Peter Berman

Use of Time by Stroke Patients. A Comparison of Four European Rehabilitation Centers

Background and Purpose— Differences exist between European countries in the proportion of patients who die or become dependent after stroke. The aim of the present study was to identify differences in the use of time by stroke patients in 4 rehabilitation centers in 4 European countries. Methods— In each of the 4 centers, 60 randomly selected stroke patients were observed at 10-minute intervals using behavioral mapping. Observations took place on 30 weekdays selected at random, on equal numbers of morning, afternoon, and evening sessions. A logistic generalized estimating equation model with correction for differences in case mix and multiple testing was used for the analysis. Results— Overall time available from different professions was the highest in the United Kingdom, but patients in the United Kingdom spent on average only 1 hour per day in therapy. This was significantly less than patients in Belgium and Germany, who spent ≈2 hours, and patients in Switzerland who spent ≈3 hours per day in therapy. In all centers, patients spent less than half their time in interactions and >72% of the time in nontherapeutic activities. Conclusions— Important differences in the use of time were established, which appeared dependent on management decisions rather than the number of staff available. Patients in the Swiss and German centers spent more time in therapy, possibly because of the structured organization of rehabilitation. Further studies will verify whether this has an effect on outcome.

Comparison of rehabilitation practice on hospital wards for stroke patients

BACKGROUND AND PURPOSE The aim of the study was to observe patients on a stroke unit and to compare their activity with that of patients on conventional hospital wards to identify aspects of rehabilitation practice that might account for differences in outcome. METHODS Stroke patients admitted to the hospital were observed on three 8-hour shifts over 3 consecutive days. An observer recorded, at 10-minute intervals, where patients were, what they were doing, and whether their positioning was as recommended by rehabilitation therapists. Patients on a stroke unit were compared with those on conventional wards. RESULTS Stroke unit patients spent less time by their beds and more time in other locations on the ward (P < .001). There were significant differences in the frequency of behaviors observed in the two types of ward (P < .001). Stroke unit patients had significantly more interaction with nurses and therapists (P < .001). They were also more often in the recommended position (P < .001). CONCLUSIONS The proportion of time in therapeutic activity was low in all locations, with patients spending many hours sitting and doing nothing. Despite this, stroke unit patients had more therapeutic contact with staff and were more often in the recommended position. These two features may account for some of the differences in outcome.

Motor and Functional Recovery After Stroke A Comparison of 4 European Rehabilitation Centers

Background and Purpose— Outcome after first stroke varies significantly across Europe. This study was designed to compare motor and functional recovery after stroke between four European rehabilitation centers. Methods— Consecutive stroke patients (532 patients) were recruited. They were assessed on admission and at 2, 4, and 6 months after stroke with the Barthel Index, Rivermead Motor Assessment of Gross Function, Rivermead Motor Assessment of Leg/Trunk, Rivermead Motor Assessment of Arm, and Nottingham Extended Activities of Daily Living (except on admission). Data were analyzed using random effects ordinal logistic models adjusting for case-mix and multiple testing. Results— Patients in the UK center were more likely to stay in lower Rivermead Motor Assessment of Gross Function classes compared with patients in the German center (&Dgr;OR, 2.4; 95% CI, 1.3 to 4.3). In the Swiss center, patients were less likely to stay in lower Nottingham Extended Activities of Daily Living classes compared with patients in the UK center (&Dgr;OR, 0.7; 95% CI, 0.5 to 0.9). The latter were less likely to stay in lower Barthel Index classes compared with the patients in the German center (&Dgr;OR, 0.6; 95%CI, 0.4 to 0.8). Recovery patterns of Rivermead Motor Assessment of Leg/Trunk and Rivermead Motor Assessment of Arm were not significantly different between centers. Conclusions— Gross motor and functional recovery were better in the German and Swiss centers compared with the UK center, respectively. Personal self-care recovery was better in the UK compared with the German center. Previous studies in the same centers indicated that German and Swiss patients received more therapy per day. This was not the result of more staff but of a more efficient use of human resources. This study indicates potential for improving rehabilitation outcomes in the UK and Belgian centers.

Stroke Rehabilitation in Europe What Do Physiotherapists and Occupational Therapists Actually Do

Background and Purpose— Physiotherapy (PT) and occupational therapy (OT) are key components of stroke rehabilitation. Little is known about their content. This study aimed to define and compare the content of PT and OT for stroke patients between 4 European rehabilitation centers. Methods— In each center, 15 individual PT and 15 OT sessions of patients fitting predetermined criteria were videotaped. The content was recorded using a list comprising 12 therapeutic categories. A generalized estimating equation model was fitted to the relative frequency of each category resulting in odds ratios. Results— Comparison of PT and OT between centers revealed significant differences for only 2 of the 12 categories: ambulatory exercises and selective movements. Comparison of the 2 therapeutic disciplines on the pooled data of the 4 centers revealed that ambulatory exercises, transfers, exercises, and balance in standing and lying occurred significantly more often in PT sessions. Activities of daily living, domestic activities, leisure activities, and sensory, perceptual training, and cognition occurred significantly more often in OT sessions. Conclusion— This study revealed that the content of each therapeutic discipline was consistent between the 4 centers. PT and OT proved to be distinct professions with clear demarcation of roles.

The Effect of a Stroke Rehabilitation Unit on Functional and Psychological Outcome: A Randomised Controlled Trial

The outcome of patients receiving rehabilitation on a stroke unit (SU) was compared with that of patients on general medical and health care of the elderly wards (conventional wards; CWs) in a randomi

Five year follow up of a randomised controlled trial of a stroke rehabilitation unit

Caring for stroke patients in stroke units, compared with other hospital locations, leads to decreased mortality and disability at one year.1 A trial of a combined acute and rehabilitation ward in Trondheim, Norway, showed that hospital care improved survival and functional outcome at five years.2 The benefits were attributed to the treatment provided in the first few weeks after stroke. The purpose of this study was to examine the effects of care in a non-acute stroke unit on outcome at five years. The methods and findings of 315 patients at one year of our randomised study comparing a non-acute stroke rehabilitation unit with care on conventional medical and geriatric wards have been published.3 In the present study, we ascertained survival to five years by using hospital records and death certificates. Survivors were traced to establish their residential status and visited by a researcher who was …

Use of time by physiotherapists and occupational therapists in a stroke rehabilitation unit: A comparison between four European rehabilitation centres

Purpose. The aim of this study was to compare the time allocated to therapeutic activities (TA) and non-therapeutic activities (NTA) of physiotherapists (PT) and occupational therapists (OT) in stroke rehabilitation units in four European countries. Method. Therapists documented their activities in 15-min periods for two weeks. They recorded: activity, number of patients, number of stroke patients, involvement of other people, location and frequency of each activity. Kruskal-Wallis tests and negative binomial regression models were used to compare activities between professional groups and between units. Results. The average proportion of TA per day ranged between 32.9% and 66.1% and was higher for PT than for OT in each unit. For OT, significant differences emerged between the units in the proportion of time allocated to TA compared to NTA with British OTs spending significantly less time in TA. In the Belgian unit, three times less time was spent on patient-related co-ordination activities (e.g., administration, ward rounds) compared to the British and Swiss units. Conclusions. Time allocation differed between PT and OT and between units, affecting the time available for TA. Further investigation is necessary to study the effect of work organization in stroke rehabilitation units on the efficiency of rehabilitation regimes.

Rehabilitation needs of community stroke patients

PURPOSE The aim was to identify stroke patients not admitted to hospital, to assess their disabilities and the rehabilitation provided. METHOD Stroke patients were notified by General Practitioners, assessed a month after stroke on measures of impairment and disability and the rehabilitation received was recorded. There were 124 patients notified and 93 assessed. RESULTS Patients showed an average decline of 1.7 on the Barthel Index and 3.6 on the Extended Activities of Daily Living scale from before to after stroke. There were 27% with severe mobility problems and 47% with clinically relevant arm impairment. Many patients had cognitive impairment with only 9% having no deficit. Mood problems were less common with 26% anxious and 13% depressed. Significant stress occurred in 15% of carers. The provision of rehabilitation was low and there was poor correspondence between impairments and services provided. CONCLUSION There is an unmet potential for rehabilitation in stroke patients not admitted to hospital.

Ten year follow-up of a randomised controlled trial of care in a stroke rehabilitation unit

Decreased mortality and reduced disability are well recognised short term benefits of care in a stroke unit.1 Early organised management improves survival up to five years after stroke.2 Only one study has examined the effects of care in a stroke unit for longer than five years,3 and it showed that treatment in a combined acute and rehabilitation stroke unit in Norway conferred benefit even 10 years after stroke. We aimed to examine whether the benefits of a non-acute stroke rehabilitation unit persist for 10 years after stroke. This study was a continuation of the five year follow-up by Lincoln and colleagues.2 We identified participants who had been randomly allocated to receive treatment in a non-acute stroke unit or on conventional wards (general medical wards or wards for the elderly) as part of an earlier trial.4 Ten years after that randomisation, we traced them on hospital and general practice databases. We asked survivors to consent to follow-up with a postal questionnaire. Participants needing help to …

Perceptual impairment and its impact on rehabilitation outcome

The aim of the study was to investigate the effect of perceptual assessment and treatment provided on a stroke unit by comparison with that provided on health care of the elderly and general medical wards. Stroke patients admitted to hospital were randomly allocated to a stroke unit or conventional wards. Perceptual impairment was assessed on entry to the study and at 3, 6 and 12 months after randomization. Stroke unit patients show significantly less impairment of perceptual abilities at all stages after stroke. Perceptual impairment, as assessed using the Rey figure copy, was a significant predictor of outcome as assessed on the Barthel Index, Extended ADL scale and Rivermead Motor Assessment at 12 months after stroke.