Development of a neurological rehabilitation environment: an observational study.

BACKGROUND: Engagement in therapeutic activity among stroke inpatients is advocated by many rehabilitation professionals. However, there is a lack of published evidence to indicate whether this is currently being achieved. OBJECTIVE: To investigate the extent and types of 'rehabilitation' activities on a new neurological rehabilitation ward, and examine change in patients' behaviour related to the new environment and new initiatives. DESIGN: Five one-week observation periods were conducted over two years, with a total of 67 patients being observed. A comparison was made with results of an earlier study of stroke patients' activities conducted at the same hospital. RESULTS: Patients spent an average 43 min per day with therapists (9% of the working day) and this was only marginally supplemented by self-exercise (2% of the working day--approximately 10 min). However, the provision of a new rehabilitation environment was associated with a marked decrease in the time patients spent at their bedsides, and a decrease in time spent passively gazing or watching others. CONCLUSIONS: Overall there was some positive change in patients' behaviour. We suggest that structured guidance is required from the whole multidisciplinary team to stimulate more self-directed therapy practice and recreation.

Differences in recovery from constructional apraxia after right and left hemisphere stroke?

Previous comparisons of constructional apraxia after right and left hemisphere damage have not investigated the influence of time since onset. This paper reports some preliminary findings from stroke patients in a physical rehabilitation trial. Fifty-five patients with right hemisphere damage and 65 with left hemisphere damage were assessed on the WAIS-R Block Design test at 1 month and 6 months post stroke. The groups were similar at 1 month but the left hemisphere group showed better average recovery by 6 months. There was great variability in amount of recovery within the left hemisphere group, suggesting individual differences in initial reasons for failing Block Design, and corresponding differences in the recovery process. Compensation by the right hemisphere is discussed as one possible process. Future detailed longitudinal studies may be useful in contrasting the cognitive deficits which underlie constructional apraxia after right-sided and left-sided lesions, and would provide evidence on mechanisms of recovery and adaptation.

Enhanced physical therapy for arm function after stroke: a one year follow up study.

Ninety seven patients with stroke who had participated in a randomised trial of conventional physical therapy nu an enhanced therapy for arm function were followed up at one year. Despite the emphasis of the enhanced therapy approach on continued use of the arm in everyday life, the advantage seen for some patients with enhanced therapy at six months after stroke had diminished to a non-significant trend by one year. This was due to some late improvement in the conventional therapy group whereas the enhanced therapy group remained static or fell back slightly. It is recommended that trials should be conducted comparing very intensive therapy for the arm with controls without treatment. This would provide a model of the effects of therapy on intrinsic neural recovery that would be relevant to all areas of neurological rehabilitation.

Enhanced physical therapy improves recovery of arm function after stroke. A randomised controlled trial.

Previous research on stroke rehabilitation has not established whether increase in physical therapy lead to better intrinsic recovery from hemiplegia. A detailed study was carried out of recovery of arm function after acute stroke, and compares orthodox physiotherapy with an enhanced therapy regime which increased the amount of treatment as well as using behavioural methods to encourage motor learning. In a single-blind randomised trial, 132 consecutive stroke patients were assigned to orthodox or enhanced therapy groups. At six months after stroke the enhanced therapy group showed a small but statistically significant advantage in recovery of strength, range and speed of movement. This effect seemed concentrated amongst those who had a milder initial impairment. More work is needed to discover the reasons for this improved recovery, and whether further development of this therapeutic approach might offer clinically significant gains for some patients.

Arm function after stroke. An evaluation of grip strength as a measure of recovery and a prognostic indicator.

The value of strength of voluntary grip as an indicator of recovery of arm function was assessed by testing 38 recent stroke patients using a sensitive electronic dynamometer, and comparing the results with those from five other arm movement and function tests (Motricity Index, Motor Club Assessment, Nine Hole Peg Test, and Frenchay Arm Test). This procedure allowed measurement of grip in a large proportion of patients, and strength correlated highly with performance on the other tests. Measuring grip over a six month follow up period was a sensitive method of charting intrinsic neurological recovery. The presence of voluntary grip at one month indicates that there will be some functional recovery at six months.

The relation between subjective and objective memory impairment after stroke.

The aim of this study was to examine the relationship between subjective memory and objective assessment using a test designed to reflect daily life memory skills, the Rivermead Behavioural Memory Test (RBMT). A total of 78 patients was assessed seven months after a stroke. Each patient completed a questionnaire about memory problems experienced in daily life. A relative or close friend completed the same questionnaire about the patient. Each patient was assessed on the RBMT and some conventional memory tests. Questionnaire responses were more highly correlated with the RBMT than with conventional tests of memory.

How stroke patients spend their days. An observational study of the treatment regime offered to patients in hospital with movement disorders following stroke.

A number of studies have suggested that early intensive rehabilitation will promote recovery after stroke. If this is so then how far does current National Health Service provision succeed in delivering this? This observational study looks at how 15 stroke patients in a general hospital spent their days. Only 12.9% of the working day, or 62 minutes, were spent in therapy. Patients spent most of their working day, 38.6%, in 'recreation', and most of this time was spent on the ward. For much of this time they could have been available for therapy sessions or involved in self-directed exercise. The impact of a new regime aimed at increasing intensity of therapy for the hemiplegic arm is examined.

Subjective memory impairment after stroke.

The responses of 95 stroke patients and 129 orthopaedic control patients were compared on a questionnaire of subjective memory abilities. Stroke patients reported more problems than orthopaedic controls, and relatives observed more problems in both groups than were reported by patients. Reassessment after 6 months showed that stroke patients rated their memories as worse but their relatives observed an improvement. Factors such as whether the patient was in hospital or at home, and the side of the lesion, were not found to be related to overall subjective memory impairment.

Cognitive ability and driving after stroke.

This study investigated the relationship between cognitive ability and driving after stroke. Thirty-nine pre-stroke drivers were assessed using a battery of cognitive tests followed by a road test over a set route. Subjects were graded into Pass, Borderline of Fail categories on the basis of the road test. Cognitive test results were compared across grades of driving performance and significant differences were found on nine of the 23 measures. A discriminant function analysis identified 10 tests which together predicted the grading of 94% of subjects into Pass or Fail categories.