From Medscape Medical News
Pauline Anderson
September 10, 2010 —The American Heart Association (AHA) has released a comprehensive scientific statement on nursing and interdisciplinary rehabilitation care for stroke patients.
The statement summarizes the best available evidence for poststroke therapies and includes recommendations for management of stroke survivors and their families during inpatient, outpatient, chronic care, and end-of-life settings.
"It's like a large dictionary, but people can find kernels of very useful information in terms of recovery of a stroke patient," said Ralph Sacco, MD, a stroke neurologist and president of the AHA.
Dr. Sacco emphasized the comprehensive nature of the AHA statement. "Nobody has really sat down and tried to tackle all of the evidence that's out there in both the evaluation and the rehabilitation of people with deficits related to stroke," he told Medscape Medical News. "The statement includes 602 references, which is tremendous."
The statement was published online September 2 and will appear in the October issue of Stroke.
The guidelines should help educate nurses and other members of the interdisciplinary team about the potential for recovery in the more chronic phases of stroke care. Healthcare professionals are often unaware of patients' potential for improvement during this later phase, said the authors.
"What this document is saying is that there is evidence that stroke survivors continue to improve," said Dr. Sacco. "What I tell my patients is that language and speech can recover for years after a stroke, while motor recovery is often something people think about in the early phases."
Reframing Complexities
The report represents "an initial effort to reframe the complexities of interdisciplinary, postacute care of stroke survivors into a format that optimizes the potential for the highest achievable outcomes and quality care," the authors write.
The writing group, chaired by Elaine L. Miller, PhD, RN, from the University of Cincinnati College of Nursing in Ohio, prepared the statement on behalf of the AHA Council on Cardiovascular Nursing and the Stroke Council.
According to background information in the statement, stroke continues to represent the leading cause of long-term disability. About 50 million stroke survivors worldwide currently cope with significant physical, cognitive, and emotional deficits, and 25% to 74% of these survivors require some assistance.
WHO Classifications
The report includes the World Health Organization (WHO) international classification of functioning, disability, and health. This model of disease is being used to provide a common framework to deliver and study the efficacy of rehabilitation outcomes across settings, said the authors.
The statement outlines the roles of key members of the interdisciplinary team and emphasizes the diverse skills necessary for poststroke rehabilitation. "It makes it clear that it's not just physicians: it's physicians, it's nurses, it's speech therapy, it's cognitive therapy, it's occupational therapy," said Dr. Sacco.
Treating care settings in a continuum, as the authors have done, is a novel approach, said Dr. Sacco. "They broke the evidence down into care in the inpatient rehabilitation setting, care in the outpatient setting, and care in the chronic care setting and then supported it across all the types of rehabilitation focus areas."
The statement provides an overview of the evidence for various screening tests and medical treatments, including traditional rehabilitation therapies and newer techniques, such as robot-assisted therapies, electrical stimulation, and weight-assisted treadmill devices.
Support for Caregivers
It also discusses approaches to personal and environmental factors and education and support for caregivers. One of the recommendations is that caregivers should be active members of the interdisciplinary team with common shared goals for recovery and community reintegration.
Dr. Sacco also noted the attention paid to "underemphasized" areas such as depression in the poststroke phase and communication and cognition. "It really does make us recognize the need for multidimensional rehabilitation of stroke patients."
Once published, the next step is to determine how best to distribute the statement. AHA councils will develop an implementation plan to disseminate the information "to get it into the right hands," said Dr. Sacco.
"It's one thing to write a great comprehensive document; it's another to determine what measurements to use to see how we're doing and how we can then try to improve performance and adherence to these guidelines."
Recommended Reference
Approached for a comment, Howard S. Kirshner, MD, professor and vice chair in the Department of Neurology at Vanderbilt University Medical Center, Nashville, Tennessee, and a member of the American Academy of Neurology, agreed the review is "comprehensive" and said he would recommend it as a reference source for medical and allied health professionals.
"The interested physician, nurse, therapist, or family member can find a summary of virtually all treatments given for the rehabilitation of stroke, along with the level of evidence for benefit," Dr. Kirschner wrote in an email to Medscape Medical News. "What is new about this overview is the context not only of the patient's medical and functional limitations, but also the patient's social environment, access to health care, and family support."
However, Dr. Kirshner found some of the emphasis on meta-analyses rather than individual studies "problematic." One example, he said, is the evidence for antidepressant therapy of poststroke depression "The result is a mixed statement of benefit, whereas a look at individual studies would bring up the stronger evidence in the better organized and controlled studies."
Time Factor
He noted that the meta-analyses did not include the factor of time. "Studies done in the first weeks after stroke tend to find a close correlation between depression and left hemisphere, especially anterior lesions, whereas studies performed several months after onset tend to find equal incidence of depression in patients with right and left hemisphere strokes."
He felt there were other omissions, too. For example, the discussion of fall risk omits emphasis on cognitive issues such as confusion and dementia, which could greatly increase such risk, said Dr. Kirshner. In the discussion of electrical stimulation, there is no mention of external stimulators built into splint devices, and discussion of treatments for spasticity did not mention oral baclofen, he noted.
But what he missed perhaps the most was an appeal to a stroke patient's "bill of rights" in terms of what the healthcare system should ideally provide to all stroke survivors and their families, he said.
Although he would recommend it as a reference, Dr. Kirshner acknowledged that few healthcare professionals would read the entire report. "Its comprehensive nature and summary of evidence make it not the easiest article to read."
Disclosures for all authors appear in the original report.
Stroke. Published online September 2, 2010.
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