Assessments are completely worthless unless they point directly to the 100% recovery protocols. I see nothing here that suggests you go from the assessment to the chosen 100% recovery protocol. When the hell will the stroke medical world do ANYTHING TO GET STROKE SOLVED? I'd have you all fired! A lot of dead wood needs to be removed in stroke and until that occurs stroke will never be solved!
Look how bad this is; NOT EVEN MEASURING 100% RECOVERY!
Are you that blitheringly stupid? 100% recovery is the only goal in stroke, if you don't measure that you'll never get there!
You measure RESULTS AND RECOVERY! Not assessments!
Revisiting the core principles of physical rehabilitation after stroke: Recapping the guidelines and underlining the importance of assessment
Background
Both
the UK National Clinical Guideline for Stroke and the NICE Guideline
for Stroke Rehabilitation in Adults were published in 2023 and provide
an important resource for healthcare professionals working in the field
of stroke rehabilitation (Intercollegiate Stroke Working Party, 2023; National Institute for Health and Care Excellence, 2023).
These guidelines are based upon a substantial body of current evidence,
reviewed and interpreted by groups of experts, and distilled into
concise recommendations. Guidelines aim to improve patient care(NOT RECOVERY!) by
summarising the evidence-base to empower healthcare professional and
patient decisions about appropriate healthcare interventions but are not
designed to provide rigid rules that dictate practice (Brouwers et al., 2010; Intercollegiate Stroke Working Party, 2023; Rethnam et al., 2021).
Exact protocols to deliver the recommended interventions are not
described in either NICE or UK National Clinical guidelines(THAT IS YOUR WHOLE FUCKING PROBLEM: NOT WRITING PROTOCOLS! Guidelines are fucking worthless! I'd fire all of you!); however,
the guidelines do reference professional consensus documents and
protocols to inform clinical implementation.
This
is the first of two linked editorials in which we seek to complement
the guidelines by focusing on the core principles that underpin several
of the key interventions they recommend, to support their optimal
delivery. In this first editorial, we will precis the guidelines’
recommendations for motor interventions after stroke, using upper limb
rehabilitation as a critical example. We will then summarise some of the
key elements of assessment, which forms the bedrock for goal setting
and treatment selection. The second editorial will build on these
discussions by drawing upon theories of motor learning and research from
preclinical and clinical studies that inform how selected physical
rehabilitation interventions for the upper limb after stroke can be
delivered to provide maximal benefit.
Despite a clear focus on how,
it is beyond the scope of these editorials to provide a step-by-step
guide for specific interventions for clinicians. Nonetheless, we hope
they will provide occupational and physiotherapists with a useful
clinically relevant summary of the core principles that support the
optimal delivery of recommended physical rehabilitative interventions
for people after stroke.
What do the guidelines tell us?
Where
robust research evidence of effectiveness is available, guidelines
articulate the main elements of treatment (what), subtypes of
presentation (who), location of therapy (where), the timeframe in which
interventions are likely to be effective (when) and how much therapy
(dose) may be beneficial. In addition to the much-discussed increase in
the daily dose of therapy articulated in both guidelines, the 2023
National Clinical Guideline for Stroke has a large section dedicated to
motor recovery, with a focus on exercise, motor retraining and
repetitive task practice as the primary approach of targeted therapy.
The guidelines recommend that rehabilitation services are needs-led,
removing the time constraint to community stroke services, and reflect
the significant time course of recovery. Methods to support personalised care(NOT RECOVERY!) and practice are particularly prominent in the UK National
Clinical Guideline, including a focus on patient education,
self-directed and semi-supervised practice where possible, as well as
group work and telerehabilitation when appropriate. The recommendations
acknowledge fatigue, patient activation and preference are crucial
elements to be considered in designing treatment plans.
There
are nine recommendations for the upper-limb based upon the current
evidence base in the 2023 UK National Clinical Guideline (Intercollegiate Stroke Working Party, 2023).
These include recommendations for use of repetitive task training,
self-directed training, consideration of constraint-induced movement
therapy, electrical stimulation, mental practice, mirror box for
appropriate patients, and for the first time, a recommendation to
consider transcutaneous vagal nerve stimulation for those with mild or
moderate upper-limb weakness. Recommendations pertaining to sensation,
shoulder pain and spasticity, which are all important features of
upper-limb rehabilitation are also covered and remain largely unchanged
from previous editions.
The importance of assessment(Boy are you wrong)
It
is recognised that accurate assessment of impairment and function forms
the bedrock of treatment planning. Skilled clinicians frequently begin
by analysing movement, to identify impairments including
musculoskeletal, neurological and non-motor limitations to function.
Observation and physical assessment are used to guide reasoning of the
cause of limits to range of movement, assess weakness and movement
accuracy, smoothness, speed and pattern which will, in turn, direct
treatment priorities. As we do not yet have readily available kinematic
tools that can reliably assess motor control in clinical settings (Kwakkel et al., 2017),
skilled therapists rely on skilled observation and physical assessment
to guide detailed movement analysis. Particularly during the assessment,
the clinicians use of their hands can provide valuable information
about muscle activation (Bolognini et al., 2016).
It may also give useful somatosensory input to the person with stroke,
with afferent sensory information thought to enhance the person’s
ability to activate muscles, although this has yet to be established
empirically (Bolognini et al., 2016).
The skilled analysis of movement enables prioritisation of the key
components of movement to target to improve performance. In concert with
individual’s goals, these data are vital to guide treatment selection,
starting points and titrate the level of challenge.
We
hope that this first editorial has provided a useful summary of some of
the recommendations for motor recovery in the latest UK guidelines for
stroke and highlighted the importance of several features of assessment
that are vital to guide treatment. In the next editorial, we will
consider the theories that underpin some of the recommended
interventions from the guidelines and provide a summary of the core
principles of motor rehabilitation which inform their optimal delivery.
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