Outcome measurement in stroke rehabilitation research

Aspects of Selecting Outcome Measures to Demonstrate the Effectiveness of Comprehensive Rehabilitation

To enable clinicians to make an informed choice when selecting outcome measures to demonstrate the effectiveness of comprehensive rehabilitation, what objective criteria should be examined? This article considers the importance of the purpose, content, psychometric properties and ease of administration in selecting measures. Several outcome instruments evaluating self-care and mobility, mental health interventions and comprehensive rehabilitation approaches are examined with reference to these selection criteria. Measures that evaluate physical, psychological and social functioning, taking into account the desired outcome of the patient and his/her carers, are highlighted.

Coordinating and Planning Services for Stroke Patients in Hospital and the Community

Much published research into the rehabilitation of patients following stroke has documented the lack of coordination between the various services for stroke patients and the Ineffectiveness of the targeting of services for patients. In an attempt to improve this situation, a stroke liaison officer has been recruited from the occupational therapy profession in South Staffordshire. Her role is to coordinate and plan services for stroke patients in hospital and the community and to act as a focal point for communication for patients, relatives and carers. The article explains the background to the project and identifies those areas where the stroke liaison officer may have an impact.

The reliability of stroke outcome measures

Assessments of outcome in stroke should include measures of the broader aims of rehabilitation, such as handicap, mood and perceived health, and these measures should be reliable. This study compared the test-retest reliability of the Barthel, Nottingham Extended Activities of Daily Living, Geriatric Depression Score (GDS) and the Nottingham Health Profile (NHP) by postal survey of 21 stroke patients six months after their stroke. There was significant variation between test and retest scores in all the scales but the NHP and GDS were much less reliable than the disability measures, perhaps because they measure less objective or more intrinsically variable quantities. Unreliability is important because it adds to the observed variance of any study population, making it more difficult to detect real differences between groups. Analysis of test-retest reliability should be an essential part of the development of questionnaires. Currently recommended outcome measures require further development to improve reliability.

Patients' satisfaction with stroke services

Patient satisfaction with stroke services is a key aspect of the evaluation of the quality of services but there are no adequate means of assessing satisfaction in this area. A questionnaire derived from in-depth interviews was piloted on two samples. The resulting questionnaire consisted of two sections, one on inpatient services (Hospsat) and the other on services in the community (Homesat). It was sent to 219 patients, who had had a stroke six months previously, along with postal versions of the Barthel ADL index, the Nottingham Extended ADL Scale, the Nottingham Health Profile, the short form of the Geriatric Depression Scale and the Faces Scale. The response rate for the questionnaires was 87%.

Test-retest reliability and tests of internal consistency of the satisfaction scales were carried out on a subsample of this population. Convergent and discriminant validity were explored by examining correlations with the above measures.

The satisfaction questionnaire had construct validity with significant correla tions between the Barthel ADL Index ( r = 0.39), the Nottingham Extended ADL Scale ( r= 0.38) and the physical mobility subsection of the Nottingham Health Profile ( r= -0.36). Internal consistency was high for both sections (Cronbach's Alpha: Hospsat 0.86; Homesat 0.77). Test-retest reliability was fair; the mean difference for total scores was 0.59 (SD = 2.4) for Hospsat, and 0.32 (SD = 2.1) for Homesat.

A high level of dissatisfaction was uncovered. Just under half (48%) of people were dissatisfied with some aspect of the care they received in hospital and over half (53%) were dissatisfied with some aspect of the services they received in the community. The highest rate (54%) of dissatisfaction was with the amount of therapy received.

Good patient satisfaction measures are useful since they complement 'objective' outcome measures and may highlight areas in need of evaluation and improvement.

Understanding the experience of stroke: a mixed-method research agenda

The use of both quantitative and qualitative strategies to examine a single research question has been a subject of considerable controversy and still remains a largely uncommon practice in the sociology of health and illness. Yet, when seeking to understand the meaning of a chronic disabling condition in later life from a social psychological perspective, a mixed-method approach is likely to provide the most comprehensive picture. This article provides an overview of the usefulness and appropriateness of a mixed-method approach to understanding the stroke experience. I comment on the current state of research on the experience of stroke, including epistemological and ontological orientations. Using real data examples, I address paradigmatic assumptions, methods of integration, as well as challenges and pitfalls in integrating methods. I conclude by considering future directions in this field of research.

Satisfaction with medical rehabilitation in patients with orthopedic impairment

OBJECTIVE

To examine patient satisfaction after orthopedic impairment at 80 to 180 days after inpatient rehabilitation.

DESIGN

Retrospective design examining records from facilities subscribing to the Uniform Data System for Medical Rehabilitation (UDSmr).

SETTING

Information submitted to UDSmr from 1997 to 1998 by 177 hospital and rehabilitation facilities from 40 states.

PARTICIPANTS

The sample (N=7781) was 72.63% female and 88.60% non-Hispanic white, with a mean age +/- standard deviation of 73.07+/-11.81 years, and average length of stay (LOS) of 13.84+/-10.48 days.

INTERVENTION

Usual rehabilitation care. Main outcome measures Level of satisfaction 80 to 180 days after discharge as well as motor, cognitive, and subscale ratings for the FIM trade mark instrument. Predictor variables included gender, age, English language, marital status, discharge setting, LOS, rehospitalization, FIM gain, and primary payer.

RESULTS

A logistic regression model was used to predict patient satisfaction at follow-up. Five statistically significant (P<.05) variables were found and correctly classified 94.9% of the patients. Discharge motor FIM rating, rehospitalization, age, patient's primary language, and discharge setting were associated with increased satisfaction. Discharge motor FIM ratings were significantly associated with increased satisfaction in patients with joint replacements and lower-extremity fractures.

CONCLUSION

unctional and demographic variables were identified as predictors of satisfaction in patients with orthopedic impairments.

Effect of functional gain on satisfaction with medical rehabilitation after stroke

OBJECTIVE

To examine the association between gain in motor and cognitive functional status with patient satisfaction 3-6 mo after rehabilitation discharge.

DESIGN

Patient satisfaction and changes in functional status were examined in 18,375 patients with stroke who received inpatient medical rehabilitation. Information was obtained from 144 hospitals and rehabilitation facilities contributing records to the Uniform Data System for Medical Rehabilitation and the National Follow-up Services.

RESULTS

Data analysis revealed significant (P < 0.05) differences in satisfaction responses based on whether information was collected from patient self-report or from a family member proxy, and the two subsets were analyzed separately. Logistic regression revealed the following significant predictors of satisfaction for data collected from stroke patients: cognitive and motor gain, rehospitalization, who the patient was living with at follow-up, age, and follow-up therapy. In the patient-reported data subset, compared with patients who showed improved cognitive or motor functional status, those with no change, respectively, had a 31% and 33% reduced risk of dissatisfaction. In addition, rehospitalized patients had a higher risk of dissatisfaction. For the proxy reported data subset, significant influences on satisfaction were health maintenance, rehospitalization, stroke type, ethnicity, cognitive FIM gain, length of stay, and follow-up therapy.

CONCLUSIONS

Ratings of satisfaction with rehabilitation services were affected by change in functional status and whether the information was collected from patient rating or proxy response.

Brief comprehensive quality of life assessment after stroke: the assessment of quality of life instrument in the north East melbourne stroke incidence study (NEMESIS)

BACKGROUND AND PURPOSE

Generic utility health-related quality of life instruments are useful in assessing stroke outcome because they facilitate a broader description of the disease and outcomes, allow comparisons between diseases, and can be used in cost-benefit analysis. The aim of this study was to validate the Assessment of Quality of Life (AQoL) instrument in a stroke population.

METHODS

Ninety-three patients recruited from the community-based North East Melbourne Stroke Incidence Study between July 13, 1996, and April 30, 1997, were interviewed 3 months after stroke. Validity of the AQoL was assessed by examining associations between the AQoL and comparator instruments: the Medical Outcomes Short-Form Health Survey (SF-36); London Handicap Scale; Barthel Index; National Institutes of Health Stroke Scale; and Irritability, Depression, Anxiety scale. Sensitivity of the AQoL was assessed by comparing AQoL scores from groups of patients categorized by severity of impairment and disability and with total anterior circulation syndrome (TACS) versus non-TACS. Predictive validity was assessed by examining the association between 3-month AQoL scores and outcomes of death or institutionalization 12 months after stroke.

RESULTS

Overall AQoL utility scores and individual dimension scores were most highly correlated with relevant scales on the comparator instruments. AQoL scores clearly differentiated between patients in categories of severity of impairment and disability and between patients with TACS and non-TACS. AQoL scores at 3 months after stroke predicted death and institutionalization at 12 months.

CONCLUSIONS

The AQoL demonstrated strong psychometric properties and appears to be a valid and sensitive measure of health-related QoL after stroke.

Postacute stroke guideline compliance is associated with greater patient satisfaction

OBJECTIVE

To determine if the structure of care or the process of stroke care, as measured by compliance with stroke guidelines published by the Agency for Healthcare Research and Quality (AHRQ), is associated with patient satisfaction.

DESIGN

Prospective inception cohort study of new stroke admissions including postacute care with follow-up interviews at 6 months poststroke.

SETTING

Eleven Veterans Affairs medical centers (VAMCs).

PARTICIPANTS

A total of 288 new stroke patients admitted to VAMCs.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Compliance with AHRQ stroke guidelines and patient satisfaction with care using a stroke-specific instrument.

RESULTS

Process of care was positively and significantly associated with greater patient satisfaction even after controlling for patient functional outcome. The most visible (to the patient) process of care dimensions correlated most highly with patient satisfaction. Sixty-four percent (73/115) of patients expressed some dissatisfaction with 1 or more survey items.

CONCLUSIONS

"What we do" and "how we do it" while providing postacute care to stroke patients was associated with patient satisfaction. This linkage of process to outcome is an important validation of satisfaction as a significant patient outcome. This linkage is further evidence that compliance with AHRQ stroke guidelines may be a valid quality of care indicator.

Satisfaction with medical rehabilitation in patients with cerebrovascular impairment

OBJECTIVE

Overall satisfaction has important social and economic implications for patients who have received inpatient medical rehabilitation. We conducted this study to examine the overall satisfaction level at 3- to 6-mo follow-up for inpatients with cerebrovascular impairments discharged from medical rehabilitation.

DESIGN

The study was retrospective using information from a national database representative of medical rehabilitation patients across the United States. Information submitted in 1997 and 1998 to the Uniform Data System for Medical Rehabilitation by 177 hospital and rehabilitation facilities from 40 states was examined. The final sample included 8,900 patient records. The main outcome measure was the level of satisfaction with medical rehabilitation at 80-180 days postdischarge follow-up.

RESULTS

A logistic regression model including ten independent variables was used to predict satisfied vs. dissatisfied at follow-up. Three statistically significant variables were included in the final model and correctly classified 95.1% of the patients. Higher FIM instrument discharge scores were associated with increased satisfaction. Further analysis of the FIM instrument subscales indicated that higher ratings in transfers, social cognition, and locomotion were significantly associated with increased satisfaction.

CONCLUSION

We identified several functional variables associated with increased satisfaction after medical rehabilitation in persons with stroke. The ability to objectively assess patient satisfaction is important as consumer-based outcome measures are integrated in accreditation and healthcare evaluation.

Living with stroke: a phenomenological study

Understanding how stroke sufferers experience their stroke and recovery is essential if the development of rehabilitation services is to be effective and appropriate. Previous research in this area has tended to be either cross-sectional or with a limited amount of informant follow-up, and consequently has limited utility. This paper describes a study underpinned by a phenomenological approach, which tracked the experiences of six patients admitted to a rehabilitation unit in the north-west of England. Informants were followed for at least 12 months after stroke, and a total of 73 interviews were undertaken during the study. The data demonstrate that recovery from stroke involved restructuring and adaptation in physical, social and emotional aspects of an individual's life. Two important features of recovery were highlighted. First, whilst aspects of pre-stroke life may be used to describe individual progress, no end-point to recovery was identified as informants described and anticipated life with stroke. Second, informants focused on the social context of recovery where engagement in the social world was emphasized over discrete physical function. Although no common path of recovery was found, it is recommended that stroke services are structured to take account of the long-term needs of stroke patients and their families in their home environment.

Social reintegration after stroke: the first stages in the development of the Subjective Index of Physical and Social Outcome (SIPSO)

OBJECTIVE

To ensure at outset the content validity of a measure (to be developed) of social integration following stroke.

DESIGN

Qualitative study, using in-depth interviews with patients at least six months following stroke.

SETTING

Community setting, Bristol, UK.

SUBJECTS

Thirty survivors of stroke, discharged at least six months previously from a neurological rehabilitation unit in a district general hospital.

RESULTS

Patients reported a change, usually for the worse, in their levels of integration following stroke. More specifically they alluded to a decrease in both the quantity and quality of activities, especially with regard to leisure and those activities occurring outside the home. Social interaction was reduced in most patients, in terms of frequency and quality of contact. From the data, six dimensions of change in quality of interaction emerged. Finally, changes in patients' physical and financial environments were reported. Based on the findings, four diagrams were developed, providing a structure for questionnaire development.

CONCLUSIONS

The results of this study confirm the findings of previously reported research. An individual's level of social integration can be affected by stroke in a wide variety of areas and along many different dimensions. Data from this study have highlighted the importance of the patient's subjective impression of the quality of both functional and social performance. This has provided the opportunity to develop a questionnaire based on the patient's perspective, rather than that of health professionals.

Longer term quality of life and outcome in stroke patients: is the Barthel index alone an adequate measure of outcome?

OBJECTIVES

To consider whether the Barthel Index alone provides sufficient information about the long term outcome of stroke.

DESIGN

Cross sectional follow up study with a structured interview questionnaire and measures of impairment, disability, handicap, and general health. The scales used were the hospital anxiety and depression scale, mini mental state examination, Barthel index, modified Rankin scale, London handicap scale, Frenchay activities index, SF36, Nottingham health profile, life satisfaction index, and the caregiver strain index.

SETTING

South east London.

SUBJECTS

People, and their identified carers, resident in south east London in 1989-90 when they had their first in a life-time stroke aged under 75 years.

INTERVENTIONS

Observational study.

MAIN OUTCOME MEASURES

Comparison and correlation of the individual Barthel index scores with the scores on other outcome measures.

RESULTS

One hundred and twenty three (42%) people were known to be alive, of whom 106 (86%) were interviewed. The median age was 71 years (range 34-79). The mean interval between the stroke and follow up was 4.9 years. The rank correlation coefficients between the Barthel and the different dimensions of the SF36 ranged from r = 0.217 (with the role emotional dimension) to r = 0.810 (with the physical functioning dimension); with the Nottingham health profile the range was r = -0.189 (with the sleep dimension, NS) to r = -0.840 (with the physical mobility dimension); with the hospital and anxiety scale depression component the coefficient was r = -0.563, with the life satisfaction index r = 0.361, with the London handicap scale r = 0.726 and with the Frenchay activities index r = 0.826.

CONCLUSIONS

The place of the Barthel index as the standard outcome measure for populations of stroke patients is still justified for long term follow up, and may be a proxy for different outcome measures intended for the assessment of other domains.

The Frenchay Activities Index in stroke patients: agreement between scores by patients and by relatives

The aim of the study was to compare stroke patients' own scorings of the Frenchay Activities Index with scorings based on interviews with their nearest relatives. Fifty-two patients and relatives were interviewed separately 1 year after the stroke. The mean sumscore based upon information from the patients was 29.0, and that based upon the relatives' replies was 27.7 (mean difference 1.4, 95% confidence interval (CI) -0.1 to 2.8). The Kendall tau B correlation between the two sumscores was 0.72 (95% CI 0.63 to 0.81). In half of the patients the two sumscores differed by four points or more, and in every fourth the two sumscores differed by six points or more. The weighted kappa for the single items varied between 0.36 and 0.89. No characteristics of patients or relatives were identified that were related to disagreement between the two scores.

Clients' view of neuropsychological rehabilitation

Postacute neuropsychological rehabilitation cannot be done successfully without the personal engagement of the brain-injured client. However, systematically collected data referring to clients' satisfaction with rehabilitation programmes are rare. In this study a structured interview was developed to assess various aspects of treatment evaluation by clients. In addition, handicap was judged by primary therapists. An aetiologically mixed sample of 130 mildly to moderately brain-injured clients undergoing a comprehensive neuropsychological rehabilitation programme was investigated. About two-thirds of the sample seemed content with the training programmes whereas a minority (13%) of mostly highly handicapped persons reported being largely discontented. In this respect no differences between cognitive, speech/language, and physical therapies were found. Even though many subjects were satisfied with the programme, a majority of clients desired a substantial amelioration in the future (80%), judged their life quality as reduced in comparison to the time preceding brain injury (77%), reported difficulties in accepting 'deficits' (52%), and were frightened of becoming dependent on others (52%).

Therapists and the rehabilitation process after stroke

Therapists working in an experimental stroke unit were interviewed about how they set goals for rehabilitation, how they measure progress, and about problems of discharging patients. In addition the interview covered the topics of quality in rehabilitation, the relationship between patient and therapist, and therapists' evaluation of the stroke unit. The therapists felt that current outcome measurement instruments did not capture the kinds of results that they felt were important. They were process-oriented, and not only outcome-oriented as in traditional studies of stroke rehabilitation. This explorative study provides an insight into how therapists view the stroke rehabilitation process, and elaborates themes for future studies of physical and occupational therapy in rehabilitation.

A population-based assessment of the impact and burden of caregiving for long-term stroke survivors

BACKGROUND AND PURPOSE

Little attention has been focused on the demands on caregivers in stroke outcome research. A major aim of this study was to identify factors in patients associated with emotional distress in caregivers 1 year after stroke.

METHODS

One-year stroke survivors with residual handicap (defined by the Oxford Handicap Scale) and their chief caregivers were interviewed as part of the follow-up activities for patients (n = 492) registered with the Perth Community Stroke Study. We assessed emotional distress in caregivers using the Hospital Anxiety and Depression Scale and the 28-item General Health Questionnaire. Appropriate sections of the Social Behaviour Assessment Schedule were used to assess the patient's behavior and the impact on the caregiver's life. Other aspects of the patient's functional state were assessed with the Barthel Index, the Mini-Mental State Examination, the Frenchay Activities Index, and the Psychiatric Assessment Schedule (at 4 months after stroke).

RESULTS

Of 241 patients who survived to 1 year after stroke and were living outside of an institution, 103 patients (43%; 95% confidence interval, 37% to 49%) were handicapped. Eighty-four patient/caregiver units were assessed from this latter group. Almost all caregivers reported adverse effects on their emotional health, social activities, and leisure time, and more than half reported adverse effects on family relationships. Forty-six caregivers (55%) showed evidence of emotional distress on either of the two screening instruments, particularly if they were caregiving for patients with dementia and/or abnormal behavior. There was no significant relationship between emotional illness among caregivers and the degree of patients' physical disability.

CONCLUSIONS

In this population, the high level of emotional distress among caregivers of stroke patients suggests that many caregivers have unmet needs. Community services need to focus attention on the neuropsychological aspects of stroke patients and the social functioning of caregivers who support them.

Patients' experience of rehabilitation after stroke

In this study patients were interviewed concerning their experience of rehabilitation in an experimental stroke unit. The patients reported positive effects of being together with other stroke patients and used the unit in a self-help group fashion. They felt that they could have used more rehabilitation, even though they were hospitalized for longer than reported in other studies. Patients felt that there were important non-physical problems in connection with their rehabilitation, and that sufficient attention was not given to all of these. Finally patients underlined the positive effects of the rehabilitation process in helping them organize their coming life in the community.

Handicap one year after a stroke: validity of a new scale

The aim was to determine the handicap experienced by subjects one year after a stroke, and assess the acceptability, validity, and reliability of a new handicap measurement scale. A cross sectional survey of 141 survivors of a cohort of consecutive hospital admissions with acute stroke was undertaken. The London handicap scale (a new health outcome measurement scale), Barthel index, Nottingham extended activities of daily living scale, Nottingham health profile, Geriatric depression score, and a global life satisfaction scale were used. 94 subjects (67%) responded to a single mailing; 89 (95%) responses were usable. Mean handicap was 0.40 (range 0.06-1.0, SD 0.20) on a scale of 0 (maximum handicap) to 1 (no handicap). All handicap dimensions showed a wide range of problems, with physical independence and occupation particularly affected. Correlations between handicap score and other outcome measures were all in the expected direction and of about the strength expected (0.36 < r < 0.69). The reliability coefficient was 0.91, limits of agreement +/- 0.19. The measurements demonstrated substantial handicap one year after a stroke, reflecting considerable unmet rehabilitation needs. The scale proved acceptable to subjects, and the results were consistent with good validity.

Views of survivors of stroke on benefits of physiotherapy

OBJECTIVE

To describe the components of physiotherapy valued by survivors of a stroke.

DESIGN

Qualitative study using in-depth interviews.

SETTING

Two adjacent districts in North East Thames Regional Health Authority.

PATIENTS

82 survivors of stroke taken consecutively from a stroke register when they reached the tenth month after their stroke, 40 of whom agreed to be interviewed.

MAIN MEASURES

Content analysis of interviews.

RESULTS

Patients who agreed to the interview were significantly less likely to be disabled 12 months after stroke than those who did not. Twenty four patients had received physiotherapy, and these were more disabled than those who had not. Patients appreciated physiotherapy. It was believed to bring about functional improvement; the exercise component was valued because it was perceived to keep them active and busy and exercise programmes to follow at home were also valued for the structure they gave to each day; and therapists were considered a source of advice and information and a source of faith and hope.

CONCLUSIONS

Many of the positive aspects of caring which patients described in the context of physiotherapy could be incorporated into the mainstream of rehabilitation care and training. However, health professionals need to be careful not to promote false expectations about recovery.

IMPLICATIONS

The outcome of treatment is of critical importance to patients and should become a central dimension of patient satisfaction questionnaires. The impact of physiotherapy is not confined to reducing physical disability but may also affect wellbeing. The choice of outcome measures in rehabilitation research should reflect this situation.

Functional status and health status

Functional status assessment originated in clinical practice in rehabilitation. Health status assessment, a growing part of health services research, grew from the need to survey the health of large populations. In spite of many common interests, the two fields have had little cross-fertilization. The origins and current status of health status measurement are described, including examples of the most frequently used instruments. Conceptual and methodological issues shared by the two fields are examined with the aim of determining what might be of value to rehabilitation. Health-related quality of life provides a conceptual framework that could broaden the rehabilitation perspective. Health status measures may not be appropriate for clinical management but might be useful as quality of care and outcome indicators.

Stroke rehabilitation outcome. A potential use of predictive variables to establish levels of care

BACKGROUND AND PURPOSE

The most powerful predictors of functional recovery and eventual home discharge among stroke survivors are the initial severity of the stroke and the patient's age. We analyzed a large population of stroke rehabilitation admissions by stratifying subgroups with coherent outcomes in an attempt to define potentially more efficient patterns of providing rehabilitation care.

METHODS

We retrospectively analyzed 520 consecutive patients admitted to a rehabilitation hospital (1 calendar year) with cerebral infarction or hemorrhage. Side of index stroke, age, and functional disability at admission were the independent variables. Change in functional disability and home versus nursing home discharge were the dependent measures.

RESULTS

Recovery was overall most closely related to admission severity and age, but the relations between recovery and independent measures were complex. Patients aged < 55 years all were discharged home whatever their initial severity. Patients admitted with modest functional disability were almost all discharged home (96%), whatever their age. For the remainder of the patients, admission severity and age interacted to create two groups with very different prospects for home discharge (P < .0001). Within the groups that eventually returned home, there were very different rates of functional improvement that were directly related to length of hospital stay.

CONCLUSIONS

Standard clinical measures available at rehabilitation admission carry enough predictive power to define management strategies for stroke survivors. A management algorithm is proposed that might increase the efficiency of stroke rehabilitation programs and might allow comparisons of efficacy between different treatment settings.

The influence of depression, social activity, and family stress on functional outcome after stroke

BACKGROUND AND PURPOSE

This study was designed to assess the quality of life after an active poststroke period of rehabilitation and to investigate the possibility of a return to a working environment for those still of working age.

METHODS

The study was conducted on 180 consecutive patients affected by stroke who were hospitalized for the first time and discharged at least 1 year before the study. The group consisted of 65% men and 35% women with a mean age 65.29 years (SD, 11.22). The period between the stroke and the interview ranged from 12 to 196 months, with a mean of 37.5 months. The average Rankin score on discharge from the rehabilitation center was 2.718 (moderate handicap). The interview took place at home after consent obtained by telephone. The questionnaire included general and personal information regarding the individuals, their socioeconomic position, and scales for daily activity, depression, social activity, and stress produced in the family. The control group consisted of 167 age-matched subjects.

RESULTS

A close correlation was observed in all patients between depression, social activity, and stress caused to relatives. The scores on the individual scales were clearly worse than those for control subjects. The patients received approximately 5 months of rehabilitation after the stroke. Differences emerged between men and women for depression and social activities, with the women scoring worse. In reference to daily life, 70% of prestroke ability was required on average after rehabilitation. The daily activity score at the time of the interview was also strongly influenced by the discharge score. The majority of patients were retired. Of the total, 20.64% returned to work, but not always to the same job and often after readapting to new conditions. Of this population, only 31.5% were women. With regard to the population aged younger than 65 years, 21.42% returned to work. Lesions in the dominant hemisphere do not necessarily seem to rule out return to work, even if associated with aphasia. The main discriminating element was the ability to understand language. The patients were often criticized by their cohabitants; the criticisms most often raised concerned apathy, irritability, and self-centeredness. Sexual activity was depressed in almost all cases.

CONCLUSIONS

Despite the progress made in studying cerebral vasculopathies, patients in the aftermath of a stroke still seem to live unsatisfactorily, as they did many years ago. Useful measures include valid treatment against spasticity, psychological assistance, and greater social support.

Evaluation of stroke rehabilitation by randomized controlled studies: a review

In all, 22 reports of 20 randomized, controlled rehabilitation studies were evaluated. In 18 of these, the design of the trial was parallel, with a cross-over format being employed in the remaining 2 instances. Seven studies related to intensive rehabilitation during the early post-acute period. In six others, specific techniques--sometimes associated with traditional physiotherapy procedures--were compared: biofeedback, perceptual retraining, and amphetamine treatment. Eight experiments evaluated speech therapy in aphasia. Frequently, methodological considerations limited the interpretation of the results. The review showed that: 1) as regards activities of daily life and motor function, differences as between rehabilitation in stroke units on the one hand and non-rehabilitation or rehabilitation in medical wards on the other, were detected in relatively few quality studies and remained particularly inconclusive insofar as life in the home environment was concerned; 2) rehabilitation for aphasia and perceptual dysfunction proved effective for at least several months after acute stroke; 3) in general, examination of the reports cited revealed no differences in the effects of biofeedback and perceptual retraining vs conventional physiotherapy; 4) rehabilitation, whether administered by specialists or amateur caregivers purpose-trained by specialists, proved equally effective for aphasia. These conclusions constitute a valuable basis for the development and evaluation of modern rehabilitation programs for stroke patients.

Stroke: evaluation of long-term rehabilitation effects

A planned prospective documentation of the course of rehabilitation of 303 stroke patients was undertaken using the Bathel-Index as a measure of basic everyday functions and the Guttman-Scale as a measure of complex activities of daily living. These were determined at the beginning of rehabilitation, after an average of 7 weeks of in-patient treatment and one year following the stroke. Four patterns in the course of rehabilitation could be differentiated. The causes of the differing functional results were investigated. Besides a positive spontaneous progress of the underlaying disease with an early reparation of the neurological deficits it is the premorbid status, the overprotection of the physically disabled and the determinative cognitive and mental functions that decide the long term fate of stroke patients.