Accessing rehabilitation after stroke - a guessing game?

AIM: To explore the use, meaning and value of the term "rehabilitation potential". METHOD: The authors of this commentary met to discuss concerns relating to the pressure on health service staff created by reduced length of stay in acute settings of those who have suffered a stroke and the need to determine the potential of a patient for rehabilitation in order to inform discharge arrangements. Points raised at this meeting were shared with an email group who over a 12-month period contributed to this paper. RESULTS: The group agreed that: (a) Given that there is very limited evidence to guide judgements regarding rehabilitation potential following stroke at an early stage the need for rehabilitation needs to be reviewed on a regular basis over a long period and that this needs to be reflected in clinical guidelines. (b) Rehabilitation needs to be available in a broad range of care settings, in order that discharge from hospital is not equated with a lack of rehabilitation potential. (c) Research related to rehabilitation potential needs to be conducted. This should examine influences of decision-making and the algorithms associated with recovery and local policy on rehabilitation potential. (d) The economic benefits of rehabilitation needs further exploration. (e) Assessment of rehabilitation potential should be made more explicit and supported by appropriate evidence. CONCLUSION: Whilst further research is required to assist in determining the right time for people to benefit from formal rehabilitation this gives the impression that one dose of rehabilitation at a specific time will meet all needs. It is likely that a rehabilitation pathway identifying features required in the early stages following stroke as well as that required over many years in order to prevent readmission, maintain fitness and prevent secondary sequelae such as depression and social isolation would be beneficial. Implications for Rehabilitation The potential of a patient to benefit from rehabilitation may be overlooked due to other pressures. Some patients following a stroke will demonstrate potential to benefit from rehabilitation later than the majority and this is not always easy to predict. Regular reassessment is required in order to identify whether an individual will benefit from rehabilitation at a particular time.

Effects of mobilization and tactile stimulation on chronic upper-limb sensorimotor dysfunction after stroke.

OBJECTIVE: To explore the effects of Mobilization and Tactile Stimulation (MTS) and patterns of recovery in chronic stroke (>12mo) when upper limb (UL) "performance" has reached a clear plateau. DESIGN: Replicated single-system experimental study with 8 single cases using A-B-A design (baseline-intervention-withdrawal phases); length of baseline randomly determined; intervention phase involved 6 weeks of daily MTS to the contralesional UL. SETTING: Community setting, within participants' place of residence. PARTICIPANTS: Individual stroke survivors (N=8; male-to-female ratio, 3:1; age range, 49-76y; 4 with left hemiplegia, 4 with right hemiplegia) discharged from ongoing therapy, more than 1 year post stroke (range, 14-48mo). Clinical presentations were varied across the sample. INTERVENTIONS: Participants received up to 1 hour of daily (Monday to Friday) treatment with MTS to the UL for 6 weeks during the intervention (B) phase. MAIN OUTCOME MEASURES: Motor function (Action Research Arm Test [ARAT]) and motor impairment (Motricity Index [MI] arm section) of the UL. RESULTS: UL performance was stable during baseline for all participants. On visual analysis, improvements in motor impairment were seen in all participants, and clinically significant improvements in motor function were seen in 4 of 8 participants during the intervention phase. Latency between onset of intervention and improvement ranged from 5 to 31 days (ARAT) and from 0 to 28 days (MI). Improvements in performance were maintained on withdrawal of the intervention. Randomization tests were not significant. CONCLUSIONS: MTS appears to improve UL motor impairment and functional activity many months, even years, after stroke onset. Improvement can be immediate, but more often there is latency between the start of intervention and improvement; recovery can be distal to proximal.

Intervenção nutricional em grupo de funcionários com sobrepeso ou obesidade praticantes de atividade física: um ensaio clínico randomizado / Nutritional intervention in a group of overweight or obese practitioners of physical activity: a randomized clinical trial

Objetivo: Avaliar o impacto da intervenção nutricional em praticantes de atividade física com sobrepeso ou obesidade. Métodos: Ensaio clínico randomizado com adultos praticantes de atividade física com sobrepeso ou obesidade (n=35). Os indivíduos foram divididos em dois grupos: controle (n=15) e intervenção (n=20). Ambos os grupos foram submetidos a um protocolo de exercício misto composto de atividades aeróbicas e com pesos durante três meses. O grupo intervenção recebeu prescrição de dieta individualizada e acompanhamento nutricional. Foram mensurados peso e estatura para cálculo posterior do IMC, circunferência abdominal, circunferência de quadril, percentual de massa magra e percentual de gordura corporal. Resultados: O grupo intervenção reduziu 3 kg de peso ao final do estudo, enquanto o grupo controle, apenas 1 kg (p=0,008). Após três meses, o IMC (p=0,008) e a relação cintura-quadril (p=0,011) foram menores no grupo intervenção. Conclusões: A intervenção nutricional aliada à atividade física promoveu redução no peso, IMC e RCQ em grupo de praticantes de atividade física com sobrepeso ou obesidade.

Aim: To evaluate the impact of nutritional intervention in overweight or obese practitioners of physical activity. Methods: Randomized clinical trial of overweight or obese adult practitioners of physical activity (n=35). The subjects were divided into two groups: control (n=15) and intervention (n=20). Both groups were submitted to a mixed exercise protocol of aerobic activities and weight training during three months. The intervention group was prescribed an individualized diet and nutritional follow-up. Weight and height were measured to calculate later BMI, waist circumference, hip circumference, percentage of lean mass, and percentage of body fat. Results: The intervention group reduced 3 kg at the end of the study, whereas the control group reduced only 1 kg (p=0.008). After three months, both BMI (p=0.008) and waist–hip ratio (WHR) (p=0.011) were reduced in the intervention group. Conclusions: Nutritional intervention combined with physical activity promoted reduction in weight, BMI, and WHR in a group of overweight or obese practitioners of physical activity.

Prevalência de síndrome metabólica em uma população de pacientes com excesso de peso (funcionários de um hospital de referência) / Prevalence of metabolic syndrome in a population of overweight workers at a reference hospital

Objetivo: Avaliar a prevalência da síndrome metabólica (SM) em uma população de pacientes com excesso de peso. Métodos: Estudo transversal realizado com 290 pacientes atendidos no ambulatório de medicina interna do Serviço de Medicina Ocupacional do Hospital de Clínicas de Porto Alegre, que consultaram por queixa de excesso de peso. Os critérios de inclusão foram idade acima de 18 anos, índice de massa corporal igual ou superior a 25 kg/m2 e ausência de diabetes melito. A SM foi definida segundo os critérios do National Cholesterol Education Program Adult Treatment Panel III. Resultados: A prevalência geral da SM neste grupo de indivíduos foi de 20,0%. Quando avaliamos apenas os pacientes com obesidade, a prevalência foi de 24,6%. Conclusões: A prevalência da SM foi semelhante à da população em geral, mesmo no grupo de obesos – um grupo teoricamente com maior risco de desenvolvimento da síndrome

Objective: To evaluate the prevalence of metabolic syndrome (MS) in a population of overweight patients. Methods: A crosssectional study was conducted in 290 patients, regularly receiving care at the internal medicine ambulatory of the Division of Occupational Medicine at Hospital de Clínicas de Porto Alegre, who had complaints of overweight. Inclusion criteria were age over 18 years, body mass index equal or higher than 25 kg/m2 and absence of diabetes mellitus. MS was defined according to criteria by the National Cholesterol Education Program Adult Treatment Panel III. Results: Prevalence of MS in this group of individuals was 20.0%. When only patients with obesity were assessed, prevalence was 24.6%. Conclusions: Prevalence of MS was similar to that of the general population, even in the group of obese patients, a group that theoretically has higher risk of developing MS