Posts Tagged rehabilitation program
[ARTICLE] Changes in actual arm-hand use in stroke patients during and after clinical rehabilitation involving a well-defined arm-hand rehabilitation program: A prospective cohort study – Full Text
Improvement of arm-hand function and arm-hand skill performance in stroke patients is reported by many authors. However, therapy content often is poorly described, data on actual arm-hand use are scarce, and, as follow-up time often is very short, little information on patients’ mid- and long-term progression is available. Also, outcome data mainly stem from either a general patient group, unstratified for the severity of arm-hand impairment, or a very specific patient group.
To investigate to what extent the rate of improvement or deterioration of actual arm-hand use differs between stroke patients with either a severely, moderately or mildly affected arm-hand, during and after rehabilitation involving a well-defined rehabilitation program.
Design: single–armed prospective cohort study. Outcome measure: affected arm-hand use during daily tasks (accelerometry), expressed as ‘Intensity-of arm-hand-use’ and ‘Duration-of-arm-hand-use’ during waking hours. Measurement dates: at admission, clinical discharge and 3, 6, 9, and 12 months post-discharge. Statistics: Two-way repeated measures ANOVAs.
Seventy-six patients (63 males); mean age: 57.6 years (sd:10.6); post-stroke time: 29.8 days (sd:20.1) participated. Between baseline and 1-year follow-up, Intensity-of-arm-hand-use on the affected side increased by 51%, 114% and 14% (p < .000) in the mildly, moderately and severely affected patients, respectively. Similarly, Duration-of-arm-hand-use increased by 26%, 220% and 161% (p < .000). Regarding bimanual arm-hand use: Intensity-of-arm-hand-use increased by 44%, 74% and 30% (p < .000), whereas Duration-of-arm-hand-use increased by 10%, 22% and 16% (p < .000).
Stroke survivors with a severely, moderately or mildly affected arm-hand showed different, though (clinically) important, improvements in actual arm-hand use during the rehabilitation phase. Intensity-of-arm-hand-use and Duration-of-arm-hand-use significantly improved in both unimanual and bimanual tasks/skills. These improvements were maintained until at least 1 year post-discharge.
After stroke, the majority of stroke survivors experiences significant arm-hand impairments [1, 2] and a decreased use of the paretic arm and hand in daily life . The actual use of the affected hand in daily life performance depends on the severity of the arm-hand impairment [4–6] and is associated with perceived limitations in participation [7, 8]. Severity of arm-hand impairment is also associated with a decrease of health-related quality of life , restricted social participation , and subjective well-being [11, 12].
Numerous interventions and arm-hand rehabilitation programs have been developed in order to resolve arm-hand impairments in stroke patients [6, 13]. In the Netherlands, a number of stroke units in rehabilitation centres implemented a well-described ‘therapy-as-usual’ arm-hand rehabilitation program, called CARAS (acronym for: Concise Arm and hand Rehabilitation Approach in Stroke), serving a broad spectrum of stroke patients across the full stroke severity range of arm-hand impairments. The arm-hand rehabilitation program has been developed to guide clinicians in systematically designing arm-hand rehabilitation, tailored towards the individual patient’s characteristics while keeping control over the overall heterogeneity of this population typically seen in stroke rehabilitation centres. A vast majority of stroke patients who participated in CARAS improved on arm-hand function (AHF), on arm-hand skilled performance (AHSP) capacity and on (self-) perceived performance, both during and after clinical rehabilitation . The term ‘arm-hand function’ (AHF) refers to the International Classification of Functioning (ICF)  ‘body function and structures level’. The term ‘arm-hand skilled performance’ (AHSP) refers to the ICF ‘activity level’, covering capacity as well as both perceived performance and actual arm-hand use .
Improved AHF and/or AHSP capacity do not automatically lead to an increase in actual arm-hand use and do not guarantee an increase of performing functional activities in daily life [18–20]. Improvements at function level, i.e. regaining selectivity, (grip) strength and/or grip performance, do not automatically lead to improvements experienced in real life task performance of persons in the post-stroke phase who live at home [18, 21]. Next to outcome measures regarding AHF, AHSP capacity and (self-) perceived AHSP, which are typically measured in controlled conditions, objective assessment of functional activity and actual arm-hand use outside the testing situation is warranted [22, 23].
Accelerometry can be used to reliably and objectively assess actual arm-hand use during daily task performance [24–32]and has been used in several studies to detect arm-hand movements and evaluate arm-hand use in the post-stroke phase [20, 33–35]. Previous studies have demonstrated that, in stroke patients, movement counts, as measured with accelerometers, are associated with the use of the affected arm-hand (Motor Activity Log score) [36, 37] and, at function level, with the Fugl-Meyer Assessment . Next to quantifying paretic arm-hand use, accelerometers have also been used to provide feedback to further enhance the use of the affected hand in home-based situations . Most studies consist of relatively small [27, 30, 40–44] and highly selected study populations  with short time intervals between baseline and follow-up measurements. As to our knowledge, only a few studies monitored arm-hand use in stroke patients for a longer period, i.e. between time of discharge to a home situation or till 6 to 12 months after stroke [19, 44, 46]. However, they used a relatively small study sample and their intervention aimed at arm-hand rehabilitation was undefined. Both studies of Connell et al. and Uswatte et al. describe a well-defined arm hand intervention where accelerometry data were used as an outcome measure [27, 47]. However, the study population described by Connell et al. consisted of a relative small and a relative mildly impaired group of chronic stroke survivors. The study population described by Uswatte et al. consisted of a large group of sub-acute stroke patients within strict inclusion criteria ranges , who, due to significant spontaneous neurologic recovery within this sub-acute phase, had a mildly impaired arm and hand [48, 49]. This means that the group lacked persons with a moderately to severely affected arm-hand, who are commonly treated in the daily rehabilitation setting.
The course of AHF and AHSP of a broad range of sub-acute stroke patients during and after rehabilitation involving a well-defined arm-hand rehabilitation program (i.e. CARAS)  has been reported by Franck et al. . The present paper provides data concerning actual arm-hand use in the same study population, and focuses on two objectives. The first aim is to investigate changes in actual arm-hand use across time, i.e. during and after clinical rehabilitation, within a stroke patient group typically seen in daily medical rehabilitation practice, i.e. covering a broad spectrum of arm-hand problem severity levels, who followed a well-described arm-hand treatment regime. The second aim is to investigate to what extent improvement (or deterioration) regarding the use of the affected arm-hand in daily life situations differs between patient categories, i.e. patients with either a severely, moderately or mildly impaired arm-hand, during and after their rehabilitation, involving a well-defined arm-hand rehabilitation program.[…]
Background and Purpose: Aerobic training (AT) is recommended for people after stroke, yet uptake and operationalization of AT in clinical practice in Canada have not been measured. We surveyed inclusion of structured AT and barriers to implementation in public inpatient/outpatient stroke rehabilitation programs across Canada.
Methods: A Web-based questionnaire was sent to 89 stroke rehabilitation program leads.
Results: Forty-six programs from 7 of 9 eligible Canadian provinces/territories completed the questionnaire. Seventy-eight percent of programs reported including AT, with most (75%) excluding participants with severe physical impairments, and 28% excluding those with coexisting cardiac conditions. A greater proportion of dedicated stroke rehabilitation programs prescribed AT, compared to nondedicated stroke units (68.8% vs 31.3%, P = 0.02). The top 2 challenges for programs that included and did not include AT were “insufficient time within therapy sessions” and “length of stay in rehabilitation.” Programs that did not include AT ranked “not a goal of most patients” and “not an organizational/program priority” as third and fourth, whereas they were ranked eighth and thirteenth by programs with AT. Best practice recommendations were inconsistently followed for conducting preparticipation exercise testing (36.1%) and for monitoring patients from higher-risk populations, specifically people with diabetes at risk for hypoglycemia (78.8%) and hypertension (36.6%). Of programs conducting preparticipation exercise testing, 91% did not monitor electrocardiography.
Discussion and Conclusions: Most stroke rehabilitation programs across Canada include AT. People with severe physical impairment and those with cardiac, metabolic, and hemodynamic comorbidities may be excluded or not appropriately monitored during exercise. More detailed guidelines and training practices are needed to address these challenges.
Video Abstract available for more insights from the authors (see Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A233).