General practitioners (GP) distributed a guide from a community-based study of cognitive disorders and quality of life (CognitiVA) after a stroke. The guide was given three months after the stroke. For the final measurement of the study, which was 12 months later, the patients and caregivers participated in a telephone survey, which asked about three things: 1) professional stroke-care providers, 2) other sources of information, 3) the guide. Fifty one patients and 38 caregivers were contacted, of which 18 patients and 11 caregivers declined to be interviewed for various reasons. The results showed that the GP’s, neurologist, and physical therapists were both the actual and desired information providers. As for the content, the actual content was the guide, whereas the desired was mostly medical information concerning the course of the disease, its cause, consequences, and treatment. Regarding the frequency, the actual and desired was within 24 hours of the stroke, and one day to two weeks later, and after two weeks. As for the method of presentation of information, the patients and caregivers mostly desired only verbal (73% patients, 89% caregivers) (16).

Methods:

This comparative design research project will compare the stroke rehabilitation program implemented in Kuwait with the established guidelines for stroke rehabilitation in the United States of America. The rehabilitation program stroke patients are receiving in Kuwait’s Ministry of Health hospitals, specifically, Al-Jahra, Mubarak, Farwanya, Physical Medicine and Rehabilitation, and Al-Sabah hospitals will be investigated. Subjects of the study will be physical therapists practicing in the stroke rehabilitation field. We will provide physical therapists experienced in stroke rehabilitation with self-administered questionnaires, which will be collected after one week. We will also examine patient records over a three week period. To access the records, we will get permission from the head of the physical therapy department of each hospital as well as each hospitals director. Institutional Review Board (IRB) approval will be obtained prior to any data collection. Approval from the Ministry of Health’s IRB will be obtained as well as approval from Kuwait University. Data will then be compared with the established American Stroke Guidelines. All data gathered during the study will be kept under lock and key. Any identifiable information obtained from patient files and records will only be accessible to the primary investigator. No identifiable information will be used for publication purposes. Confidentiality will be insured throughout the study duration.

Subjects:

The subjects of this study will be physical therapists working in Kuwait’s Ministry of Health hospitals’ neurology department and with experience in out-patient stroke rehabilitation.

Tools:

To investigate the frequency and duration of treatment, we will look into the records, which are the patients’ files. There is also a section in the questionnaire that will ask about the frequency and duration of sessions.

As for finding out the treatment approach patients are receiving, a self-administered questionnaire will be distributed at selected MOH hospitals, specifically at Al-Jahra, Mubarak, Farwanya, Physical Medicine and Rehabilitation, and Al-Sabah hospitals. Therapists will be given the questionnaire to fill out. In order to evaluate the type of education given to patients, educational guides, or pamphlets, about the patient’s condition available at the hospital and distributed to patients will be looked at. The questionnaire will also ask about different patient education techniques used by the participants.

For comparison of data, we will compare the data we obtain with the American Stroke Association guidelines.

Questionnaire:

The questionnaire will consist of several questions used in the Ogiwara (9) questionnaire as well as others pertinent to our study population. The questionnaire will consist of four parts:

1. demographic information
2. questions concerning the therapist’s professional history and experience
3. Questions concerning the rehabilitation program: treatment approach, and frequency and duration of sessions.
4. questions concerning the types of education techniques

Each questionnaire will have a cover letter explaining the purpose of the study, and a consent form.

Data Analysis

The data will be analyzed using SPSS (Statistical Package for Social Sciences) (v. 17.0) to describe means, standard deviations, frequencies, and percentages.

Once the data is analyzed, we will compare the data we collected with the general guidelines and treatment approaches in the literature.

Expected Outcomes and Recommendations

Our expectation for this study is that physical therapists in the state of Kuwait will not be following the American stroke rehabilitation guidelines. Due to cultural differences between the two countries, establishing new guidelines for the stroke rehabilitation in Kuwait might be necessary, addressing the nature of referral to physical therapy in Kuwait, and making recommendations for increasing treatment duration if needed. Also, it should be mentioned what type of special equipment might be used in the process of rehabilitation.

References:

Rudd A, Olfe C.W. (2002, Feb). Aetiology and pathology of stroke. Vol. 9, pg 32-36.

Hafsteinsdottir T.B, Vergunst M, Lindeman E, Schuurmans M. (2010, 29 July). Educational needs of patients with a stroke and their caregivers: A systematic review of the literature. www.elsevier.com/locate/pateducou

Hoffman T, McKenna K, Herd C, Wearing S. Written stroke materials for stroke patients and their careers: perspectives and practices of health professionals. Top Stroke Rehabil 2007;14(1):88-97

Duncan P, Zorowitz R, Bates B, Choi J, Glasberg J, Graham G, Katz R, Lamberty K, Reker D. Management of Adult Stroke Rehabilitation Care: A Clinical Practice Guideline. (Stroke. 2005; 36:e100-e143.)

Brocklehurst J.C, Andrews K, Richards B, Laycock P. J. (1978, 20 MAY). How much physical therapy for patients with stroke? Vol. 1, 1307- 1310. British Medical journal.

Kollen, B, Kwakkel G, Lindeman E. (2006, 11 July). Functional Recovery after Stroke: A Review of Current Developments in Stroke Rehabilitation Research. Vol.1, No.1, 75-80.

Reker D.M, & Duncan P. W, Horner R.D, Hoenig H, Samsa G.P, Hamilton B, Dudley T.K.(2002, June) Post acute Stroke Guideline Compliance Is Associated With Greater Patient Satisfaction. Arch Phys Med Rehabil Vol. 83, pg 750-756.

Salbach N, Guilcher S, Jaglal S, Davis A. (2010) Determinants of research use in clinical decision making among physical therapists providing services post-stroke: a cross-sectional study. http://www.implementationscience.com/content/5/1/77

Ogiwara S. (1997) Physical therapy in stroke rehabilitation: A comparison of bases for treatment between Japan and Sweden.vol.9 Pg. 63-69, Journal of physical therapy sciences.

McNaughton H, DeJong G, Smout J, Melvin L, Brandstater M. (2005, Dec) A Comparison of Stroke Rehabilitation Practice and Outcomes between New Zealand and United States Facilities. Vol. 86, suppl.2, Arch Phys Med Rehabil.

Horn D, DeJong G. Smout J, Gassaway J, James R, Conroy B. (2005, Dec) Stroke Rehabilitation Patients, Practice, and Outcomes: Is Earlier and More Aggressive Therapy Better? Vol. 86, pg. 101-114, suppl. 2, Arch Phys Med Rehabil.

Life after stroke: New Zealand guideline for management of stroke (November 2003).

Jette D.U, Latham N.K, Smout R.J, Gassaway J, Slavin M.D, Horn S.D (2005, March) Physical Therapy Interventions for Patients with Stroke in Inpatient Rehabilitation Facilities. Vol. 85, num. 3, pg. 238-248, physical therapy.

Huang H, Chung K, Lai D, Sung S. The Impact of Timing and Dose of Rehabilitation Delivery on Functional Recovery of Stroke Patients (J Chin Med Assoc: May 2009 , Vol 72, No 5)

Iles R, Davidson M. Evidence based practice: a survey of

physiotherapists’ current practice. Physical therapy. Res. Int. 11(2) 93-103 (2006)

Watchers-Kaufmann C, Schuling J, The H, Jong B. Actual and desired information provision after a stroke. Patient Education and Counseling 56 (2005) 211-217

Appendices

Appendix 1

American Stroke Association Guidelines:

E. Patient and Family/Caregiver Education

Background

The patient and family/caregivers should be given information and provided with an opportunity to learn about the causes and consequences of stroke, potential complications, and the goals, process, and prognosis of rehabilitation.

Recommendations

Recommend that patient and family/caregiver education be provided in an interactive and written format.

Recommend that clinicians consider identifying a specific team member to be responsible for providing information to the patient and family/caregiver about the nature of the stroke, stroke management rehabilitation and outcome expectations, and their roles in the rehabilitation process.

Recognize that the family conference is a useful means of information dissemination.

Recommend that patient and family education be documented in the patient’s medical record to prevent the occurrence of duplicate or conflicting information from different disciplines.

N. Educate Patient/Family, Reach Shared Decision about Rehabilitation Program, and Determine Treatment Plan

Objective

ensure the understanding of common goals among staff, family, and caregivers in the stroke rehabilitation process and, therefore, optimize the patient’s functional recovery and community reintegration.

Recommendations

Recommend that the clinical team and family/caregiver reach a shared decision about the rehabilitation program.

   The clinical team should propose the preferred environment for rehabilitation and treatments on the basis of expectations for recovery.

   Describe to the patient and family the treatment options, including the rehabilitation and recovery process, prognosis, estimated length of stay, frequency of therapy, and discharge criteria.

   The patient, family, caregiver, and rehabilitation team should determine the optimal environment for rehabilitation and preferred treatment.

Recommend that the rehabilitation program be guided by specific goals developed in consensus with the patient, family, and rehabilitation team.

Recommend that the patient’s family/caregiver participate in the rehabilitation sessions and be trained to assist patient with functional activities, when needed.

Recommend that patient and caregiver education be provided in an interactive and written format. Provide the patient and family with an information packet that may include printed material on subjects such as the resumption of driving, patient rights/responsibilities, support group information, and audiovisual programs on stroke.

Recommend that the detailed treatment plan be documented in the patient’s record to provide integrated rehabilitation care.

Intensity of Therapy

The heterogeneity of the studies in all aspects-patients, designs, treatments, comparisons, outcome measures, and results-combined with the borderline results in many of the trials limits the specificity and strength of any conclusions that can be drawn from them. Overall, the trials support the general concept that rehabilitation can improve functional outcomes, particularly in patients with lesser degrees of impairment. Weak evidence exists for a dose-response relationship between the intensity of the rehabilitation intervention and the functional outcomes. However, the lack of definition of lower thresholds, below which the intervention is useless, and upper thresholds, above which the marginal improvement is minimal, for any treatment, makes it impossible to generate specific guidelines.

Partridge et al did not find any differences in functional and psychological scores at 6 weeks in 104 patients randomized between a standard of 30 and 60 minutes of physical therapy.

Kwakkel et al randomized 101 middle-cerebral-artery stroke patients with arm and leg impairment to additional arm training emphasis, leg training emphasis, or arm and leg immobilization, each treatment lasting 30 minutes, 5 days a week, for 20 weeks. At 20 weeks the leg training group scored better for ADLs, walking, and dexterity than the control group, whereas the arm training group scored better only for dexterity.

The clinical trials provide weak evidence for a dose response relationship of intensity to functional outcomes.