Review of stroke rehabilitationBMJ 2007; 334 doi: https://doi.org/10.1136/bmj.39059.456794.68 (Published 11 January 2007) Cite this as: BMJ 2007;334:86
All rapid responses
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
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-
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
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
Competing interests: No competing interests
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: No competing interests