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Stroke Patients Rehabilitation 1

Submitted in partial fulfilment of the BA (Hons) Professional practice

(NURSING/MIDWIFERY), Faculty of Health and Well Being, Sheffield Hallam

University.

September, 2012

Word Count: 7946


Acknowledgements

I would like to thank my professors at Sheffield Hallam University, who have been

essential in supporting me through this research, encouraging me through the problems

I faced and motivating me through the process.


Table of Contents

Acknowledgements..................................................................................................................................2

Table of Contents.....................................................................................................................................3

Abstract......................................................................................................................................................5

Chapter I: Introduction..............................................................................................................................6

1.1. Background....................................................................................................................................6

1.2. Introduction....................................................................................................................................7

1.3. Research Motivation.....................................................................................................................8

Chapter II: Literature Review..................................................................................................................9

2.1. Introduction....................................................................................................................................9

2.2. Symptoms of a stroke.................................................................................................................11

2.3. Prevention of stroke....................................................................................................................13

2.4. Rehabilitation...............................................................................................................................15

2.4.1. Goals of Rehabilitation........................................................................................................15

2.4.2. Types of Rehabilitation........................................................................................................16

2.5. Rehabilitation after Stroke..........................................................................................................16

2.6. Various methods of rehabilitation..............................................................................................17

2.6.1. Relieve spasticity.................................................................................................................17

2.6.2. Exercises to regain mobility................................................................................................18

2.6.3. Stem cells..............................................................................................................................18

2.7. Specialized Professionals in Rehabilitation after Stroke........................................................18

2.7.1. Doctors..................................................................................................................................18

2.7.2. Rehabilitation Nurses..........................................................................................................19

2.8. Rehabilitation of Stroke Patients at Home...............................................................................21

Chapter III: Methodology.......................................................................................................................25

3.1. Introduction..................................................................................................................................25

3.2. Research Design.........................................................................................................................26

3.3. Aim of Research..........................................................................................................................27


3.4. Ethical Consideration..................................................................................................................28

Chapter IV: Result..................................................................................................................................29

4.1. Outcomes of patients..................................................................................................................31

4.1.1 Mortality..................................................................................................................................31

4.1.2 Death or requiring institutional care....................................................................................32

4.1.3 Death or dependency...........................................................................................................32

4.1.4 Activities of daily living (ADLs)............................................................................................33

4.1.5. Subjective state of health....................................................................................................33

4.1.6. Patient satisfaction...............................................................................................................33

4.2. Outcomes of caregivers.........................................................................................................34

4.2.1. Mood......................................................................................................................................34

4.2.2 Satisfaction of caregivers.....................................................................................................34

4.3. Discharge.....................................................................................................................................34

4.4. Connection with Past..................................................................................................................35

4.5. Interpretation of results...............................................................................................................36

Chapter Five: Conclusion......................................................................................................................39

References..............................................................................................................................................41

Appendices..............................................................................................................................................44

Appendix I............................................................................................................................................44

Appendix II...........................................................................................................................................45

Appendix III..........................................................................................................................................47


Abstract

This paper presents a research on comparing stroke patients that have been

rehabilitated at homes and hospitals and the factors behind the differences if any. The

research mainly focuses on the rehabilitation techniques and the different roles of

specialists in this field. The methodology is based on the patients that have been

introduced to ADA and how they have been able to rehabilitate at homes after their

treatment and the efforts done by the hospitals to ensure minimum readmissions of the

patients.


Chapter I: Introduction

1.1. Background

Stroke to a disorder called sudden cerebral circulation, which alters the function

of a particular brain region. These are disorders that have in common a sudden onset,

which typically affect older people and, although they can also occur in young-and are

often the end result of the confluence of a number of personal, environmental, social,

etc., To we term the risk factors. Although the human brain signifies only 2% of the

weight of the body however it requires almost 20% of the flow to meet their needs (i.e.

energy intensive) and not otherwise available energy reserves (not groceries). These

conditions a constant supply of oxygen and nutrients, thus being very sensitive in the

absence of cerebral blood flow, in charge of providing the energy required for running.

For this reason the brain has a large amount of blood vessels and multiple mechanisms

to maintain constant the amount of circular blood for him and ensure proper delivery of

oxygen and nutrients, yet in bad circumstances. When blood vessels are injured by one

cause or another and the blood does not reach suitably (even small interruptions of

blood flow) cause the reduction or cancellation of the function of the brain affected. If

the irrigation decreases for longer than a few seconds, the cells in that area brain are

destroyed and cause permanent damage to that area the brain has security

mechanisms. There are many small connections between different brain arteries and if

the blood decreases progressive, these small connections increase in size and serve as

referral to blocked area. This is called collateral circulation. If there is sufficient collateral

circulation, a completely blocked artery may not cause deficiencies.


1.2. Introduction

The family is the oldest social institution of humanity, where we form all it is the

place where we feel more protected, for children is an example and an ideal place for

learning. It has the responsibility to provide its members the opportunity to develop and

enrich their personality and function to meet the physical and emotional needs of its

members by establishing positive patterns of relationships. This should promote

socialization, learning and creativity.

The current population ages rapidly this leads to the emergence of diseases

caused by the passage of time and risk factors relating to the health-disease process.

That is why modern life requires of new knowledge to meet the new needs and

challenges of the future, as well as the disadvantages that may arise along the way.

The disease, individually designed, is a process that creates an imbalance not only in

the sick person, but covers larger areas. An individual in this state involves a family

while sick because recoveries include economic sectors, employment, relationships,

social and emotional.

Strokes predominate in the middle Ages and later life. They affect about 5% of

the population over 65 years and represent 9 and 10% respectively of total deaths,

occurring more than 90% of deaths in people 50 years or older, among which 50%

survive or Most left with a sequel. According to the World Health Organization (WHO),

strokes are "rapidly developing clinical signs of focal disturbance of cerebral function of

vascular origin and presumably more than 24 hours." This definition is included in most

cases of cerebral infarction, cerebral haemorrhage and subarachnoid haemorrhage, but

excluding those cases in which the recovery occurs within 24 hours.


A stroke is the blockage of a blood vessel which interrupts the supply of oxygen to the

cells causing their death. The consequences of a stroke and the severity and extent of

the functions affected depends on where the blockage has occurred in the brain and

how great was the damage. Stroke was defined as ischemic or hemorrhagic, as caused

by a blockage in an artery or a laceration of the artery wall that causes bleeding in the

brain.

People at higher risk of having a stroke are those with high blood pressure, who

are sedentary, obese, who smoke, drink or have diabetes. High blood pressure (over

160/95 mm Hg.) is responsible for the largest number of strokes. Atherosclerosis

caused by high cholesterol or diabetes are at increased risk of stroke. Other factors

such as atria fibrillation in the heart by pumping deficiencies can form clots that can then

break off and travel to the brain as emboli. The abuse of drugs and other substances

are also at risk. Headaches or migraine are stroke risk. Genetic factors also by the

person's predisposition and stress.

1.3. Research Motivation

I have chosen rehabilitation and early discharge is to find out the best way to

rehabilitate stroke patients as we receive many patients that cannot cope at home and

therefore are admitted to nursing homes after hospital discharge.


Chapter II: Literature Review

2.1. Introduction

A cerebrovascular accident (CVA), formerly stroke (CVA) and sometimes called

brain attack, is a deficit neurological origin sudden vascular caused by infarction or

haemorrhage in the brain . The term "accident" is used to emphasize the sudden

appearance or sudden onset of symptoms, although in fact this is actually a disease, its

causes are internal in nature (Warlow, 1996).

Symptoms can vary widely from one case to another depending on the type of

stroke ( ischemic or hemorrhagic ), the location and size of the brain lesion, which

explains a wide spectrum: no sign remarkable loss motor skills, sensory loss, speech

disorder, loss of sight, loss of consciousness, death. These symptoms, if they occur

very rapidly (within minutes), can disappear immediately or within a few hours (called to

TIA) or otherwise persist longer. Stroke whose symptoms persist are called strokes

made. In case of survival, the recovery process is still poorly understood, but a period of

spontaneous recovery from a few weeks to a few months, followed by a period of slower

evolution for several years, is recognized.

A previous review (Langhorne, 1999) focused on care systems that have been

established as a total care options during admission, i.e., services such as the "hospital

at home", which aims to prevent stroke patients entering the hospital. A second

approach has been to develop services that can accelerate the discharge of patients

already admitted to the hospital.


In Western countries (Europe, U.S., etc.), 600 individual suffers from a stroke

each year (120,000 in France). 80% of them are ischemic and 20% haemorrhage

(Isard, 1992). Approximately the probability of ischemic stroke increases with age while

the probability of hemorrhagic stroke is independent of age (Mackay, 1995).

When nerve cells are deprived of oxygen, if only for a few minutes, they die, they

do not regenerate. Also, the more time between stroke and medical care are shorter,

the risk of serious squeal is shrinking (Barnes, Dobkin, & Bogousslavsky, 2005).

There are two forms of stroke: ischemic stroke - when there is a blockage of a

blood vessel that supplies blood to the brain, and hemorrhagic stroke - when an

ensangramiento in the brain and there around. The following sections describe these

forms of stroke detail.

2.2. Symptoms of a stroke

A stroke can cause paralysis or loss of consciousness. Sometimes it is detected by one

or more of the following signs (Burkman, 2010):

dizziness and sudden loss of balance;

a sudden numbness, loss of sensation or paralysis of the face, arm, leg or one

side of the body;

confusion, sudden difficulty speaking or understanding;

sudden loss of vision or blurred vision in one eye;

Sudden headache, exceptionally intense, sometimes accompanied by vomiting.

All cases, you must contact emergency services as soon as possible.


It is essential to contact an emergency medical team as soon as possible after the

onset of stroke.

A stroke occurs suddenly and may have an immediate effect on speech and

movement. Some people have a blurred vision, while others experience sudden

confusion and loss of balance, have difficulty speaking or have a sudden severe

headache with no obvious reason. Stroke (stroke) is the third leading cause of death

in many countries and the leading cause of acquired disability in adults. Stroke is

primarily a disease of the elderly: 75% of patients over 65 years but 20% still have a

work at the time of the accident (Barnes, Dobkin, & Bogousslavsky, 2005).

Sudden paralysis or numbness on one side of the body, sudden difficulty in

speaking, loss of attention, very sudden decrease of vision in one eye, without an

immediate treatment, the lesions may become irreversible. Every minute counts in

this case (Burkman, 2010).

A stroke occurs when blood flow is interrupted in the brain due to a blockage by a

clot (it is ischemic stroke, which accounts for 80% of strokes) or the bursting of a

blood vessel (AVC colitis). Deprived of oxygen and nutrients, certain nerve cells are

damaged and others die.

The transient ischemic attack (TIA) is a precursor of stroke. It is caused by an

interruption of short duration, the flow of blood in a part of the brain. Signs appear

suddenly and disappear completely in a few minutes. AIT multiplies by 50 the risk of

stroke, says the SFNV.


2.3. Prevention of stroke

Since strokes and heart attacks are caused by both atherosclerosis and high

blood pressure, methods to prevent or control cardiovascular disorders may help reduce

the risk of stroke. The three most important risk reducers are controlling high blood

pressure, quitting smoking and exercising properly. Smoking is the second leading

cause of stroke, but quitting smoking can reduce the risk of stroke to normal levels in

five years. Although reducing the levels of cholesterol, which protects against

atherosclerosis and ischemic stroke, the risk for hemorrhagic stroke slightly less

common, this is not an argument for keeping unhealthy levels. Everyone should reduce

their intake of saturated fat, maintain a healthy diet rich in fruits and vegetables, and

avoid being overweight and try to reduce stress. People with diabetes should try to

control the levels of blood sugar strictly (Hutton, 2005).

People whose diets are low in vitamin C have the same high risk for stroke as

people with hypertension. Although a protective role of vitamin supplements is not clear

yet, found that women with diets rich in fruits and vegetables reduced their risk of stroke

over women with diets low in these foods. A long-term study of men found that for every

three servings of fruits and vegetables in the diet, the risk of stroke was reduced (Kalra,

Evans, Perez, Knapp, Donaldson, Swift, 2000).

The accidents are caused by hemorrhagic rupture of a blood vessel, often

damaged or in poor condition at the origin and subjected to excessive blood pressure.

Tobacco and alcohol are factors particularly debilitating blood vessels.


Depending on the location of the vessel, the bleeding may be meningitis due to

rupture of an aneurysm in the arterial subarachnoid spaces, cerebral intra (also called

intraparenchymal) and may be associated with ventricular flood. The hematoma formed

rapidly, showing signs of focal neurological onset in relation to structures destroyed or

compressed by the lesion. Moreover, it is edema around the hematoma, which

increases the compression of the brain in the skull, causing or aggravating a intracranial

hypertension (intracranial hypertension). The hematoma may rupture in a cerebral

ventricle. Sometimes during hemorrhagic there is also a release of calcium ions which

induce a vaso-spasm causing sudden ischemic attacks.

The ischemic is due to occlusion of a cerebral artery or to the brain (carotid or

vertebral arteries). The brain is partially deprived of oxygen and glucose. This occlusion

causes myocardial stroke (also called a softening of the brain). The mechanism of this

occlusion is often either an atherosclerotic obstruction or clot (local training or

embolism, in this case, usually of cardiac origin). However, other causes may exist:

tearing the wall of the artery (dissection), compression by a tumour. The deficit for a

defined territory of the brain: it is said systematized.

The ischemic cerebral infarction may be complicated by secondary bleeding at

the lesion: it is then a question of hemorrhagic softening. The cerebral thrombophlebitis

is an occlusion of a cerebral vein (not an artery). It is much rarer. The brain gap is a

complication of hypertension and is characterized by multiple small areas affected by

cerebral infarction.


Hypertension is the main risk factor for stroke. In a healthy person, the blood

pressure should be below 140/90 mm Hg. If hypertension is (> 14/9), the pressure at

which the blood vessels are constantly subjected becomes too high and the cerebral

vessels have an increased risk of rupture, causing a brain haemorrhage.

2.4. Rehabilitation

Rehabilitation increases the chances of a successful recovery after a stroke. The

first few days after a stroke are very critical. During this time, the brain may swell,

causing more brain damage. In rare cases, this could cause death (Law & MacDermid,

2007).

Rehabilitation begins as soon as the patient is medically stable. This usually

takes place several days after the stroke. For rehabilitation to be successful, it is

important that the patient and family cooperate and show enthusiasm. Although

therapies are programmed only a few times a week, patient and family should do

therapeutic exercises every day. Although rehabilitation has improved in the last 20 to

30 years, the victims of sometimes strokes cannot return to the condition they were in

before the spill. It is important to continue working with skill and techniques discouraged

(Carey, 2012).

2.4.1. Goals of Rehabilitation

There are two main goals of rehabilitation (Levine, 2010):

a. Strengthen and re-educate the patient to help him improve.

b. Instruct the patient to lead a life as normal as possible within the limits of their

condition.


2.4.2. Types of Rehabilitation

Rehabilitation is a combination of three types of therapy (Gresham, Duncan, & Stason,

2004):

a. Physical Therapy: strengthens muscles and improves the ability to walk patient.

b. Speech therapy: re-instruct the patient in all that relates to speech. This includes how

to speak, understand, read, write, solve problems, and so on.

c. Occupational therapy: teaches patients different "tricks" that help to lead a life as

normal as possible.

2.5. Rehabilitation after Stroke

Rehabilitation is a set of physical exercises or cognitive therapies to help stroke

victims regain neurological function and recover their deficits. The goal of therapy after

stroke is better to adapt to her new life and regain maximum independence.

Rehabilitation is a key step recovery after stroke and should be customized to the

fullest. The most important advances are made in the months after your stroke. This is

why it is crucial to begin the rehabilitation exercises as soon as possible. Rehabilitation

is usually divided into three phases: acute phases, sub acute and chronic. During each

phase, patients focus on different skills working with different therapists (Dunn, Lewis,

Vetter, Guy, Hardman & Jones, 1994).

The first steps involve promoting independent movement because many patients

are paralyzed or seriously weakened. Patients are instructed to change positions

frequently while they are lying in bed and passively or actively participate in exercises

scope to increase their mobility and strengthen their stroke-impaired limbs.


(Rehabilitation exercises should help you regain maximum independence. Often

patients do not recover completely physical function and then work on alternative

methods to compensate for their disabilities (Carey, 2012).

The nurses and rehabilitation therapists help patients perform progressively more

complex and demanding, such as bathing, dressing, and using the toilet, and encourage

them to begin using their stroke-impaired limbs to perform these tasks. The first step in

the return to functional independence for stroke survivor is to begin to reacquire the

ability to perform these basic activities of daily living.

2.6. Various methods of rehabilitation

2.6.1. Relieve spasticity

There are different ways to assess your spasticity. We can estimate the mobility of your

arms and legs, your muscle activity, flexibility, etc.. Depending on your results,

therapists will establish an appropriate rehabilitation program, combining physical

exercise and medication. Stretching is a classic example of exercise can increase

flexibility and reduce muscle spasms. You may suggest braces to relax your leg, for

example.

2.6.2. Exercises to regain mobility

Many stroke victims are physically blocking them at home. Physical exercises will help

them regain mobility, strength and endurance, or improve their balance and

coordination. The progress can regain some independence and are also a source of

motivation and a good way to prevent another stroke.


2.6.3. Stem cells

Stem cells are unspecialized cells. Their function in the body is not yet determined, it is

possible to use them to replace damaged cells or other tissues, and resume their duties

in certain areas of the brain. Therapy with stem cells is therefore to guide the healing of

the body. This solution remains controversial, but is nevertheless used during

amputations, transplants or to treat certain cancers such as leukaemia. Research is

now trying to use stem cells in neurological diseases such as Alzheimer's or

Parkinson's.

2.7. Specialized Professionals in Rehabilitation after Stroke

Rehabilitation after a stroke mainly involves a number of physicians,

rehabilitation nurses, physical, occupational, recreational, speech and language,

vocational and mental health professionals (Challis, Darton, Johnson, Stone & Traske,

1991).

2.7.1. Doctors

Physicians have the primary responsibility for managing and coordinating long-

term care of stroke survivors, including recommending rehabilitation programs that best

suit the needs of each patient. Doctors also are responsible for general care of the

health of a stroke survivor and advise how to prevent a second apoplectic attack, for

example, controlling high blood pressure or diabetes and eliminating risk factors such

as smoking, excessive weight a diet high in cholesterol, and high consumption of

alcohol (Donald, 1995).


Physiotherapists you work the motor functions, in order to gain mobility or reduce your

pain and spasticity. We seek to develop your strength, regain mobility and endurance.

During rehabilitation exercises, you ability to walk; move your arms back a little spastic

limb control, etc. During the rehabilitation period, your brain works and how to master

rediscovered functions missing. Physical therapy is difficult and exhausting. On

average, patients undergoing therapy hour per day the chances of recovery are much

larger than rehabilitation is intensive. Nurses and caregivers will also explain how you

practice these exercises alone, so you can continue your therapy when you get home.

2.7.2. Rehabilitation Nurses

Nurses specializing in rehabilitation help survivors relearn how to perform basic

activities of daily living. They also educate survivors about the regular health care, for

example, how to follow a medication schedule, how to care for your skin, how to move

from bed to a wheelchair, and how to address the special needs of people with

diabetes. Rehabilitation nurses also work with survivors to reduce risk factors that can

cause a second stroke, and provide training for caregivers.

Pharmacist. Provides prescribed medications and can answer questions about

them.

The physiotherapist. If you have difficulty to move, you use an arm or leg, keep

your balance or coordinating your movements, your case is conifer a

physiotherapist. It will teach you techniques and special exercises to improve

muscle control, balance, movement and walking.


The occupational therapist. An occupational therapist can help you learn to do

only the activities of daily life and learn new techniques that will be useful in

everyday life. This specialist can help you achieve your personal goals and to

make maximum use your mental and physical abilities.

The speech therapist. If you are experiencing difficulties with speech, language

comprehension, reading and writing, speech works with you. It will help you

speak or learn other ways to communicate. The therapist can also help you if you

have difficulty in swallowing.

Psychologist. If you have any problems with concentration or memory, or

emotional disorder, a psychologist can help.

The social worker. A social worker can help you and your family copes with

feelings of anger, sadness, depression, confusion and anxiety are common after

a stroke. These stakeholders also provide support in respect to community

services, finance of family, work and planning caption discharge from the

hospital.

The recreational therapist. A recreational therapist can help planning first new

hobby and discover new interests, or to learn new ways to indulge in your

favorite activities.

The dietitian. The dietitian can help you and the caregiver in planning healthy

meals first to let you control your weight and cholesterol, as well as to meet other

needs food or any problem when you swallow or eat.


Other important factors are your rehabilitation your caregiver, your family and

friends. They can provide significant emotional support. Your caregiver and your family

can also help you continue your rehabilitation at home.

Even when you have completed your rehabilitation program, one or more members of

your health care team can continue to monitor your progress for a while. Some health

professionals do home visits, while others make you come to their office. Rehabilitation

services may also be available in hospitals, nursing homes, health centers and social

services and support groups in your area. Ask your rehabilitation team if these services

are available in your area.

2.8. Rehabilitation of Stroke Patients at Home

Rehabilitation at home allows greater flexibility so that patients can design their

own program of rehabilitation and follow a single path. Survivors of a stroke can

participate at a level of intensive therapy several hours a week or follow a less

demanding. These arrangements are often the most convenient for people who do not

have transportation or requiring treatment of a single type of rehabilitation therapist.

Patients dependent on Medicare program for rehabilitation must meet Medicare's

requirements to be "homebound" or "homebound" to qualify for these services, but for

now, the lack of transportation is not a valid reason for therapy at home. The major

disadvantage of rehabilitation programs at home is the lack of specialized equipment

(Challis, Darton, Johnson, Stone & Traske, 1991). However, performing the treatment at

home gives people the advantage of practicing skills and developing compensation

strategies within their own environment.


Most patients need stroke rehabilitation to help them recover after leaving the

hospital. The stroke rehabilitation will help you regain the ability to take care of him.

When we talk about output is first returning home is imagined by the patient and by

caregivers. This is the goal for all. The output of the rehabilitation centre at home can

mean many things. It can, firstly, represent a conclusion for example healthcare team

centre. "This is the end of the physical cycle of care and stop supported. This phase is

much stronger than most of the time teams upstream and downstream of the outlet do

not know "and released once the patient and family will not return unless another stay

rehabilitation. It can be regarded as a sanction for the patient's status changes: in the

centre of rehabilitation he was sick, when it comes out it becomes "disabled." As if

nothing could hope the best for him and that somehow "it is not worth it remains long,

"he has reached the maximum recovery capabilities. There is often a gap between the

patient's ability in a protected environment and what it is capable home. The transition

between these two environments is often too brutal for the patient to his entourage

It is also a goal motivating rehabilitation: 'he works to return. “This transition can be

experienced by the patient as reassuring as it will go inside his home in a familiar

environment, familiar with his family where he has his habits. It will "get his life before

his cocoon ... family.” This is often a place to live for many years; this is its identity and

history. This output can finally be feared or sign of anxiety for the patient's family. Most

do not yet know what to expect or what they will face. Often families not imagine

disabilities of hemiplegic patients, using daily or they are going to need. Even to the

patient himself. It can be aware of their disability and understand to return without being

able to do as before the stroke. It should be this output should be a transition, a turning


point. We should anticipate, prepare and continue home rehabilitation. This is a follow-

up care, which tends to be developed by AVC streams. The Rehabilitation is a process

that begins with the stabilization of the patient's condition after stroke until years later.

Whatever it is, the output to the home will only be possible under certain conditions

Rehabilitation after stroke (CVA) is effective. It aims to stimulate brain plasticity

processes, prevention of secondary complications and the best range returned to the

patient. It involves a team dedicated to the best structure in physical medicine and

rehabilitation. From the first days after stroke, it is to prevent the occurrence of

complications, including shoulder pain and musculotendinous retractions. Active

rehabilitation begins gradually according to the patient's condition and relies on a few

key principles: strong interaction sensitivity-motor-motor and cognition and the

importance of taking into account the individual from himself and from its environment;

exercises focused on the task to improve the selection of tasks with a purpose

meaningful to the patient, the repetition of the exercise to learning, the increasing

intensity of stimulation. And, as appropriate, rehabilitation improves grip, balance,

walking, or communication disorders visuospatial. The first months after stroke are

essential, but rehabilitation may be necessary beyond one year after the stroke and

recovery late it can be very useful.

After a stroke, you may need to learn new ways to think, talk and move you.

Rehabilitation after a stroke is a learning process in which a rehabilitation team works

closely with you and the people you care. Together, you set goals, make a plan and

participate in treatment that will give you the strength and confidence to live as

independently as possible.


Rehabilitation begins when your doctor thinks that your condition is stable and you will

reap the maximum. Rehabilitation services are offered in different institutions and

contexts. Where you go will depend on what is available in your area and the type of

rehabilitation program that best suits your recovery needs. Rehabilitation services

offered in different locations can include:

Treatment programs inpatient in a hospital providing acute care, rehabilitation

centre or a centre for long-term care;

Outpatient programs in different types of institutions;

Home care with the help of agencies that provide this type of care

It should normally be directed by a physician to have access to rehabilitation services. If

you have not been directed to these services and you feel you need it, do not hesitate to

talk to your doctor.


Chapter III: Methodology

3.1. Introduction

Chapter 3 includes an examination of the theoretical framework of the research

and the appropriateness for addressing the point of this study. Chapter 3 also includes

information regarding research design; qualitative tradition used; the role of the

researcher; questions and sub-questions; the context for the study; ethical protection of

participants; criteria for selecting participants; the justification of the data collected; how

and when the will be analyzed; and changes that were made from a prior exploratory

study to enhance this research study.

To ensure validity and reliability, this qualitative research utilized various

methods. A reflection of the various tools to be employed to ensure reliability of

research is included in this section. The research design was derived logically from the

problem statement by focusing on where and when a learning disability in reading could

develop.

Methodology is the philosophical source on which the study that was performed

and assessed which can guides to obtain the research aim. The common theories of

research approaches, research approach; data collection approaches and research

tools. This part will end with research limitation and the time structure of the research. A

methodology is one that continues to make the shares of an investigation. In simple

terms it is the guide indicating what we will do and how to act when you want to get

some kind of research. You can define a methodology and approach that allows


observing a problem in a total, systematic, disciplined and with some discipline

(Panneerselvam, 2004).

3.2. Research Design

It is the structure to be followed in an investigation to exercise control of it to find reliable

results and its relation to the questions arising from the hypothesis. The problem

statement defined the initial scope of the investigation and made assumptions (or not

set due to wing nature of the study), the investigator must display the practical and

concrete way to answer the research questions, as well meet their objectives. This

involves selecting or developing one or more research designs and applies them to the

particular context of their study. The term design refers to the plan or strategy designed

to get the information you want. In the quantitative approach, the researcher uses his or

her designs to analyze the accuracy of the assumptions made in a particular context or

to provide evidence about the lines of research (if you do not have hypotheses) (Laurel,

2003).

The researcher searched the trials register of the Cochrane Stroke (Cochrane Stroke

Group's Trials Register), the latest of which was conducted by the Review Group

Coordinator in August 2004. Furthermore, additional information was obtained from the

trials. The researcher included all randomized, unconfined, who had compared the

procedures and high conventional care with alternative services, whose aim was to

accelerate the discharge of patients. Therefore, randomisation will have occurred

relatively early after hospital admission and before discharge.


3.3. Aim of Research

The aim of this research is to compare the stroke patients that have been discharged

from hospital to those who are rehabilitated in the hospitals.

3.4. Qualitative Research

The qualitative research prevents quantification. Qualitative researchers are narrative

records of the phenomena being studied by techniques such as participant observation

and unstructured interviews (Thomas, 2003).

3.5. Quantitative Research

The quantitative research is one in which data are collected and analyzed

quantitative variables. The fundamentals of quantitative methodology can be found in

positivism that arises in the first third of the nineteenth century as a reaction to the

empiricism that was dedicated to collect data without introducing knowledge beyond the

field of observation (Thomas, 2003).

3.6. Reliability and Validity

To ensure reliability, I ensured that the data were collected from three quality

sources and that all data and conclusions were reported accurately and with integrity to

the meaning acquired from the individuals to the best of my ability. Validity was

established by using collection methods that were appropriate for this study to ensure

that the data sources and collection methods answered the main questions being asked

by this research study. The inquiry reflected the theory and research questions, and the

conclusions being drawn from the research were conducted based on triangulation.


Validity was also accomplished by bracketing all personal experiences related to the

phenomena so that emphasis was placed on the information provided by the

participants of the study.

3.4. Ethical Consideration

When conducting a medical research it is important for the researchers to ensure that

the subjects being involved in the research are protected from any unethical

involvement. The data that is being provided by the hospital and reports should be kept

confidential and should not be used for any other purpose other than mentioned. It is my

duty as a researcher to respect the confidentiality of the patients and work ethically.

Also even after the conduction of the result the data will be kept securely and

confidentially and will not be used by the researcher further.


Chapter IV: Result

Despite physical therapy, however, remains a degree of disability which limits the

autonomy of the patient and makes it very difficult to re- house. With the new type of

organization problems they are much reduced, because the patient is resigned after a

rehabilitation cycle complete. In view of the discharge can create however, a certain

degree of conflict with the patient that would prolong the hospital stay and relatives who

are afraid of not being able to cope with the problems of his return home. Now it is not

possible to tackle best these problems. The method we have adopted to solve this- ste

conflict situations is to take note of the problems of the whole family (Patient and family)

and look together for solutions possible, thus transforming the conflict into a common

problem to solve. This task of course it is not only the responsibility of the physician, but

is faced with a coordinated effort by the whole team physician.

Usually it is considered that the purpose of a hospitalization re-consists in formulating a

diagnosis and set appropriate treatment. This goal can go well for much acute

pathology, for example for a bronchopneumonia, so that the dismissal did not present

the particular problems. In the case of a patient with- task from a stroke, however, we

agreed that Our intervention is intended to enable him to return home and to be able to

undertake, with possible, its usual activities. In practice we deem mo that a shelter ends

in the best way when the patient is able to recover the maximum mo can function

compromised, he learned to compensate adequately the possible disability remaining

and was able to accept the damage is not editable. Based on this approach, the


preparation of the return-to-home becomes the common goal that allows us to

overcome the initial conflict.

No doctor would be able alone to bear the problems related to reintegration.

Traditionally the search for solutions to these problems was entrusted given to the

social worker, but experience has shown layer that a delegation mechanism is not

sufficient for you. When the social worker operates without a connection closely with

other operators, its activity tends to be reduced to a paperwork that, even if necessary,

is too small to solve the many difficulties. We have gained the conviction it that the

problem must be addressed in a coordinated by the whole team physician, each

according to their skills, starting from the con- division of a common goal. To achieve

this project we gather systematically a discussion of the cases. When the clinical

condition of the patient are stabilized and the rehabilitation program is being advanced,

the treating team is able to predict with sufficient approximation the maximum level

recovery reached and the day on which program discharge. These conditions are

realising in variable times depending on the severity stroke, usually within sixty days

provided for estimate by the region for the post-hospital rehabilitation coetaneous of

these patients. The meeting takes place every week on Wednesdays, from 11.30 to

12.30, and involves the team physician for the team as described above. Every fourth

now is called a nuclear family. Considered random who are discharged every week 7:00

to 10:00 patients are convened only the families of the cases "Difficult" while you

prepare the other patients return home with the same care, but without use collegial

meeting. The presence of the patient encounter is of importing necessary and often his

condition allows them to participate only limited to working together. With its


participation we want to mo emphasize the active role in decisions that concern and the

search for solutions. During the meeting, we explain how understanding the clinical

situation and the results achieved. Often parents express their anxieties and practical

difficulties of reorganization family. The internist, the physical therapist and social

worker, each according to their competence, provide the information requests, propose

solutions to the problems that arise and, when appropriate, initiate the necessary

paperwork to obtain aid specific. Group work that is being done is based the maximum

concreteness, every problem is addressed in operational terms and solutions looking for

in the realm of the possible, with the con- awareness that the residual disability often

associated cite with a very advanced age and the presence of multiple diseases, in any

case entails a load relevant care for family members

Analyzes Plan - The interpretation and analysis time results are shown in Tables (Table

01, Table 02, and Table 03 in Appendices).

4.1. Outcomes of patients

4.1.1 Mortality

Data were available for this outcome in the 11 trials. It was assumed that patients with

missing data were alive. Overall, there was no significant difference in mortality between

the services team and conventional ATA. To reduce mortality and functional squeal of

stroke, there is ample evidence that the measure is essential emergency hospitalization

in specialized stroke units, which can better meet the demands required by diagnostic

and therapeutic stroke:


- Diagnosis of stroke itself, its type (cerebral haemorrhage, subarachnoid haemorrhage,

stroke, venous thrombosis etc ...) and its cause (atherosclerosis, cardiac embolism, a

disease of small cerebral arteries dissection etc ...), which requires access to

emergency MRI, arterial and cardiac explorations.

- Therapeutic requirements: general measures and prevention of complications, use of

antithrombotic aspirin for the vast majority of alteplase (tissue plasminogen activator in

recombinant form or rt-PA) for ischemic stroke within three hours of respecting cons-

indications (currently less than 5% of cerebral infarctions) any recourse to the surgery or

neuro-interventional radiology).

4.1.2 Death or requiring institutional care

Data were available for this outcome in nine trials. It was assumed that patients with

missing data were alive and at home. Overall, there was a significant reduction in the

odds of passed away patients requiring institutional care or long-term.

4.1.3 Death or dependency

Data were available for this outcome in 11 trials. It was assumed that patients with

missing data were alive and were independent. - Increase the number of stroke units

with access to MRI and cardiac exams so that they can all hospital emergency stroke

(currently in France, neurovascular units can accommodate only 10% of stroke) .

- Officially recognized among stroke units, intensive care units (ICU) neurovascular

addressing the seriously ill, unstable, which may require the use of neuro-interventional

radiology or neurosurgery. Recognize their status similar to cardiac ICU.


- Make every effort within institutions to accelerate the circuit further examinations

required before thrombolytic.

- Start as soon as possible neurological rehabilitation.

- Develop a curriculum in vascular neurology.

4.1.4 Activities of daily living (ADLs)

Despite the methodological difficulties of studies on the effectiveness of rehabilitation

after stroke, the benefit is demonstrated, including hemiplegic and aphasia, and this

benefit is even more important that rehabilitation is early and intense time.

Rehabilitation (excluding acute phase) is for about 80% of survivors after stroke. It can

be done at home in case of disability and mild disability or specialized centre where

more severe squeal, which corresponds to approximately 20-25% of stroke

4.1.5. Subjective state of health

These data were available in 10 trials. Overall, there was no significant difference in

scores of subjective health status between the two groups. We found no significant

degree of heterogeneity.

4.1.6. Patient satisfaction

These data were available in five trials. Also, it was concluded that the patients will

- Continue as necessary for neurological rehabilitation intense and prolonged

- Increase the number of beds for neurological rehabilitation supports the aftermath of

stroke


- Development of alternatives to hospitalization (home hospitalization rehabilitation, day

hospital etc ....)

- Continuation of secondary prevention.

4.2. Outcomes of caregivers

Subjective health status 2.1 - These data were available (in a variety of formats) in six

trials (613 caregivers). Overall, there was no significant difference in the scores or

heterogeneity.

4.2.1. Mood

These data were available in only two trials, with 58 caregivers. Overall, there was no

significant reduction in mood score of carers receiving services ATA, but there was

significant heterogeneity between trials.

4.2.2 Satisfaction of caregivers

These data were available (in a variety of formats) in four trials (279 caregivers).

Overall, no significant difference in the odds of those caregivers who received services

ATA expressed satisfaction with services (OR 1.56, 95% CI 0.87 to 2.81).

4.3. Discharge

Everything we do during hospitalization need to get well prepared for this moment. After

a variable period of four to eight-week it, the patient and his family are having to re-

examined the daily life in different conditions- if the previous. The patient usually goes

from the hospital after getting a recovery- persistent, but its level of autonomy is almost

always less than the previous one. Often need help or supervision for at least

performance of activities of daily living. The whole family must be reorganized: the


patient, relatives and partners also that of the relatives not living that did not it occupied.

When we deliver the letter discharge, we take this opportunity to summarize- re the

history of the disease. We make sure that the patient can be appropriate, is capable of

talk to his friends and knows how to manage the life as a person with disability as

better. Explain clearly how to take therapies and we advise you of new reference chin to

the primary care physician for the management of pro- clinical problems. Of course the

actual situations are different for each patient, and there are situations more or less

problems. They range from the case of the patient who out completely self-sufficient, to

what only needs to check with the doctor physician, to what must continue treatment

with the help of local services. In fact the patient is discharged when it reaches the

maximum recovery possible for him or when it is not longer necessary to continue the

treatment, bearing in mind that a further improvement can take place in the phase

domiciliary both in spontaneously or continuing physiotherapy (Outpatient, day hospital

or at home). In selected cases we offer to patients and their family to participate in an

outpatient group to return to work everyday

4.4. Connection with Past

On 7 December 2004, the National Academy of Medicine recommended to consider

cerebrovascular accident (CVA) as a vital emergency and increase the number of

stroke units. Four years later, under the responsibility of neurologists, 80 units of the

140 needed to effectively treat 130 to 150 000 strokes annual open. Noting the major

breakthrough for public health posed Units Neuro-Vascular and aware that these

creations have meaning complemented by the development and structuring of post

hospital sectors, the National Academy of Medicine recommends:


In accordance with Decree No. 2008-377 of 17 April 2008 on the implementation

conditions applicable to the activity follow-up care and rehabilitation, the development of

health care delivery in acute care and rehabilitation (SSR) specialized to accommodate

early, 40% of stroke patients requiring neurological rehabilitation. These structures must

have a personal and a technical platform for an intensive rehabilitation for patients who

need rehabilitation and suitable for all.

The development of the supply of shelters and reception centres in medico-social

structures. Such structures must have the means to support patients 'neurological'

disabled regardless of age (day care, home specialized care, foster care medical zed

residences for elderly dependents or nursing homes). In accordance with the circular of

2003, the development of health care delivery units in Long Term Care (LTC) for

patients with neurological disabilities, identifying beds for youth.

Reduction, from the stage of initial hospitalization, delays in administrative procedures,

either for orientation or medico-social aid awards. When returning home, the possibility

of early rehabilitation, if necessary, in partnership with the back support structures and

maintaining the home. Implementation, to promote coordination of care throughout the

journey of mobile multidisciplinary rehabilitation and / or networks around the

neurological disability acquired adult. These medical teams should include neurologists,

occupational therapists, psychologists, social workers and doctors trained in disability

and work closely with the physician. (Scheinberg, Koren, Bluestone & McDowell,

1986).


4.5. Interpretation of results

The authors acknowledge that the interpretation of the characteristics of services and

patients creates the potential for post-hoc explanation of the results. However, as far as

possible be attempted to plan a priori analysis. While recognizing that the amount of

data available was limited, it seems possible to establish some general conclusions.

a. Most of the evidence of the benefit of ATA services comes from trials with ATA

multidisciplinary team whose work is coordinated through regular meetings.

b. The ATA multidisciplinary team comprised staff characteristic physical, occupational

and speech therapy and speech therapy, with the support of doctors, nurses and social

workers.

c. These services appear to be effective even when compared to a service-based

standard of care in a stroke unit.

d. Although no evidence could be found that the level of service (hospital or community)

influenced the results, all teams ATA reported here had a specialist interest in stroke or

rehabilitation.

e. All trials enrolled a selected subgroup (40% average) of stroke patients living in an

urban environment generally.

f. Most of the evidence for benefit of ATA seems to correspond to patients with

moderate disability (initial Barthel index> 9/20), although the cost - benefit is not clear

for this subgroup. For patients with more severe disabilities, substantial savings in bed

days may well be outweighed by the risk of poorer outcomes.


In conclusion, ATA teams adequately resourced and well coordinated can offer an

additional option of effective service for a selected group of stroke patients and should

be considered, along with attention to organized inpatient (stroke unit) as part a

comprehensive service for the disease (Stroke Unit Trialists' Collaboration, 2001).


Chapter Five: Conclusion

The selected stroke patients who received inpatient care of ATA service returned

home sooner than those who received conventional care. They also were more likely to

be independent and live at home six months after stroke, and to express satisfaction

with the services received. There was no observable adverse effect on the health or

subjective mood of patients or caregivers. Observable benefits ATA services largely

derived from trials where the services were provided by teams coordinated ATA and

enrolled patients with less severe disabilities.

About a week after a stroke, the condition of patient begins to change and initial

deficit may tend to alone improved. After the deficit improved, weakening and speech

difficulties are some of the remaining problems and can incapacitate in large scale

patient. Rehabilitation can help improve some of the damage caused by stroke (Harvey,

Macko, Stein, Zorowitz, & Winstein, 2008).

If it is true that the achievement of higher level of autonomy possible for the patient is

the purpose of each rehabilitative treatment, from the point of view both individual and

social a measure of the effectiveness of treatment is also made from the success of the

re- inclusion of the patient at home. Safe mind what depends on numerous factors

including non- strictly medical. Considering the new address that was given to

department with its transformation from a division of medicine inpatient post-acute

rehabilitation, we realized that it was necessary to make the change- that compared to

the traditional working style. We have identified and implemented some of them: - The

choice of rehabilitation at home as target primary. The orientation of all activities


towards achievement of this objective, team work, the involvement of relatives, the

choice of appropriate organizational tools (the Physical medicine and social-medical

team, the meeting with patient and family, the group for re- insertion at home), choice

and prescription of assistive devices may necessary, the connection to local services In

our experience, these changes are proved useful to assist the reintegration of home

patients have improved their level of satisfaction relatives and have been a source of

gratification to all those who are engaged in the process of changes.

The conclusions of this review are based on a relatively small number of trials. More

research is needed to define the most important characteristics of effective services and

the balance cost ATA - benefits for different groups of patients and services. Further

research is needed to determine whether more generic ATA devices (for example,

services for a diverse population of elderly) get the same results as specific services for

stroke described here. Not been adequately evaluated the role of ATA services in rural

communities.


References

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Cambridge: Cambridge University Press.

Burkman, K. (2010). The Stroke Recovery Book: A Guide for Patients and Families.

Omaha: Addicus Books.

Carey, L. M. (2012). Stroke Rehabilitation: Insights from Neuroscience and Imaging.

Oxford: Oxford University Press.

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Health Visitor intervention to reduce unplanned hospital readmission of days in

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Darby: DIANE Publishing.

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and Rehabilitation. New York: Demos Medical Publishing.

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Medical Publishing.

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Scotland. Cerebrovascular Diseases, Vol. 2, pp. 47-50

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Strategies for stroke care: a prospective randomized controlled trial.

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Appendices

Appendix I

Table 1: Primary Analyses: Plan and Timings

Trial Death Institutional Care

Dependency Defined dependent

Length of Stay

Patient 1 6 weeks 6 weeks 6 weeks Barthel index <95/100

Initial hospital discharge


Not used - only available for acute hospital





Patient 5 12 weeks

12 weeks 12 weeks Barthel index <19/20


Patient 6 12 weeks

12 weeks 12 weeks Barthel index <19/20

Initial hospital stay (acute and rehabilitation wards)


Initial hospital stay

Patient 8 3 weeks 3 weeks 3 weeks Rankin score 3-5


Patient 9 6 weeks 6 weeks 6 weeks Rankin score 3-5


Patient 10

6 weeks 6 weeks 6 weeks Barthel index <95/100


Patient 11

6 weeks 6 weeks 6 weeks Barthel index <95/100



Appendix II

Table 2: Plan of Secondary Analyses: Patient outcomes (P stands for Patients)

Trial Timing of

outcome

ADL score

Extended ADL

score

Subjective health

Mood Service satisfaction

Hospital Readmis

-sion

P 1 6 weeks

Barthel index (median, IQR)

Adelaide Activities Profile

SF-36 (General health perceptions)

SF-36 (mental health)

Satisfied with Rehabilitation Programme

6 weeks

P 2 7 weeks

Barthel index (median, SD imputed)

- SF-36 (general health perceptions)


- -

P 3 - - - - - - -P 4 6

weeksBarthel index

Nottingham extended ADL

SF-36 (general health perceptions)


Satisfied with outpatient rehabilitation

6 weeks

P 5 12 weeks

Barthel index

Rivermead ADL score

Nottingham Health Profile (score reversed)

Number abnormal on Hospital Anxiety and Depression Scale

Satisfied with care in general

12 weeks

P 6 12 weeks

Barthel index

Nottingham Extended ADL score

Euroquol scale (0-100)

Hospital Anxiety and Depression Scale (depression

- -


subscore, reversed score)

P 7 3 weeks

Barthel index

Instrumental ADL (OARS) scale

SF-36 (general health perceptions)


- -

P 8 3 month

- Nottingham Extended ADL score (median, IQR)

Dartmouth COOP chart overall health section (median, IQR; reversed scale)

Dartmouth COOP chart feelings section (median, IQR; reversed scale)

- 3 weeks

P 9 6 weeks

- Nottingham Extended ADL score (median, IQR)

General Health Questionnaire (reversed score)

MADRS score

Satisfied with care in general

-

P 10 8 weeks

- Frenchay Activities Index (median, IQR)

Sickness Impact Profile score (median, IQR)

- Satisfied with care received

6 weeks

P 11 12 weeks

- Social Frenchay Activity Index

Nottingham Health Profile (average of sum 1 & 2)

MADRS

- -


Appendix III

Table 3: Plan of Secondary Analyses: Carer outcomes

Trial Timing of Outcome

Subjective Health

Mood Service Satisfaction

P 1 6 weeks SF-36 General Health Perceptions

SF-36 Mental Health

Satisfied with Rehabilitation Programme

P 2 - - - -P 3 - - - -P 4 6 weeks Caregiver strain

index (score reversed)

- Satisfied with outpatient services

P 5 12 weeks Caregiver strain index (score reversed)

- Satisfied with outpatient services

P 6 12 weeks Caregiver strain index (score reversed)

Hospital Anxiety and Depression Scale (depression subscore, reversed score)

-

P 7 - - - -P 8 3 weeks General Health

Questionnaire (median, range, score reversed)

- -

P 9 6 weeks General Health Questionnaire (score reversed)

- Satisfied with care in general

P 10 - - - -P11 12 weeks Caregiver

Burden Score- -

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