Rapid Responses to:

CLINICAL REVIEW: John Young and Anne Forster Review of stroke rehabilitation BMJ 2007; 334: 86-90 [Full text]

Rapid Responses: Submit a response to this article

Rapid Responses published:

Changing needs of Stroke Care & Rehabilitation

Peter Khin Tun   (12 January 2007)

Rehabilitation in the elderly: not just stroke.

Anushka Soni, Katie Walter, Simon M Ward, Hywel Jones, Radcliffe Infirmary, Oxford   (16 January 2007)

Changing needs of Stroke Care & Rehabilitation 12 January 2007
Peter Khin Tun, Associate Specialist in Neuro-rehabilitation Medicine Royal Berkshire Hospital Foundation Trust, London Road, Reading, RG1 5AN Send response to journal: Re: Changing needs of Stroke Care & Rehabilitation	In the first 14 days, acute stroke unit care, consisting of early neuro-imaging, thrombolysis for selective patients, swallow assessment, prevention of aspiration pneumonia, DVT, pressure sores, shoulder pain and foot drop are important. Careful monitoring of fluid & electrolyte balance (to avoid cerebral oedema in first 48 hours, especially in younger patients with tight brain), maintaining optimal blood glucose level, body temperature are needed. Urinary catheterisation should be done only for those who have retention or incontinence, and are unable to transfer onto commode or toilet in time. Timely detection & treatment of aspiration pneumonia, urinary infection, deep vein thrombosis & pulmonary embolism, and mental depression are important. Control of blood pressure, cholesterol and secondary prevention (antiplatelet/anticoagulation treatment for ischaemic strokes) are essential. In an audit of 400 neuro-rehab inpatients in Berkshire Neurorehabilitation Service (year 2000-2004), median length of inpatient rehabilitation, before safe transfering to intermediate & community care was 63 days. They had intensive neuro-physiotherapy, occupational therapy, speech & language therapy & clinical psychology input in addition to daily medical review & rehabilitation nursing care. Median waiting time from admission to rehab was 16 days; median Barthel score on starting rehab was 9 (on discharge median Barthel 18). 80% of patients were in wheel-chairs on admission (80% walked home with a walking aid). Cognitive difficulty (low Short Orientation Memory & Concentration Score) was present in 75% of patients on admission (50% still have cognitive problems on discharge). These findings fits with your review on Stroke Rehabilitation. Medical review, nursing care, physiotherapy and occupatinal therapy as well as some speech & language therapy & clinical psychology input are essential in the 1st 2-3 months of stroke rehabilitation. Early involvement of Social Services is essential for timely transfer of care from hospital to the community. In the intermediate care & the community rehabilitation, some follow up physiotherapy, and more intermittent occupational therapy, longer term speech & language therapy and clinical psychology review & rehabilitation are required. Family & carer's education on stroke care, cognitive & behavioural therapy, more vocational rehabilitation & leisure rehabilitation should be provided. Competing interests: None declared
Rehabilitation in the elderly: not just stroke. 16 January 2007
Anushka Soni, Clinical Fellow in Rheumatology Great Western Hospital, Swindon, Katie Walter, Simon M Ward, Hywel Jones, Radcliffe Infirmary, Oxford Send response to journal: Re: Rehabilitation in the elderly: not just stroke.	As Young and Forster1 highlight, the benefits of a devoted stroke unit are now well recognised. However, the advantages of specialised rehabilitation for unselected elderly patients are less widely accepted. With distinct stroke and general geratology rehabilitation units, we were able to conduct a retrospective study investigating the impact of rehabilitation on functional status of general geratology patients. Case notes of 95 patients were reviewed (31% male, average age 85, average length of stay 52 days). Patients were referred from a variety of specialties (acute general medicine (72%), trauma (11%), non-orthopaedic surgery (5%)) and the reason for initial admission to hospital was categorised as fall or musculoskeletal injury (30%), infection or acute confusional state (29%), other medical problem (31%) or surgical problem (5%). All patients were assessed and managed by a dedicated team of doctors, nurses, physiotherapists, occupational therapists, pharmacists, speech and language therapists and dieticians. The average Barthel index on admission to the rehabilitation unit was 9, as compared to 12 on discharge. 45% reached a functional capacity allowing discharge straight to their pre-admission home. The positive effect on functional status was significant (p<0.0001) and, importantly, independent of the acute diagnosis precipitating admission. With an ageing population, increasing numbers of elderly patients are managed in hospital. Studies have shown that the effect of specific geriatric evaluation on health related quality of life persists at one year after discharge2 and that improved function can be achieved even in particularly complex patients with depression and cognitive impairment3. Running a dedicated geratology rehabilitation unit may be expensive, but by avoiding nursing home admission, it has been shown to actually reduce the overall cost of care4. Although we welcome Young and Forster highlighting the benefits of integrated stroke care, we are keen to emphasise the transferability of this approach to general geratology patients. 1. Young J, Forster A. Rehabilitation after Stroke. BMJ 2006;334:86- 90.(13 January) 2. Cohen HJ, Feussner JR, Weinberger M, Carnes M, Hamdy RC, Hsieh F et al. A controlled trial of inpatient and outpatient geriatric evaluation and management. N Engl J Med 2002;346:905-912. 3. Esperanza A, Miralles R, Rius I, Fernandez B, Digon A, Gonzalez P et al. Evaluation of functional improvement in older patients with cognitive impairment, depression and/or delirium referred to a geriatric convalescence hospitalization unit. Arch Gerontol Geriatr Suppl 2004;9:149 -53. 4. Phibbs CS, Holty JEC, Goldstein MK, Garber AM, Wang Y, Feussner JR et al. The effect of geriatrics evaluation and management on nursing home use and health care costs. Results from a randomised trial. Medical Care 2006;44:91-95. Competing interests: None declared