Rehabilitation nursing approaches to cerebrovascular accident: a comparison of two approaches

Physical rehabilitation approaches for the recovery of function and mobility following stroke

BACKGROUND

Various approaches to physical rehabilitation may be used after stroke, and considerable controversy and debate surround the effectiveness of relative approaches. Some physiotherapists base their treatments on a single approach; others use a mixture of components from several different approaches.

OBJECTIVES

To determine whether physical rehabilitation approaches are effective in recovery of function and mobility in people with stroke, and to assess if any one physical rehabilitation approach is more effective than any other approach.For the previous versions of this review, the objective was to explore the effect of 'physiotherapy treatment approaches' based on historical classifications of orthopaedic, neurophysiological or motor learning principles, or on a mixture of these treatment principles. For this update of the review, the objective was to explore the effects of approaches that incorporate individual treatment components, categorised as functional task training, musculoskeletal intervention (active), musculoskeletal intervention (passive), neurophysiological intervention, cardiopulmonary intervention, assistive device or modality.In addition, we sought to explore the impact of time after stroke, geographical location of the study, dose of the intervention, provider of the intervention and treatment components included within an intervention.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (last searched December 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 12, 2012), MEDLINE (1966 to December 2012), EMBASE (1980 to December 2012), AMED (1985 to December 2012) and CINAHL (1982 to December 2012). We searched reference lists and contacted experts and researchers who have an interest in stroke rehabilitation.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of physical rehabilitation approaches aimed at promoting the recovery of function or mobility in adult participants with a clinical diagnosis of stroke. Outcomes included measures of independence in activities of daily living (ADL), motor function, balance, gait velocity and length of stay. We included trials comparing physical rehabilitation approaches versus no treatment, usual care or attention control and those comparing different physical rehabilitation approaches.

DATA COLLECTION AND ANALYSIS

Two review authors independently categorised identified trials according to the selection criteria, documented their methodological quality and extracted the data.

MAIN RESULTS

We included a total of 96 studies (10,401 participants) in this review. More than half of the studies (50/96) were carried out in China. Generally the studies were heterogeneous, and many were poorly reported.Physical rehabilitation was found to have a beneficial effect, as compared with no treatment, on functional recovery after stroke (27 studies, 3423 participants; standardised mean difference (SMD) 0.78, 95% confidence interval (CI) 0.58 to 0.97, for Independence in ADL scales), and this effect was noted to persist beyond the length of the intervention period (nine studies, 540 participants; SMD 0.58, 95% CI 0.11 to 1.04). Subgroup analysis revealed a significant difference based on dose of intervention (P value < 0.0001, for independence in ADL), indicating that a dose of 30 to 60 minutes per day delivered five to seven days per week is effective. This evidence principally arises from studies carried out in China. Subgroup analyses also suggest significant benefit associated with a shorter time since stroke (P value 0.003, for independence in ADL).We found physical rehabilitation to be more effective than usual care or attention control in improving motor function (12 studies, 887 participants; SMD 0.37, 95% CI 0.20 to 0.55), balance (five studies, 246 participants; SMD 0.31, 95% CI 0.05 to 0.56) and gait velocity (14 studies, 1126 participants; SMD 0.46, 95% CI 0.32 to 0.60). Subgroup analysis demonstrated a significant difference based on dose of intervention (P value 0.02 for motor function), indicating that a dose of 30 to 60 minutes delivered five to seven days a week provides significant benefit. Subgroup analyses also suggest significant benefit associated with a shorter time since stroke (P value 0.05, for independence in ADL).No one physical rehabilitation approach was more (or less) effective than any other approach in improving independence in ADL (eight studies, 491 participants; test for subgroup differences: P value 0.71) or motor function (nine studies, 546 participants; test for subgroup differences: P value 0.41). These findings are supported by subgroup analyses carried out for comparisons of intervention versus no treatment or usual care, which identified no significant effects of different treatment components or categories of interventions.

AUTHORS' CONCLUSIONS

Physical rehabilitation, comprising a selection of components from different approaches, is effective for recovery of function and mobility after stroke. Evidence related to dose of physical therapy is limited by substantial heterogeneity and does not support robust conclusions. No one approach to physical rehabilitation is any more (or less) effective in promoting recovery of function and mobility after stroke. Therefore, evidence indicates that physical rehabilitation should not be limited to compartmentalised, named approaches, but rather should comprise clearly defined, well-described, evidenced-based physical treatments, regardless of historical or philosophical origin.

Physical rehabilitation approaches for the recovery of function and mobility following stroke

BACKGROUND

Various approaches to physical rehabilitation may be used after stroke, and considerable controversy and debate surround the effectiveness of relative approaches. Some physiotherapists base their treatments on a single approach; others use a mixture of components from several different approaches.

OBJECTIVES

To determine whether physical rehabilitation approaches are effective in recovery of function and mobility in people with stroke, and to assess if any one physical rehabilitation approach is more effective than any other approach.For the previous versions of this review, the objective was to explore the effect of 'physiotherapy treatment approaches' based on historical classifications of orthopaedic, neurophysiological or motor learning principles, or on a mixture of these treatment principles. For this update of the review, the objective was to explore the effects of approaches that incorporate individual treatment components, categorised as functional task training, musculoskeletal intervention (active), musculoskeletal intervention (passive), neurophysiological intervention, cardiopulmonary intervention, assistive device or modality.In addition, we sought to explore the impact of time after stroke, geographical location of the study, dose of the intervention, provider of the intervention and treatment components included within an intervention.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (last searched December 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 12, 2012), MEDLINE (1966 to December 2012), EMBASE (1980 to December 2012), AMED (1985 to December 2012) and CINAHL (1982 to December 2012). We searched reference lists and contacted experts and researchers who have an interest in stroke rehabilitation.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of physical rehabilitation approaches aimed at promoting the recovery of function or mobility in adult participants with a clinical diagnosis of stroke. Outcomes included measures of independence in activities of daily living (ADL), motor function, balance, gait velocity and length of stay. We included trials comparing physical rehabilitation approaches versus no treatment, usual care or attention control and those comparing different physical rehabilitation approaches.

DATA COLLECTION AND ANALYSIS

Two review authors independently categorised identified trials according to the selection criteria, documented their methodological quality and extracted the data.

MAIN RESULTS

We included a total of 96 studies (10,401 participants) in this review. More than half of the studies (50/96) were carried out in China. Generally the studies were heterogeneous, and many were poorly reported.Physical rehabilitation was found to have a beneficial effect, as compared with no treatment, on functional recovery after stroke (27 studies, 3423 participants; standardised mean difference (SMD) 0.78, 95% confidence interval (CI) 0.58 to 0.97, for Independence in ADL scales), and this effect was noted to persist beyond the length of the intervention period (nine studies, 540 participants; SMD 0.58, 95% CI 0.11 to 1.04). Subgroup analysis revealed a significant difference based on dose of intervention (P value < 0.0001, for independence in ADL), indicating that a dose of 30 to 60 minutes per day delivered five to seven days per week is effective. This evidence principally arises from studies carried out in China. Subgroup analyses also suggest significant benefit associated with a shorter time since stroke (P value 0.003, for independence in ADL).We found physical rehabilitation to be more effective than usual care or attention control in improving motor function (12 studies, 887 participants; SMD 0.37, 95% CI 0.20 to 0.55), balance (five studies, 246 participants; SMD 0.31, 95% CI 0.05 to 0.56) and gait velocity (14 studies, 1126 participants; SMD 0.46, 95% CI 0.32 to 0.60). Subgroup analysis demonstrated a significant difference based on dose of intervention (P value 0.02 for motor function), indicating that a dose of 30 to 60 minutes delivered five to seven days a week provides significant benefit. Subgroup analyses also suggest significant benefit associated with a shorter time since stroke (P value 0.05, for independence in ADL).No one physical rehabilitation approach was more (or less) effective than any other approach in improving independence in ADL (eight studies, 491 participants; test for subgroup differences: P value 0.71) or motor function (nine studies, 546 participants; test for subgroup differences: P value 0.41). These findings are supported by subgroup analyses carried out for comparisons of intervention versus no treatment or usual care, which identified no significant effects of different treatment components or categories of interventions.

AUTHORS' CONCLUSIONS

Physical rehabilitation, comprising a selection of components from different approaches, is effective for recovery of function and mobility after stroke. Evidence related to dose of physical therapy is limited by substantial heterogeneity and does not support robust conclusions. No one approach to physical rehabilitation is any more (or less) effective in promoting recovery of function and mobility after stroke. Therefore, evidence indicates that physical rehabilitation should not be limited to compartmentalised, named approaches, but rather should comprise clearly defined, well-described, evidenced-based physical treatments, regardless of historical or philosophical origin.

Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke

BACKGROUND

There are a number of different approaches to physiotherapy treatment following stroke that, broadly speaking, are based on neurophysiological, motor learning and orthopaedic principles. Some physiotherapists base their treatment on a single approach, while others use a mixture of components from a number of different approaches.

OBJECTIVES

To determine if there is a difference in the recovery of postural control and lower limb function in patients with stroke if physiotherapy treatment is based on orthopaedic or neurophysiological or motor learning principles, or on a mixture of these treatment principles.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (last searched May 2005), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2005), MEDLINE (1966 to May 2005), EMBASE (1980 to May 2005) and CINAHL (1982 to May 2005). We contacted experts and researchers with an interest in stroke rehabilitation.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials of physiotherapy treatment approaches aimed at promoting the recovery of postural control and lower limb function in adult participants with a clinical diagnosis of stroke. Outcomes included measures of disability, motor impairment or participation.

DATA COLLECTION AND ANALYSIS

Two review authors independently categorised the identified trials according to the inclusion and exclusion criteria, documented their methodological quality, and extracted the data.

MAIN RESULTS

Twenty-one trials were included in the review, five of which were included in two comparisons. Eight trials compared a neurophysiological approach with another approach; eight compared a motor learning approach with another approach; and eight compared a mixed approach with another approach. A mixed approach was significantly more effective than no treatment or placebo control for improving functional independence (standardised mean difference (SMD) 0.94, 95% confidence intervals (CI) 0.08 to 1.80). There was no significant evidence that any single approach had a better outcome than any other single approach or no treatment control.

AUTHORS' CONCLUSIONS

There is evidence that physiotherapy intervention, using a mix of components from different approaches, is significantly more effective than no treatment or placebo control in the recovery of functional independence following stroke. There is insufficient evidence to conclude that any one physiotherapy approach is more effective in promoting recovery of lower limb function or postural control following stroke than any other approach. We recommend that future research should concentrate on investigating the effectiveness of clearly described individual techniques and task-specific treatments, regardless of their historical or philsophical origin.

Rehabilitation Nurses Working as Collaborative Research Teams

Rehabilitation nurses conducting research would benefit from working within collaborative research teams. The development of intradisciplinary (one discipline) and interdisciplinary (many disciplines) research teams is described in this article. A research team is defined as more than a single person in the role of the researcher while studying the same topic of interest in a joint or collaborative manner. Strategies to ensure successful research team collaboration are described. Exemplars of developing and maintaining a team at one site, which consists of members of the same discipline, as well as another team that consists of multiple professional disciplines, are shared. Collaboration among research team members in practice, administration, and education settings transcends degrees and roles to make substantial contributions to professional practice.

Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke

BACKGROUND

There are a number of different approaches to physiotherapy treatment following stroke. Central to these are approaches based on 'neurophysiological' principles, 'motor learning' principles and 'orthopaedic' principles.

OBJECTIVES

To determine if there is a difference in the recovery of postural control and lower limb function in patients with stroke if physiotherapy treatment is based on orthopaedic or neurophysiological or motor learning principles, or on a mixture of these treatment principles.

SEARCH STRATEGY

This review drew on the search strategy developed by the Stroke Group as a whole. Relevant trials were identified in the Stroke Group Trials Register of Controlled Trials which was last searched in May 2001. We also searched the Cochrane Controlled Trials Register (Cochrane Library, Issue 4 1999), MEDLINE (1966-1999), EMBASE (1980-1999) and CINAHL (1982-1999) and contacted experts and researchers with an interest in stroke.

SELECTION CRITERIA

Studies - randomised or quasi-randomised controlled trials. Participants - adults with a clinical diagnosis of stroke. Interventions - physiotherapy treatment approaches aimed at promoting the recovery of postural control and lower limb function. Outcomes - measures of disability, motor impairment or participation.

DATA COLLECTION AND ANALYSIS

Two independent reviewers categorised the identified trials according to the inclusion/exclusion criteria, documented the methodological quality and extracted the data.

MAIN RESULTS

Eleven trials were included in the review, three of which were included in two comparisons. Four trials compared a neurophysiological approach with another approach; four trials compared a motor learning approach with another approach; four studies compared a mixed approach with another approach; two trials reported comparisons of sub-groups of the same approach. A large number of heterogeneous outcome measures were used, limiting the comparison of trial results. No one type of approach had a significantly better outcome than any other type of approach.

REVIEWER'S CONCLUSIONS

There is insufficient evidence to conclude that any one physiotherapy treatment approach is more effective than another in promoting the recovery of postural control or lower limb function.

Neurological rehabilitation nursing: a review of the research

Neurological rehabilitation is increasingly seen as a specialist form of rehabilitation requiring specialist nursing knowledge. However, as in many areas of nursing, nurses in this field recognize that there is a need to increase their knowledge base to ensure that they provide the best and most up-to-date quality care for their patients and their families. To achieve high levels of competence, neurological rehabilitation nurses need to be aware of the existing body of research in this field so that they can make sound decisions regarding their practice and future research endeavours. This review aims to validate the existing knowledge base in this area by identifying and critically analysing research conducted in the area of neurological rehabilitation nursing during the decade 1988-1998 and by identifying any gaps and weaknesses that may be addressed by future research. Studies were included in the review if they examined an aspect of rehabilitation nursing, were concerned predominately with the neurological patient and were conducted in an in-patient setting. Research with a medical focus was not included and only research published in English was reviewed. Relevant research located examined the following areas: (1) the role of the rehabilitation nurse; (2) specific problems concerning the neurological rehabilitation patient; (3) specific nursing interventions; (4) rehabilitation nursing practice; (5) the delivery of rehabilitation programmes and team working; and (6) the family of the rehabilitation patient. The review concludes that research in this speciality remains limited both in quantity and quality. Most of the studies lack rigour and, because they were conducted at a single site, their generalizability to other clinical sites may be limited.

Collaborative Research Among Clinical Nurse Specialists and Staff Nurses

BACKGROUND

Conducting research in clinical settings can be problematic for many nurses in practice due to lack of experience and support.

METHOD

Research collaboration between clinical nurse specialists and staff nurses in clinical settings can promote development of their research process skills.

RESULTS

Strategies identified can be applied by clinical nurse specialists involved in continuing education and staff development in clinical practice through further research development.

CONCLUSION

Collaboration among clinical nurse specialists and staff nurses provides a unique and strong link that transcends degrees and roles to make substantial contributions to professional nursing practice.

Patients' conceptions of their life situation within the first week after a stroke event: a qualitative analysis

The aim of this study was to find out how stroke patients conceived their life situation within the first week of the acute care phase as seen from the nurses' viewpoint. Six patients were interviewed within 3 weeks from their first stroke, using questions based on a holistic philosophy and analysed with the phenomonographic approach. Two main categories emerged from the results: the feeling of unreality and the awareness of a changed role in life, together with six subcategories; feeling of a changed perception of the body; feeling of being confused; loss of capability; awareness of confined life space; the importance of support and encouragement; and the will to look for new opportunities. The study concludes that the body change resulting from a stroke leads to both physical and psychological trauma, in which the psychological crisis can be very deep and best described as a personal catastrophe. The patient's capability to receive and understand information becomes blocked, which influences both the nurse and the patient's next of kin with regard to their care of the patient. Conversations with the patient must be frequent so that the acute care can be evaluated and agreement reached between the patient's wishes and the nurses' objectives. The results indicate the significance of intervention programmes based on crisis theory within the first week of a stroke event.

Implications for nurses in approaches to the management of stroke rehabilitation: a review of the literature

There is as yet no general agreement on how best to manage stroke rehabilitation in terms of the approaches to the management of this client group. Approaches include the Stroke Rehabilitation Unit (SRU), applying the principles of SRU management to general medical wards and the use of peripatetic stroke therapy teams. Each of these approaches has implications for nurses yet the contribution of nurses to the rehabilitation of stroke patients receives only scant attention in the literature. It is suggested that understating and undervaluing nursing leads to under use of this essential resource.