The Role of Community Physiotherapy for Stroke Patients

Methodology of a stroke rehabilitation trial

The effectiveness of rehabilitation after stroke remains largely unproven. Attempts have been made to evalute domiciliary therapy,1 community stroke teams2 and the intensity of therapy,3 but much of the evidence is inconclusive. We have been engaged in a randomized comparison trial of day hospital and home physiotherapy for elderly stroke patients discharged from hospital. This paper describes the background to the study and the pilot work from which the methodology was determined.

The Bradford community stroke trial: eight week results

To evaluate two commonly practised methods of stroke aftercare we have conducted a randomized comparison trial of day hospital (DH) and home physiotherapy (HPT). Patients over 60 years discharged from hospital following a new stroke event were eligible. One hundred and twenty-four patients were recruited, stratified by disability measured on the Barthel Index and by length of time since stroke onset, then randomized to attend a DH twice weekly or to receive HPT. Outcome measurements included the Barthel Index, Motor Club Assessment, Frenchay Activities Index, Nottingham Health Profile and the General Health Questionnaire.

One hundred and seven patients completed an eight week course of treatment. Both the DH and the HPT treated patients showed a significant but small further improvement in functional abilities with the HPT patients being significantly more able on stairs. Social function of both groups was poor but the HPT treated patients were significantly less so. More than a third of patients in each treatment group were depressed and more than a quarter of the carers were 'stressed'. The HPT patients received significantly less physiotherapy and virtually no occupational therapy compared to the DH group.

The findings suggest that HPT is slightly more effective for stroke aftercare than DH attendance and is considerably more resource efficient.

Exploring the Content of Physiotherapeutic Home-Based Stroke Rehabilitation in New Zealand

OBJECTIVE

To address the paucity of information on the content of home interventions for people with stroke by reporting on the practice of physiotherapeutic home-based stroke rehabilitation in New Zealand.

DESIGN

Qualitative research methodology comprising a series of semi-structured interviews.

SETTING

Community setting in 6 cities in New Zealand.

PARTICIPANTS

A purposeful sampling strategy recruited 20 physiotherapists working in home-based stroke rehabilitation.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Not applicable.

RESULTS

Participants described patients as being fatigued, frustrated, depressed, and scared once discharged home and said that the primary aim of rehabilitation in the home environment is preparation for life after stroke. Physiotherapists aimed at optimal independent functioning by building patients' confidence, self-responsibility, and problem-solving skills while ensuring patient safety. Participants, illustrating the complexities of stroke rehabilitation, described a wide range of interventions. We identified a number of factors that influenced the practice decisions made by participants. The success of intervention was measured more by the successful attainment of carefully set patient-centered goals than by the use of validated outcome measures.

CONCLUSIONS

This study presents a conceptual model or framework for physiotherapy practice for people with stroke living in the community.

Reliability of gait speed measured by a timed walking test in patients one year after stroke

OBJECTIVE

To assess the reliability of gait speed in late-stage stroke patients.

DESIGN

Test-retest reliability of three timed walks to 10 metres repeated during two assessments one week apart.

SETTING

The patient's home.

SUBJECTS

Twenty-two stroke patients with mobility problems more than one year after stroke.

MAIN OUTCOME MEASURE

Gait speed measured in seconds taken to walk 10 metres.

STATISTICAL ANALYSIS

Intraclass correlations (ICCs) with 95% confidence interval (CI) and the Bland and Altman method for assessing agreement by calculating the mean difference between measurements (d); the 95% CI for d; the standard deviation of the difference (SDdiff); a reliability coefficient and the 95% limits of agreement.

RESULTS

There was a trend for decreased times taken to walk 10 metres both within each assessment and between assessments. ICCs for within-assessment reliability were 0.95-0.99. The d (SDdiff) for the second and third walks for assessment 1 was -1.00 (2.63) seconds and for assessment 2 was -0.70 (1.58) seconds. The reliability coefficient was 5.26 for assessment 1 and 3.17 for assessment 2. ICCs for between-assessment reliability were 0.87-0.88. The d (SDdiff) for the comparison of the third walks at assessment 1 and assessment 2 was -0.90 (5.01) seconds. The reliability coefficient was 10.02 and the 95% limits of agreement were -10.92 to +9.12 seconds.

CONCLUSION

Within-assessment gait speed measured at home is highly reliable. The between-assessment reliability of gait speed measurement is less reliable but comparable with other studies.

Impact on health care consumption of an experimental daycare intervention

The purpose of the present study was to assess the impact on health care utilization of a controlled intervention programme for geriatric daycare patients. Sixty-five patients referred to daycare were allocated to an intervention and control group respectively. The 12-week programme was added to the ordinary daycare agenda and was designed in active collaboration with the patients in order to counteract passivity and enhance active patient involvement. Evaluations were made before and after 6 and 12 weeks of intervention, as well as 3 and 9 months after the conclusion of the programme. No extra resources were allocated to either the intervention or the control group. During the intervention period there were no changes in the utilization of home care for either group during the whole study period. Noticeably, there was a significant difference in the number of patients readmitted to hospital between the intervention and control groups (13/33 and 21/32 respectively). There was also a significant difference in favour of the intervention group concerning mean length of hospital stay (22.1 and 61.9 days respectively). The mean corresponding saving for each 12-week intervention patient during a one-year follow-up was calculated at 57,500 SEK. Even if our calculations are tentative and do not cover all aspects of the total cost, they indicate the importance of further studies of elderly patients discharged from daycare units and institutional settings.

The Bradford community stroke trial: results at six months

OBJECTIVE

Comparison of day hospital attendance and home physiotherapy for stroke patients leaving hospital to determine which service produces greater functional and social improvement for the patient, reduces emotional stress for the care giver, and lessens the need for community support.

DESIGN

Stratified, randomised trial of stroke patients attending day hospital two days a week or receiving home treatment from a community physiotherapist. The six month assessment results are reported in this paper.

SUBJECTS

Patients over 60 years old resident within the Bradford metropolitan district discharged home after a new stroke with residual disability.

SETTING

Four day hospitals in two health authorities and domiciliary work undertaken by experienced community physiotherapists.

MAIN OUTCOME MEASURES

Barthel index, functional ambulatory categories, Motor Club assessment, Frenchay activities index, and Nottingham health profile were used. Carers' stress was indicated by the general health questionnaire. Treatment given and community care provided were recorded.

RESULTS

Of 124 patients recruited, 108 were available for reassessment at six months. Both treatment groups had significantly improved in functional abilities between discharge and six months. The improvements were significantly greater for patients treated at home (Mann-Whitney test; Barthel index, median difference 2 (95% confidence interval 0 to 3) p = 0.01; Motor Club assessment, median difference 2 (1 to 5), p = 0.01). The home treated patients received less treatment (median difference 16 (11 to 21) treatments, p less than 0.001). More than a third of patients in both groups showed depressed mood, and a quarter of care givers were emotionally distressed.

CONCLUSIONS

Home physiotherapy seems to be slightly more effective and more resource efficient than day hospital attendance and should be the preferred rehabilitation method for aftercare of stroke patients. New strategies are needed to address psychosocial function for both patients and care givers.