Abstract
3.1
Brock K1, Ilett P1, Graven C1, Cotton S2
1 St Vincent's Hospital, Melbourne, VIC, Australia
2 ORYGEN Youth Health, University of Melbourne, VIC, Australia
Background: It is common practice for rehabilitation units to send an assessor to the acute hospital to evaluate the patient's suitability for rehabilitation. This process of selection may lead to inequities of access to rehabilitation for patients with stroke.
Aims: To investigate whether there were variations in the practice of selection for rehabilitation, after adjusting for case mix.
Methods: A prospective audit in seven acute stroke units in Melbourne. Each site collected data on 100 consecutive acute stroke admissions, including level of function at 3 days poststroke (Mobility Scale For Acute Stroke and Modified Barthel Index Scores For Continence) and discharge destination.
Results: Data were analysed for 616 stroke survivors. A multinomial logistic regression was conducted with the outcome variable being discharge destination (home, rehabilitation or nursing home), and the predictors being Mobility Scale Score, continence scores, age and social situation. The overall amount of variability explained in discharge destination by the predictors was 63% (Nagelkerke pseudo-R2). The regression analysis was repeated, adding unit code as a predictor. Unit code was a significant contributor to the model (P<0·01).
Conclusion: The results of the study indicate that, after adjusting for case mix, there may be variations in practice of selection for rehabilitation.
3.2
Zhang WW1,2, Churilov L1,2, Thuy M1,3, Bernhardt J1,4
1 National Stroke Research Institute (part of Florey Neuroscience Institutes), Melbourne, VIC, Australia
2 University of Melbourne, Melbourne, VIC, Australia
3 Austin Health, Melbourne, VIC, Australia
4 La Trobe University, Melbourne, VIC, Australia
Background: Rehabilitation is not standard in stroke care in China. However, increased interest in the efficacy of rehabilitation is evident.
Aim: To conduct a systematic review of the effect of early rehabilitation after stroke in China.
Methods: Systematic search of 24 databases including Wanfangdata (China) MEDLINE, EMBASE, CENTRAL and Cochrane Stroke Group Register. Primary outcome: activities of daily living [Barthel Index (BI)], secondary outcome: disability [Fugl-Meyer Score (FMS)]. Random effect meta-analysis was performed.
Results: Sixty-two papers were identified, 95% published since 2000, with 24 specifying the time of start of rehabilitation. A further 12 failed to report detailed outcomes of interest. This left 12 studies with 2327 patients, 1409 males (60·55%). The rehabilitation interventions consisted of additional exercise therapy. Control group patients had no or limited rehabilitation. Patients who received rehabilitation showed marked improvements in BI [standardised mean difference: 118, 95% confidence interval (CI): 0·85–1·52] and FMS (standardised mean difference: 1·39, 95% CI: 0·92–1·87) compared with controls. No evidence of publication bias was detected for either BI or FMS.
Conclusions: Recent interest in stroke rehabilitation in China has resulted in a large number of RCTs on the topic. Although reporting quality of many RCTs is low, there is evidence of overwhelmingly positive results of early rehabilitation.
3.3
Skarin M1, Sjöholm A1, Bernhardt J2, Linden T1
1 Institute of Neuroscience and Physiology, Sahlgrenska University Hospital, Gothenburg, Sweden
2 National Stroke Research Institute, Melbourne, VIC, Australia
Background: Stroke unit care improves patients' outcome. One factor contributing to improved outcomes may be that the patients are mobilised as soon as possible after stroke, but there is little high-quality research evidence.
Aim: To evaluate health professionals' practice of very early mobilisation (VEM), defined as frequent out-of-bed activities within 24 h of stroke onset.
Method: In August 2008, conference participants at the combined Stroke Society of Australasia and Smart Strokes Australasian Nursing and Allied Health Conference (Sydney) were anonymously interviewed with a nine-item questionnaire on the benefits and harms of VEM.
Results: Two hundred and two participants responded representing 38% of attendees. The majority worked in acute stroke units (46%) and stroke rehabilitation (31%). Respondents were nurses (35%), physicians (26%), physiotherapists (19%) and occupational therapists (12%). Two-thirds had < 10 years experience in stroke care. Sixty per cent had concerns regarding potential harm of VEM and more professionals were concerned for haemorrhagic (59%) than ischaemic (23%) stroke (P<0·001).
Discussion: Clinicians have to make decisions despite lack of scientific evidence and in these situations it is often considered best practise to provide bed rest as the safer option. Concern about VEM was frequent, particularly in haemorrhagic stroke with greater perceived risks.
3.4
George S
Flinders University Department of Rehabilitation and Aged Care, Repatriation General Hospital, Daws Park, SA, Australia
Background: With an increased survival rate and longevity following stroke, more people with perceptual and cognitive impairments wish to resume driving. Occupational therapists base decisions regarding licensing on the recommendations from on-road assessment reports.
Aims: To determine which driving behaviours reported in occupational therapy assessment reports make it more likely for a particular outcome to be recommended.
Methods: Retrospective audit of occupational therapy driving assessment reports of a cohort of drivers with stroke. General driving domains or categories were identified through analysis of the errors reported in the on-road driving reports. Documented driving behaviours were coded under each domain. Binary logistic regression was used to compare the outcome groups of pass and recommended lessons.
Results: Three key domains were the risk factors in being recommended lessons as opposed to being recommended to pass the on-road assessment. These risk factors were any reduction in: ‘observation’, ‘planning/judgement’ or ‘performance over time’.
Conclusions: It can be assumed that these key factors are deemed by occupational therapists as being amenable to rehabilitation.
3.5
Ross LF1, Harvey L2, Lannin NA3
1 Ipswich Hospital, Brisbane, QLD, Australia
2 Rehabilitation Studies Unit, Northern Clinical School, Faculty of Medicine, University of Sydney, Sydney, NSW, Australia
3 Rehabilitation Studies Unit, Northern Clinical School, Faculty of Medicine, University of Sydney, Sydney, NSW, Australia
Background: Much of the current best evidence for upper limb therapy following stroke provides only general guidance such as the training to be intensive and task specific. The evidence remains unclear for specific programmes other than constraint-induced movement therapy that has not been widely adopted in Australia.
Objective: To determine the benefits of additional therapy specifically directed at the hand in people with acquired brain impairment.
Design: An assessor-blinded randomised-controlled trial.
Setting: Rehabilitation hospital.
Participants: A sample of 39 adults with hand impairment following stroke (90%) or traumatic brain injury (10%).
Intervention: The experimental group (n = 19) received an additional 1-h session of task-specific motor training for the hand five times a week over a 6-week period. Both groups continued to receive standard care including 30 min of therapy directed at the shoulder and elbow.
Results: The mean between-group differences for the Action Research Arm and Summed Manual Muscle Tests were 6 points (95% CI, −20 to 8) and 3% (95% CI, −10 to 16), respectively.
Conclusion: Hand and overall arm function of all participants improved over the 6-week period; however, there was no clear benefit from providing additional hand therapy.
3.6
Ha J1, Churilov L1,2, Linden T2,3, Bernhardt J2,4
1 School of Medicine, The University of Melbourne, Melbourne, VIC, Australia
2 National Stroke Research Institute, Melbourne, VIC, Australia
3 Sahlgrenska University Hospital, Gothenburg, Sweden
4 La Trobe University, Melbourne, VIC, Australia
Background: Reflecting the absence of an evidence-base, protocols vary surrounding mobilising patients out of bed after rt-PA. The main purpose of this study was to identify factors influencing clinicians' decisions to allow/restrict very early mobilisation (VEM, within 24 h) after rt-PA.
Methods: An anonymous, online, hypothetical case study-based questionnaire was distributed to acute stroke physicians and nurses at 31 Australian hospitals. We examined: (1) protocols for mobilisation after rt-PA, (2) factors that physicians and nurses consider when mobilising a patient after rt-PA and (3) perceived benefits and harms of VEM.
Results: Fifty-four clinicians responded: 52% senior nurses and 48% senior physicians. Fifty per cent had rt-PA protocols specifying mobilisation procedures with 64% of those preventing VEM. Medical stability (median = 72·2%), falls risk (median = 75·9%), stroke severity (median = 77·8%) and blood pressure (median = 72·2%) were commonly considered. NIHSS decline (P = 0·0010), NIHSS decline with symptomatic intracerebral haemorrhage (P = 0·0000), infection of uncertain cause (P = 0·0010), severe chest infection (P = 0·0004), severe stroke (P = 0·0010), drowsiness (P = 0·0000) and confusion (P = 0·0001) were significant concerns. Benefits included improved functional outcome; and decreased risk of chest infections, pulmonary emboli and deep vein thromboses. Harms were increased by the risk of falls.
Conclusions: Many Australian hospitals have protocols for preventing VEM. Multiple factors were identified that influence decisions about VEM after rt-PA.