NEUROREHABILITATION OF STROKE AND BRAIN INJURY PATIENTS: NEW TRENDS

CONFERENCES
TOPIC: REHABILITATION

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Abstract

The stroke is a condition with unique epidemiological profiles consisting of high incidence and mortality rates, with a large proportion of survivors experiencing a significant amount of residual disability. The results show that multidisciplinary inpatient neurorehabilitation leads to functional improvement in the majority of neurological impaired patients
Rehabilitation of the brain injured patients is typically divided in two phases: acute and posacute rehabilitation brain injury rehabilitation covers not only patients with traumatic injuries but also those with acquired brain injuries due anoxia, cancer, certain types of strokes, and nontraumatic causes. Although research advances have to led to many changes in the treatment of medical complications particularly post-traumatic seizures, many more questions in brain injury rehabilitation remain to be investigated. Studies have shown that early rehabilitation decrease complications, overall cost and length of stay
Neurorehabilitation is not a separate clinical topics. Instead neurorehabilitation is integral to all management and requires the integration of many disciplines varying from physicians or surgeons through psychiatrists, therapist of all professions including nurses and extending to many non-health organization such as employment and housing. If rehabilitation is to be shown to be effective it must be focused and expert by carrying out a multidisciplinary assessment to identify areas of potential improvement.
 

Introduction

Neurorehabilitation is a subespecialty that treats patients with chronic disabling disorders of the nervous system. According to the international Classification of Impairments, Disabilities and Handicaps (1), a pathological process results in an "impairments" of organ function. This leads to a restriction or lack of ability to perform an activity in a normal manner. The disturbance in performing daily tasks is considered a "disability". When disability result in a person´s loss of capability to fulfill his or her normal roll in society, the disadvantage is referred to as a "handicap". Any treatment that would improve the functioning of patients with neurological causes for disability potentially would be part of the mission of Neurorehabilitation.

The fundamental goal of rehabilitation medicine is functional recovery in patients who have become disabled. This leads to a clearly defined scope of research they should includes studies of mechanisms of neural compensation for injuries and of regeneration in the CNS. and the development of prosthetics devices to enable patients to resume normal activities.(2)

The need for rehabilitative services is increasing rapidly due to the aging of population and the ability of acute medicine to preserve life. Almost 50-65% of patients in rehabilitation hospitals and inpatients unit have neurological cause for their disabilities and according to Wood (3) more than 50 % of the patients with severe disability were those suffering from Stroke, Parkinson and Multiple Sclerosis. More than 25 % of the patients had Rheumatoid Arthritis, neoplasias, paraplegia and geriatric conditions ( included Alzheimer's Disease ). More than 15 % had arthritis, trauma ( Neurotrauma), pediatrics conditions ( cerebral palsy, mental retardation, and congenital deficits ) and less than 15 % had other types of affectations of the nervous central system.

75 % of patients on a rehabilitation inpatient unit are affectations of the CNS, and it has been estimated that the majority of patients that admitted to a service of neurology will require rehabilitative intervention with 37 % of discharges requiring rehabilitation afterward.
 

Neurologic diseases, particularly those affecting the central nervous system, are the focus of an immense amount of research. Although only a small part of that research is directly relevant to rehabilitation, many findings published during the last year have implications for practice. Strategies to affect neglect, sensory loss, paresis, and functional performance have been examined. Approaches as diverse as exercise, feedback, electrical stimulation, patient and environment adaptations, orthotics, and task practice have been advocated.(4)

Stroke
The stroke is a condition with unique epidemiological profiles consisting of high incidence and mortality rates(5 ), with a large proportion of survivors experiencing a significant amount of residual disability.

Stroke rehabilitation is a prototypical rehabilitation activity. The aims of rehabilitation are to minimize the impact of the disability resulting from stroke and optimize the quality of life for both the patient and the personal caregiver (6).Roth(7) enumerated five major functions of stroke rehabilitation these are as follows:

-Prevention, recognition and management of comorbid illness and intercurrent medical complications
-Training for maximal functional independence
-Facilitating psychosocial coping and adaptation by the patients and family.
-Promoting community reintegration, including resumption of home, family, recreational and vocational activities.
-Enhancing quality of life.

Because presentations, problems, recovery, patterns, coping styles, social situations, and response to treatment differ in individual who survive stroke, it is necessary to individualize rehabilitation management programs. Several studies have attempted to compare the relative effectiveness of some of the therapeutic methods designs to enhance function. Although it remains controversial evidence exists that direct stroke rehabilitation affords enhance functional ability over and above the extent to which natural recovery improves function.

Following the development of fixed neurological deficit due to hemorrhagic or ischemic stroke, neurorehabilitation is important in the acute, subacute, and chronic stages to develop strategies to prevent complications and return patients to their maximal functional and vocational independence.(8,9)

Rehabilitation requires the interplay of three essential factors, namely medicine, organization and humanity. The concept of entirety and permanency implies that rehabilitation must commence on the very first day of acute therapy and continue, with the aid of relatives, after discharge from hospital.(10) Depression very frequently accompanies a stroke and requires expert handling both with psychopharmaceutical drugs and psychotherapeutical methods (including nursing staff and family) to overcome this hurdle to rehabilitation. Physiotherapy is of paramount importance, with particular emphasis on active movement. Therapeutic management with medicines must continue along the lines commenced in the acute stage.

The evidence is compelling that stroke units are effective when compared to management of patients on general medical wards(11,12). However, the evidence remains equivocal that better outcome is sustained in the longer term.

Patients with recurrence contralateral to their first stroke had markedly more severe functional disability after completed rehabilitation than patients with ipsilateral recurrence, implying that the ability to compensate functionally is decreased in patients with contralateral recurrence. The results show that multidisciplinary inpatient neurorehabilitation leads to functional improvement in the majority of neurological impaired patients.(13)

Brain Injury
Rehabilitation of the brain injured patients is typically divided in two phases: acute and posacute rehabilitation brain injury rehabilitation covers not only patients with traumatic injuries but also those with acquired brain injuries due anoxia, cancer, certain types of strokes, and nontraumatic causes. Knowledge of the pattern and overall severity of each patient's brain injury is necessary for planning treatment and predicting long-term outcome.(14)

Rehabilitation should begin early in the acute care phase in order to prevent later complications. Despite wide variation in their neurological, cognitive, and behavioral deficits, severy brain injured patients tend to pass through similar stages of neurobehavioral recovery. Specific therapy and medication protocols have been developed for patients who are unconscious or agitated. Treatment of medical complications for patients in these stages needs to be modified to avoid interference with recovery and rehabilitation. Although research advances have to led to many changes in the treatment of medical complications particularly post-traumatic seizures, many more questions in brain injury rehabilitation remain to be investigated. Studies have shown that early rehabilitation decrease complications, overall cost and length of stay.(15,16,17)

Cognitive rehabilitation
Cognitive rehabilitation refers to the use of techniques based on cognitive theories which aim to reduce the problems arising particularly from cognitive impairments such as poor memory (learning), reduced attention and visual-spatial neglect. As always it is important to separate attempts to reduce the underlying impairments (e.g. To improve memory itself) from attempts to reduce the resulting disability.

It would be premature to conclude that cognitive rehabilitation for memory, attention, visuperceptual and executive functions is now of proven and established efficacy. However, the studies reviewed suggest that positive therapeutic effects may be obtainable in certain treatments, although they are yet to be fully and rigorously tested.(18)

Acquired communication problems are more prevalent than is generally appreciated, which screened all elderly patients, found 73% of the population having speech and language problems, 11% having visual defects and 36% having hearing problems and 56% having cognitive problems on admission.

The best predictor of recovery from aphasia in a study of 67 patients was found the ability to communicate 2 weeks poststroke. Much can be learned from observing patients recovering from stroke-aphasia. The course of the recovery of aphasia demonstrates that the component of language may recover in different sequences, thus compression appears to recover more readily than expression independent to type and severity of aphasia.

A review of the efficacy of speech and language therapy for aphasia patients conclude that the verdict on the efficacy of treatment must remain open.(19)

Reviews of efficacy studies related to neurorehabilitation emphasize the difficulties and limitations of the published group studies. However, there is consistent evidence that attention to aphasia seems to be more beneficial than no attention and that intensive therapy appears to be more efficacious.
 

Neurorehabilitation is not a separate clinical topics. Instead neurorehabilitation is integral to all management and requires the integration of many disciplines varying from physicians or surgeons through psychiatrists, therapist of all professions including nurses and extending to many non-health organization such as employment and housing (20,21).

If rehabilitation is to be shown to be effective it must be focused and expert by carrying out a multidisciplinary assessment to identify areas of potential improvement.

Research into and writing about neurological rehabilitation poses several particular difficulties. Specific problems faced in rehabilitation often occur in patients with many different underlying diseases. Only common problems in common diseases are investigated. Relevant research is often published in very specialized journal is inaccessible to most therapist and does not help clinical practice.(22,23). Consequently the research of relevance is widely scattered.

Benefic can be demonstrated by measuring outcome address the effect of rehabilitation process on the patient (11,24,25)

The need for improved neurological rehabilitation strategies is self-evident. Recent developments in the computer technology of virtual reality hold the promise of exciting progress in this area(26).

Finally, the neuroscience and neurorehabilitation can readily be linked and that there is and urgent nee to foster interaction between neuroscience, clinical neurology and neurorehabilitation at both investigative and practice levels.
 

1. World Health Organization: International Classification of impairments, Disabilities and handicaps. A manual of classification relating to the consequences of disease.Geneva,WHO.1980

2. Selzer ME. Neurological rehabilitation. Annals of neurology.1992, 32(5): 695-699

3. Wood PHN: The magnitude and scope of the problem. 1984 In Basmajian JV, Kirby RL(eds):Medical rehabilitation.Baltimore, Williams&Wilkins

4. Bohannon RW. Physical rehabilitation in neurologic diseases. Current Opinion in Neurology , 1993, 6:765-772

5. Gresham GE: Stroke outcome research. Stroke 1986:17:358

6. Evans RW Postacute neurorehabilitation: roles and responsibilities within a national information system. Arch Phys Med Rehabil 1997 Aug;78(8 Suppl 4):S17-S25

7. Roth EJ. Medical Rehabilitation of stroke patient. Be Stroke Smart 1992; 8:8

8. Dijkerman HC, Wood VA, Hewer RLLong-term outcome after discharge from a stroke rehabilitation unit. J R Coll Physicians Lond 1996 Nov;30(6):538-546

9. Ferrucci L et al. Recovery of functional status after stroke: A postrehabilitation follow-up sutudy. Stroke 1993.; 24:200-205

10. Barnes MP, Skeil DA Outpatients in neurological rehabilitation. Int J Rehabil Res 1996 Mar;19(1):39-45

11. Freeman JA, Playford ED, Nicholas RS, Thompson AJ A neurological rehabilitation unit: audit of activity and outcome. J R Coll Physicians Lond 1996 Jan;30(1):21-26

12. Kalra L. The influence of stroke unit rehabilitation on fucntional from stroke. Stroke 1994:25:821-825.

13. Jorgensen HS, Nakayama H, Reith J, Raaschou HO, Olsen TS Stroke recurrence: predictors, severity, and prognosis. The Copenhagen Stroke Study. Neurology 1997 Apr;48(4):891-895

14. Macciocchi. SN,Reid DB,Barth JT. Disability following head injury. Current Opinion in Neurology 1993, 6:773-777

15. Aronow HU.Rehabilitation efectiveness with severe brain injury:translating research into policy. J Head Trauma Rehabil 1987;2:24

16. Cope DN, Date ES. Serial computerized tomographic evaluations in traumatic head injury.Arch Phys Med Rehabil.1988:69:483

17. Mackay LE, Berstein BA,Chapman PE et al Early intervention in sever head injury:long term benefit of a formalized program. Arch Phys Med Rehabil 1992; 73:635

18. Robertons IH. Cognitive rehabilitation in neurlogic disease.Current Opinion in Neurology. 1993, 6;756-760.

19. Enderby. Speech and language therapy for aphasia. Current Opinion in Neurology , 1993, 6:761-764.

20. Shahami Bhagwan, Scheinberg Labe. Neurologic rehabilitation. Neurologic Clinics.1987, 5(4)519-522

21. McGrath DA. Rehabilittaion: where are we going and how do we get there?. Clin Rehabil 1992,6:225-235.

22. Wade DT. Neurologic rehabilitation. Current Opinion in Neurology 1993, 6:753-755

23. Cozens JA, Chamberlain MA. Rehabilittaion Medicine. Postgrad Med J.1995;71:665-673

24. Fox N,Aisen ML: Predictor of outcome in multiple sclerosis rehabilitation. Neurology 1994,44(suple 2):742

25. Kidd D, Howard RS, Losseff Na, Thompson AJ: The benefit of inpatient neurorehabilittaion in multiple sclerosis. Clin Rehab 1995 (9) 191-203.

26. Rose FD,Attree EA and Johson DA. Virtual reality: an assistive technology in neurological rehabilitation.

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