http://archneurosci.com/?page=article&article_id=39089
1 Rehabilitation Unit, Spedali Civili of Brescia, Italy
*Corresponding author:
Mattioli Flavia, Spedali Civili
of Brescia, 25123 BRESCIA, Italy. Tel: +39-0302027218, E-mail: flaviacaterina.mattioli@gmail.com.
Archives of Neuroscience. In press(In press): e39089 , DOI: 10.5812/archneurosci.39089
Article Type: Research Article;
Received: May 10, 2016;
Revised: Aug 26, 2016;
Accepted: Sep 25, 2016;
epub: Oct 15, 2016;
Abstract
Background: Evidences
show that generally stroke patients receiving greater amount of
physiotherapy obtain better motor function over time, although this has
not been investigated in the early post stroke population. The aim of
the present observational retrospective study was to investigate the
relationship between the amount of physiotherapy provided to early post
acute stroke patients and their motor improvement.
Methods: Overall,
846 early stroke patients with hemiparesis, treated with physiotherapy,
were retrospectively analyzed. Clinical data at admission as well as
functional scales at the first evaluation and at discharge were
analyzed. For each patient, a rehabilitation load (resulting from the
total number of the 30’ daily consecutive physiotherapy sessions they
received) was used as the dose of physiotherapy. Pre and post
rehabilitation scales were analyzed and their change (Δ) was correlated
with the rehabilitation load.
Results: The
mean rehabilitation load was ten sessions (range 2 to 56). The scores of
Barthel index, Motor Assessment Score, Motricity index for both lower
and upper limb, Functional Ambulation Classification, Berg Balance scale
and Trunk control test significantly improved from pre to post
rehabilitation, and a significant correlation was found between the
rehabilitation load and the improvement in Barthel index (P < 0.05),
Motor Assessment Score, Motricity Index for upper and lower limb (P
< 0.001), Berg Balance scale (P < 0.05) and Trunk control test (P
< 0.001).
Conclusions: In
this study, a significant correlation was found between early post
stroke motor rehabilitation dose and greater improvement in functional
scales, assessing patient’s independence, balance and paretic limb’s
motricity.
Keywords: Stroke; Rehabilitation; Hemiparesis
1. Background
In western countries, stroke represents the third cause of death, the second cause of dementia and the first cause of severe loss of independence. Although stroke incidence and stroke-related death were reported to have decreased, longitudinal studies show an increase in the absolute number of strokes and of the stroke impact on disability in the world. Approximately 800,000 people in the USA have their first or recurrent stroke each year. The prevalence of chronic stroke in the USA is estimated at about seven million1, with about 80% of patients with stroke being over the age of 65. The prevalence of stroke is likely to increase in the future due to the aging population. Even though acute stroke care has improved, for example by large-scale application of recombinant tissue plasminogen activator (rTPA) (1, 2) and organized interdisciplinary inpatient stroke care (3) (Stroke Units in Italy), a large number of patients still remain disabled regardless of the time that has elapsed post stroke.
Only 12% of the patients with stroke are independent in basic Activities of Daily Living (ADL) at the end of the first post stroke week (4). In the long term, 25 to 74% of patients have to rely on human assistance for basic ADLs, like feeding, self-care and mobility (5). In Italy ischemic stroke was reported in 80% of cases in the whole stroke population, whereas hemorrhagic stroke was diagnosed in 20%. Stroke incidence was 6.5% in the general population, respectively 7.4% in males and 5.9% in females (6).
Multidisciplinary rehabilitation of stroke is recommended as the gold standard by several authors (7, 8) and better outcomes in patients, who underwent more intense motor rehabilitation regimens, than in patients, who received lower intensity ones have been reported, based on data taken from several randomized clinical trials, usually conducted on mixed acute and chronic large post stroke patients’ populations, including patients submitted to several different rehabilitative therapies (9). To the best of our knowledge, the role of different amounts of physiotherapy in specific timeframes after stroke has not been exhaustively investigated till now, although early post stroke rehabilitation is recommended and prescribed worldwide. Pathophysiological mechanisms underlying motor recovery after stroke are supposedly different between acute post stroke and the chronic phase (10), consequently different effects are expected to be obtained by physiotherapy in different post stroke periods.
In Italy, stroke patients, usually admitted to the Stroke Unit for acute care including thrombolysis, are referred to rehabilitation units, as soon as the critical conditions have been managed and the diagnostic procedures are concluded. Afterwards, they are often transferred to Rehabilitation Units until recovery is completed. In nearly all the Italian Stroke Units, early physiotherapy is started for patients, who present motor deficits and then are prosecuted in the rehabilitation units or (in milder cases) in outpatient settings. Their functional evaluation at admission in and at discharge from the Stroke Unit is frequently performed, including several scales measuring, both daily living patient’s abilities and independence, ambulation quality or motor functions. Obviously, only a limited number of these patients appear to be completely recovered at the time of discharge from the Stroke Unit and do not need further rehabilitation, the majority of them need to be treated at specific rehabilitation units.
Although the effects of rehabilitation on motor recovery have been studied in several researches on patients with post stroke time of more than 10 to 30 days (9), to the best of our knowledge, the effect of early post stroke rehabilitation, as offered in the Stroke Unit, on functional independence and motor abilities of patients has not been investigated till now. This has both clinical and cost-effectiveness implications, considering the allocation of rehabilitative resources within acute care hospitals (11).
This real life retrospective study was conducted on patients with hemiparesis/hemiplegia due to stroke admitted to the stroke unit of the Spedali Civili of Brescia from January 2012 to May 2015, to evaluate the correlation between the dose of physiotherapy provided in the early post stroke phase and different functional scales. We also investigated, on the basis of these results, which scales revealed to be the most useful to be used to detect functional motor improvement early after the stroke.
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