Goal setting in stroke rehabilitation: a systematic review and qualitative synthesis of the experiences and perspectives of healthcare professionals

 You INCOMPETENTLY DON'T KNOW THAT THE ONLY GOAL IN STROKE IS 100% RECOVERY!  You're all fired! Your tyranny of low expectations is complete bullshit! Don't you dare push that crapola on survivors!

Goal setting in stroke rehabilitation: a systematic review and qualitative synthesis of the experiences and perspectives of healthcare professionals

Nils Rickardsson*, Anna Fiserova, Sarlota Duchonova, 

Hannah Hafiz, Martina Hagarova, Brodie Morton, 

Helena Tessmann, Christopher D. Graham

*Corresponding author for this work

• Psychology

Research output: Contribution to journal › Article › peer-review

•  

Abstract

 Goal setting is an integral component of stroke rehabilitation. It refers to a collaborative process where patients and one or several members of the multidisciplinary team(The only voice to be listened to is the survivors; The team has no say because their incompetence needs to be exposed, not agreed to!) agree on specific, often time-limited, targets.1 Such collaboration helps ensure that goals are both personally meaningful to the patient and clinically focused in light of stroke-related impairments. In practice, goals in rehabilitation may involve short-term, quantifiable, aspects of progress in the rehabilitation setting, such walking a twenty-meter distance for someone with mobility problems.(WOW! A massively low bar, so you can declare success, even though that IS NOT SUCCES FOR THE PATIENT who demands full recovery!) Goals can also be more long-term, and relate to participation in the community, such as attending a concert with a loved one.

Empowering stroke survivors: understanding the role of multidisciplinary rehabilitation Impact of stroke

Multidisciplinary teams  KNOW NOTHING ABOUT 100% RECOVERY!  Ask them! I consider them pretty much useless. 

Oops, I'm not playing by the polite rules of Dale Carnegie;  'How to Win Friends and Influence People'. 

Telling supposedly smart stroke medical persons they know nothing about stroke is a no-no even if it is true. 

Politeness will never solve anything in stroke. Yes, I'm a bomb thrower and proud of it. Someday a stroke 'leader' will try to ream me out for making them look bad by being truthful, I look forward to that day. 

 The latest invalid chest thumping here:

 

Empowering stroke survivors: understanding the role of multidisciplinary rehabilitation Impact of stroke

• Urvashy Gopaul, PhD, MSc
• Demers Marika
• Marina Charalambous
• William R Reed

Published:April 24, 2023DOI:https://doi.org/10.1016/j.apmr.2022.12.199

Stroke is one of the leading causes of disability worldwide, with someone having a stroke every 40 seconds in the United-States[1]. A stroke can occur by clot that interrupts blood flow in the brain. It can also be caused by a burst of a blood vessel that causes bleeding in the brain. There are also other unknown causes of stroke which occur less frequently. A stroke causes brain cells to die as they no longer receive oxygen and nutrients from the blood. Some of the most common risk factors of stroke are high blood pressure, high cholesterol, heart diseases, diabetes, smoking, physical inactivity, and obesity[2]. Unfortunately, one in three adults has at least one of these conditions or habits[1].

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Multidisciplinary teams ‘need to be in lockstep’ for optimal outcomes in stroke care

Multidisciplinary teams  KNOW NOTHING ABOUT 100% RECOVERY!  Ask them! I consider them pretty much useless. 

Oops, I'm not playing by the polite rules of Dale Carnegie;  'How to Win Friends and Influence People'. 

Telling supposedly smart stroke medical persons they know nothing about stroke is a no-no even if it is true. 

Politeness will never solve anything in stroke. Yes, I'm a bomb thrower and proud of it. Someday a stroke 'leader' will try to ream me out for making them look bad by being truthful, I look forward to that day. 

 The latest invalid chest thumping here:

Multidisciplinary teams ‘need to be in lockstep’ for optimal outcomes in stroke care

Stroke is the fifth leading cause of death in the U.S., responsible for more than 160,000 deaths yearly, and is strongly tied to heart disease, the leading cause of death, which is responsible for nearly 25% of deaths, according to the CDC.

Collaboration between interdisciplinary health teams, such as neurology and cardiology departments, should be a fundamental best practice to deliver a focused team-based approach to stroke care.(NOT RESULTS OR RECOVERY! Why would you use them if they know nothing about 100% recovery?) While this approach can result in better outcomes for stroke patients, most modern hospitals and medical centers are not set up to support an interdisciplinary approach. Given the antiquated organizational structure in hospital systems, overlap between departments is limited, with each department designated with its own cost center and ultimately accountable for its own budget.This siloed structure maintains rigid fiscal accountability but often impedes the ability of teams to adopt new, innovative technologies. Newer technologies are often expensive and, unless one department can convince another to share the expense, a single department would need to pay the full cost from its own budget.

Recently, industry leaders have advocated for a centralized budgeting approach to make it easier for medical centers to adopt new technologies, and the industry has begun to make moves in this direction. Calls for an interdisciplinary approach to care for complex conditions, such as stroke, may prompt more to follow suit.

The interdisciplinary advantage

A multidisciplinary approach to stroke treatment and care has proven to result in improved outcomes for many stroke patients. Founded more than a decade ago, the Mass General Institute for Heart, Vascular and Stroke Care is a model of how multidisciplinary care teams can be structured. Its stroke service coordinates all aspects of cerebrovascular diagnosis, treatment and ongoing care.(NOT RESULTS OR RECOVERY!) Working in close contact with the medical center’s emergency department, this multidisciplinary team comprises a lead stroke physician who manages dedicated resources including emergency physicians, neurologists, neuroradiologists, cardiologists, physicians and others.

Simply assembling a cross-disciplinary stroke care team, however, doesn’t automatically result in better care outcomes. To be successful, these teams need to be in lockstep in terms of communication and coordination of care. While each team member will have their own area of expertise, treatment responsibilities and perspectives on appropriate care options, the larger group must align on the objectives of the care program as well as planning and decision-making based on the patient’s reaction to treatment.

Inevitably, distinctions between some care roles will become blurred. Potential confusion can be minimized through clear and consistent communication, both during and outside of regular meetings with the entire team. A U.K. review of randomized trials in which stroke patients were treated with a coordinated multidisciplinary approach found “unequivocal evidence” that this type of organized stroke care improved patient outcomes (Clarke DJ, et al).

The role of technology

Advanced technologies are enabling significant progress in stroke treatment. Many of these are minimally invasive or noninvasive, making stroke treatment and rehabilitation easier for the patient. Artificial intelligence holds considerable promise in honing the accuracy of platforms in use today, although it remains in relatively early phases. Other advanced technologies are in more common use today, helping to save lives and reduce the effects of stroke.

Telemedicine experienced a surge in use during the pandemic, making it one of the easiest technologies for interdisciplinary teams to implement. Telemedicine can provide patients in remote or underserved areas with access to neurologists and other stroke specialists who can coordinate treatment and rehabilitation via virtual consultations. Similarly, doctors in remote hospitals can leverage a “telestroke network” connecting remote facilities with regional stroke centers, allowing more patients to receive timely care.

Telemedicine can also be used to provide follow-up care, such as surgical checkups, physical and speech therapies, and other rehabilitation support. When paired with a wearable device such as a smartwatch, stroke patients’ vital signs can be monitored remotely, alerting health care providers if changes indicate a potential issue.

Another example is transcranial Doppler (TCD), a noninvasive monitoring technique that uses ultrasound technology to measure blood flow to the brain. TCD is used to provide real-time information that can help guide stroke treatment decisions.

For example, neurologists can use TCD to monitor patients after a brain hemorrhage to help with early identification of secondary issues like vasospasm. TCD can also be used to help determine the underlying cause of a stroke, which can enable more informed treatment decisions.

Because multiple care teams can benefit from TCD, the equipment is a good candidate for a shared investment between cardiology and neurology, and potentially the emergency department. This cost-sharing eases the impact on a single department’s budget while enabling the facility to provide leading-edge stroke care.

Increasingly, technology is being used to break down organizational barriers and facilitate interdisciplinary collaboration in stroke treatment. Only by continually working in tandem with complementary specialties will the prognosis and recovery of stroke patients improve.

References:

• Clarke DJ, et al. J Multidiscip Healthc. 2015;doi:10.2147/JMDH.S68764.
• Deaths and mortality. https://www.cdc.gov/nchs/fastats/deaths.htm.
• Hospital budget systems are holding back innovation. https://hbr.org/2018/03/hospital-budget-systems-are-holding-back-innovation. Published March 29, 2018. Accessed April 18, 2023.
• Massachusetts General Hospital launches Institute for Heart, Vascular and Stroke Care. https://www.healio.com/news/cardiology/20130411/10_3928_1081_597x_20130101_01_1098134. Published April 1, 2013. Accessed April 18, 2023.
• Multidisciplinary approach to patient care and research in the management of stroke patients. https://www.hmpgloballearningnetwork.com/site/eplab/articles/multidisciplinary-approach-patient-care-and-research-management-stroke-patients. Published April 2014. Accessed April 18, 2023.

For more information:

Ajay Yadlapati, MD, is an interventional cardiologist at Sharp HealthCare in San Diego.

Op-Ed: Treating Stroke Requires a Team of Specialists

And yet those specialists fail 88% of the time in getting patients fully recovered when tPA is given.  And that doesn't even consider the fact that only a miniscule percentage of patients that should get tPA actually get tPA.  We haven't even mentioned that only 10% of stroke survivors get fully recovered. THIS IS WHY I CONSIDER EVERYTHING IN STROKE A FAILURE.  No one is addressing any of these massive failures in stroke.  Check out these 13 problems in stroke with nothing to address them. Survivors are just supposed to accept that stroke is so fucking hard to solve that your disability for life is an acceptable consequence. Everybody in stroke needs to be fired, specially when they write chest thumping articles like this. 

Op-Ed: Treating Stroke Requires a Team of Specialists

A multifaceted approach for a multifaceted disease

by Jeremy Payne, MD, PhD July 13, 2020

A woman experiencing progressive confusion, disorientation, and finally severe hallucinations was placed in a locked psychiatric unit, where she declined rapidly.
Only when the woman exhibited facial weakness and numbness did her physicians order brain imaging and discover she had experienced a series of small strokes.
When she was eventually brought to our stroke center, our team of specialists quickly made a diagnosis of vasculitis, a rare immune condition that attacks the arteries, ultimately damaging the brain. In retrospect, her symptoms were quite classic, but by then our diagnosis was too late.
While the woman's disease was rare, this outcome was not.
Too often, stroke patients are initially sent to the wrong place. Sudden loss of vision, for example, typically results in referral to an ophthalmology clinic, although this can be a common emergent stroke symptom, too.
When a patient presents to a physician's office with a history suggestive of stroke, a common community practice is to refer to a cardiologist. Only a fraction of strokes are actually directly related to the heart, however. Hypertension is a common disease but may not actually have a bearing on the reason any particular patient has a stroke.
While there is significant overlap in the risk factors for brain and cardiac vascular disease, there are many important exceptions.
Stroke can be particularly tricky because it can present with various symptoms that mask its true cause. The symptoms result from sudden loss of function in part of the brain when its blood supply is interrupted and can be as varied as the brain's function itself.
The ideal strategy for diagnosis and treatment of brain vascular disease requires a multidisciplinary team, preferably led by a vascular neurologist.
Stroke is a multifaceted disease. As we learn to better leverage connections across clinical disciplines, we will better serve these patients. I encourage all clinicians to reach out to vascular neurologists at primary and comprehensive stroke centers, both for emergent cases and for assistance in ensuring outpatients are afforded a thorough evaluation and plan of care.
Such centers are designed to harness the knowledge of multiple clinical disciplines under the direction of vascular neurology specialists. Certified comprehensive stroke centers, in particular, offer a complete range of diagnostic and treatment strategies.(The operative word here is strategies NOT RESULTS!)
Jeremy Payne, MD, PhD, is the director of the Comprehensive Stroke Center at the Banner-University Medicine Neuroscience Institute in Phoenix.

Face and content validity and clinical utility of the Structured Observational Test of Function (SOTOF) from the perspective of patients with a neurological diagnosis and a stroke rehabilitation multi-disciplinary team

No clue.

Face and content validity and clinical utility of the Structured Observational Test of Function (SOTOF) from the perspective of patients with a neurological diagnosis and a stroke rehabilitation multi-disciplinary team

Text (MSc by Research Thesis)
MARRISON EDEN THESIS.pdf - Published Version
Restricted to Repository staff only until 31 December 2021.
Available under License Creative Commons Attribution Non-commercial No Derivatives.

Introduction
The Structured Observational Test of Function (SOTOF) is a standardised, valid and reliable test for older people with neurological conditions (Laver and Powell 1995), assessing occupational performance in four activties of daily living and associated neuropsychological deficits. The 2nd edition enhanced the dynamic element and introduced a scored graduated mediation protocol (Laver-Fawcett and Marrison 2016). This study aimed to explore the face validity, and aspects of content validity and clinical utility of the 2nd edition.

Method
Two sample groups were recruited: in-patient participants (≥ 60 years) with neurological diagnoses; and members of a stroke rehabilitation multi-disciplinary team (MDT). Patient participants undertook a semi-structured interview after completing SOTOF. MDT participants either participated in a semi-structured focus group or an online survey. Interviews and the focus group were audio-recorded, transcribed verbatim and analysed through thematic analysis. Survey data was analysed using descriptive statistics and thematic analysis.

Results
Patients (N = 10) agreed with more positive than negative rated statements related to their feelings about SOTOF. The majority recognised the purpose of the test. Themes were the: impact of the assessor on test experience; importance of the appropriateness of assessment level of difficulty; value for patients learning about their abilities / disabilities; and the realisation that patients may not absorb as much information as thought. MDT participants (N = 19) took part in the focus group (n = 11) or survey (n = 8). Themes were the: reliance on verbal handover; usefulness of scores to communicate results; lack of MDT’s awareness of SOTOF; and the usefulness of SOTOF to inform practice.

Conclusion
This study has contributed to the evidence base for the 2nd edition of SOTOF, establishing good face validity from patients’ perspectives and potential for clinical utility with the MDT. Content validity could not be established from the MDT perspective.

Item Type:	Thesis (Masters)
Status:	Published
Subjects:	R Medicine > RM Therapeutics. Pharmacology > RM695 Physical therapy. Occupational therapy
School/Department:	School of Health Sciences
URI:	http://ray.yorksj.ac.uk/id/eprint/4623

Effectiveness of a multidisciplinary approach in the rehabilitation treatment of post-stroke patients at the outpatient stage of medical rehabilitation

Multidisciplinary is a useless big word used to disguise the fact your stroke team KNOWS ABSOLUTELY NOTHING ABOUT 100% STROKE RECOVERY.

Hope your doctor knows Russian.

Effectiveness of a multidisciplinary approach in the rehabilitation treatment of post-stroke patients at the outpatient stage of medical rehabilitation

• Authors: Fakhretdinov V.V.¹, Brynza N.S.¹, Kurmangulov A.A.¹
• Affiliations:
  1. Tyumen State Medical University
• Issue: Vol 26, No 1 (2020)
• Pages: 4-9
• Section: Health care organization and public health
• URL: https://journals.eco-vector.com/0869-2106/article/view/25848
• DOI: https://doi.org/10.18821/0869-2106-2020-26-1-4-9
• Cite item

(Russian)

Abstract

Background. Current approaches to the rehabilitation of stroke patients are based on the early start of rehabilitation measures, a certain sequence, duration, and, of course, the active participation of the patient and their environment. Recently, the scientific medical community has engaged in a serious discussion on the organization of rehabilitation from the perspective of a multidisciplinary approach.
Aim. To assess the impact of the multidisciplinary approach to the outpatient rehabilitation phase on the main health components in stroke patients.
Materials and methods. An experimental, longitudinal, open study included 60 patients with stroke in the late residual period. The studied patients were classified into groups using stratification randomization: Group 1 – 30 (50%) patients with high rehabilitation potential, as well as a high degree of personal interest in undergoing the outpatient phase of medical rehabilitation; Group 2 – 30 (50%) patients who had rehabilitation potential but were, for several reasons, forced to refrain from undergoing the outpatient phase of medical rehabilitation. The duration of the outpatient rehabilitation phase was 14 days: the course of rehabilitation treatment included 10 visits to the rehabilitation department, which operates on the principles of lean manufacturing and a quality management system; 2 days of medical leave; and 2 days of independent work by patients. The multidisciplinary team included a neurologist, physiotherapy physiologist, physical therapy instructor, speech therapist, psychologist, occupational therapist, and a social worker who received special training in medical rehabilitation. As the criteria for assessing the effectiveness of rehabilitation measures during the course of this study, we identified 11 key indicators that allowed us to assess the recovery of neurological deficit, motor functions, possible risk of patients falling, psycho-emotional state, cognitive functions, level of disability, frequency of repeated strokes, number of visits to the clinic place of residence, level of independence, and quality of life of the patient.
Results. When we compared these groups in response to the course of rehabilitation treatment, the patients who passed the outpatient stage achieved a positive result of 91% (a positive response to 10/11 criteria for evaluating effectiveness(Did the effectiveness questions ask about 100% recovery? If not, you didn't ask the correct questions.), while the percentage of response to treatment in the second group was 18% (positive answer for 2/11 criteria for evaluating effectiveness).
Conclusion. To achieve the rehabilitation goals and objectives set for the patient in the late recovery period, it is advisable to conduct the outpatient phase of medical rehabilitation.

Keywords

stroke, rehabilitation, multidisciplinary approach, multidisciplinary team, drop, depression, anxiety, quality of life.

Full Text

Актуальность исследования

Инсульт является одной из самых актуальных медико-социальных и экономических проблем современного общества, продолжая занимать лидирующее место среди всех цереброваскулярных заболеваний по распространенности, смертности и стойкой инвалидизации среди взрослого населения [1, 2]. Современные подходы к реабилитации пациентов, перенесших мозговой инсульт, основаны на раннем начале реабилитационных мероприятий, определенной последовательности, длительности и, конечно, активном участии самого пациента и его окружения [3]. При этом в поздний восстановительный период (6 мес –2 года) инсульта особо возрастает значимость решения задач по поддержанию и совершенствованию когнитивных функций и речи, активному перемещению пациентов с помощью средств дополнительной опоры, совершенствованию ходьбы и навыков самообслуживания [4]. В последнее время в научном медицинском сообществе серьезно обсуждается организация реабилитации с позиции мультидисциплинарного подхода [5, 6]. Объединение специалистов в мультидисциплинарную бригаду, оказывающую помощь в лечении и реабилитации пациентов и работающих как единая команда (бригада) с четкой согласованностью и координированностью действий, открывает новые возможности в реализации задач реабилитации. С этой связи целью настоящего исследования явилась оценка влияния мультидисциплинарного подхода этапа амбулаторной реабилитации на основные компоненты здоровья у пациентов, перенесших инсульт.

Материал и методы

В экспериментальное продольное открытое исследование были включены 60 пациентов с инсультом в позднем восстановительном периоде. Критериями включения в исследование – верифицированный диагноз ишемический инсульт давностью от 6 месяцев до 2-х лет; значения по шкале реабилитационной маршрутизации (ШРМ) 2-3 балла; возможность продуктивного контакта с самим пациентом и его близкими; подписание добровольного информированного согласия на исследование и использование современных методов реабилитации. Критериями исключения из исследования – давность инсульта более 2 лет и менее 6 месяцев; возраст менее 40 и более 80 лет; тяжелая сопутствующая соматическая патология; высокие риски несоблюдения протокола исследования и др.
Исследуемые пациенты были определены в группы методом стратификационной рандомизации: 1 группа – 30(50%) пациентов, имеющих высокий реабилитационный потенциал, а также высокую степень личной заинтересованности прохождения амбулаторного этапа медицинской реабилитации; 2 группа – 30(50%) пациентов, имеющих реабилитационный потенциал, но в силу ряда причин отказавшиеся от прохождения амбулаторного этапа медицинской реабилитации. Достоверные различия групп по возрасту, полу и стадиям заболевания отсутствовали.
Длительность амбулаторного этапа реабилитации составила 14 дней. Курс восстановительного лечения включал в себя 2 дня лечебного отпуска; 2 дня самостоятельной работы пациентов, 10 посещений отделения реабилитации, функционирующего на принципах бережливого производства и системы менеджмента качества. В основе бережливого подхода устанавливалось снижение основных и дополнительных потерь со стороны пациента (прием в одном помещении, снижение трансакционных издержек, организация приема по принципу «точно-вовремя», сокращение ненужной транспортировки медицинских документов) и со стороны медицинских сотрудников отделения (организация рабочего пространства по методу 5S, визуализация данных, внедрения метода всеобщего обслуживания оборудования) [7, 8]. В состав мультидисциплинарной бригады входили прошедший специальную подготовку по вопросам медицинской реабилитации врач-невролог, врач лечебной физкультуры, инструктор лечебной физической культуры, нейропсихолог-логопед, психолог, эрготерапевт, социальный работник. В данном составе бригада разрабатывала индивидуальный план медицинской реабилитации с учетом выраженности неврологического дефицита, а также функциональных нарушений пациента. Для адекватного отражения изменений в состоянии пациента, проделанной медицинским и педагогическим персоналом работы и повышения мотивации к процессу реабилитации использовались клинические шкалы, отражающие патологический процесс, изменения в различных системах. В процессе проведения восстановительного лечения в ежедневном режиме проводилась повторная оценка состояния пациента и корректировался ход восстановительных занятий в зависимости от результатов оценки, что позволило снизить неэффективное использование ресурсов и повысить качество восстановительно лечения.
В качестве критериев для оценки эффективности реабилитационных мероприятий в ходе настоящего исследования были определены 11 основных показателей, позволяющих оценить восстановление неврологического дефицита, моторные функции, возможные риски падения пациентов, психоэмоциональное состояние, когнитивные функции, уровень самостоятельности и качества жизни пациента.
Полученные данные были обработаны статистически в программном пакете Statistica 10.0. Нормальность распределения значений параметров оценивали с использованием критерия Шапиро–Уилка. Данные были представлены в виде среднего арифметического ± стандартное отклонение. Для дальнейших расчетов использовали методы параметрической статистики: для количественных признаков в сравнении групп – критерий Стьюдента, для сравнения показателей внутри одной группы в разные моменты времени – парный критерий Стьюдента. Критический уровень значимости (p-value) при проверке статистических гипотез принимали равным 0,05.

Результаты и обсуждение

Двухнедельная динамика показателей физического компонента здоровья пациентов, перенесших инсульт, оказалась более выраженной в четырех из пяти анализируемых показателей у пациентов, которые находились на амбулаторной реабилитации (табл. 1).

Таблица 1
Динамика показателей физического компонента здоровья пациентов, перенесших инсульт, на фоне амбулаторной реабилитации
№	Показатель		1 группа	2 группа	Уровень достоверности (p)
					1-2*	1**	2***
1	ШРМ, баллы	исх.	2,53±0,5	2,40±0,5	0,309	<0,05	0,528
2		2 нед	2,20±0,5	2,33±0,5	0,251
3	Индекс Ривермид, баллы	исх.	13,40±0,7	13,53±0,6	0,432	<0,01	0,735
4		2 нед	13,97±0,8	13,57±0,6	<0,05
5	Шкала Рэнкин, баллы	исх.	2,57±0,5	2,60±0,5	0,798	<0,01	0,262
6		2 нед	2,17±0,5	2,47±0,5	<0,05
7	ВАШ, баллы	исх.	3,23±1,1	3,03±0,9	0,427	<0,05	&lt0,05
8		2 нед	2,33±0,5	2,40±0,5	0,599
9	Коэффициент падений, баллы	исх.	2,53±0,7	2,90±0,9	0,085	<0,05	0,182
10		2 нед	2,23±0,6	2,70±0,7	<0,01
Примечание. * – различия между 1 и 2 группой; ** – различия 1 группы в динамике; *** – различия 2 группы в динамике.

ШРМ (шкала реабилитационной маршрутизации) чувствительна для оценки реабилитационного потенциала пациентов, перенёсших инсульт. При сравнении эффективности восстановительного лечения при исходно одинаковых значениях в обеих группах (2-3 балла) только пациенты с амбулаторным этапом реабилитации показали статистически значимую положительную динамику (13,0%) снижения значений ШРМ. Быстрое снижение неврологического дефицита, оценённое по ШРМ, в данной группе способствует в дальнейшем более благоприятному исходу инсульта.
Уровень мобильности, оцененный по индексу мобильности Ривермид, статистически значимо увеличился (p<0,01) на 4,3% у пациентов 1 группы. В то же время пациенты 2 группы по способности перемещать собственное тело не продемонстрировали динамику через 2 недели (p>0,05).
Степень нарушенных функций и самостоятельности в повседневной жизни при исходно одинаковых значениях (p>0,05) в обеих группах статистически значимо (p<0,01) снизилась на 18,4% у пациентов, прошедших двухнедельную амбулаторную реабилитацию. При этом значение шкалы Рэнкин во 2 группе снизилось только на 5,3%, что оказалось статистически не значимо (p>0,05).
Болевой синдром статистически значимо (p<0,05) уменьшился в обеих группах вне зависимости от формы проводимого восстановительного лечения. При этом значения Визуальной аналоговой шкалы (ВАШ) в обеих группах в динамики оказались сопоставимы (p>0,05). Полученные результаты коррелируют с многочисленными литературными данными [3, 9, 10]. Большинство отечественных и зарубежных исследователей данной проблемы отмечают снижение болевого синдрома у пациентов, перенёсших инсульт, в позднем восстановительном периоде независимо от лечебной и реабилитационной тактики, в том числе и в случаях ее полного отсутствия. Вероятнее всего, в основе данного эффекта лежит активация естественных собственных адаптационных и восстановительных механизмов организма человека [9].
У пациентов 2 группы, по сравнению с группой на амбулаторной реабилитации, установлены более частые случаи травматизма, вызванные частыми падениями пациентов как исходно (+14,6%), так и в процессе двухнедельного наблюдения (+14,6%). При опросе самих пациентов и/или их близких установлено, что у 39% (12/30 человек) отмечались ежедневные падения с высоты собственного роста. В то же время у пациентов 1 группы указанный показатель был значительно ниже – 20% (6/30 человек). Данное осложнение инсульта влияет как на высокий показатель травматизма пациентов 2 группы, так и на выбор тактики восстановительного лечения. 1% (3/10 человек) пациентов 2 группы в течение позднего восстановительного периода имели серьезные повреждения: перелом бедра на стороне пареза – 1 человек, перелом таза – 1 человек, перелом запястья – 1 человек. В 1 группе риск падений был ниже, серьезных травм, полученных при падениях, зафиксировано не было, это могло опосредованно повлиять на активное желание посещения отделения медицинской реабилитации.
Двухнедельная динамика показателей психического компонента здоровья пациентов, перенесших инсульт, оказалась более выраженной по одному из трех анализируемых показателей у пациентов, которые находились на амбулаторной реабилитации (табл. 2).

Таблица 2
Динамика показателей психического компонента здоровья пациентов, перенесших инсульт, на фоне амбулаторной реабилитации
№	Показатель		1 группа	2 группа	Уровень достоверности (p)
					1-2*	1**	2***
1	Когнитивные нарушения, баллы	исх.	24,73±1,3	24,30±1,7	0,274	<0,01	0,320
2		2 нед	25,63±1,8	24,70±1,6	0,036
3	Уровень тревоги, баллы	исх.	4,60±1,5	4,17±1,1	0,209	<0,05	<0,05
4		2 нед	3,93±1,1	3,60±1,0	0,228
5	Уровень депрессии, баллы	исх.	8,77±1,9	8,47±1,8	0,526	<0,05	0,321
6		2 нед	7,93±2,0	8,13±2,4	0,726
Примечание. * – различия между 1 и 2 группой; ** – различия 1 группы в динамике; *** – различия 2 группы в динамике.

При оценке когнитивных нарушений в обеих группах при одинаково низком исходном значении по Монреальской шкале, указывающей на снижение когнитивных функций (внимание и концентрация, исполнительные функции, память, речь, абстрактное мышление, счет и ориентация), в 1 группе отмечена положительная динамика на фоне восстановительного лечения (+3,5%, p<0,01), в то время как во 2 группе динамика анализируемого показателя оказалась статистически не значимой (p>0,05).
Исходно уровень тревожных расстройств пациентов обеих групп соответствовал нормативному показателю и не превышал 7 баллов по Госпитальной школе тревоги и депрессии. Через 2 недели как в 1 группе, так и во 2 группе отмечено снижение показателя тревожности в 1,1 раза (p<0,05). Наличие или отсутствие амбулаторного этапа реабилитации не повлияло на итоговые значения уровня тревоги. Вероятнее всего, подобная динамика объясняется психологической адаптацией к сложившейся ситуации пациентов; завершением острой стадии стрессовой ситуации, вызванной основным заболеванием; принятием собственной личности и окружающего пространства в сложившейся новой реальности необходимости существования с проявлением заболевания, его осложнений и последствий.
В то же время наличие амбулаторного этапа восстановительного лечения, включающего в свой арсенал индивидуальные и групповые занятия с медицинским психологом, отразилось в статистически значимом (p<0,05) снижении уровня депрессии на 10,6% по сравнению с исходными данными. Пациенты 2 группы не показали динамики результатов (p>0,05). При этом динамическое наблюдение данной группы показало увеличение коэффициента вариации показателей с 21% до 30%, что свидетельствует о расширении разброса значений данного признака спустя 2 недели.
Социальная дезадаптация человека является одной из острейших проблем реабилитации постинсультных больных как для системы здравоохранения, так и для общества, в целом. Двухнедельная динамика показателей социального компонента здоровья пациентов, перенесших инсульт, оказалась более выраженной во всех анализируемых показателях у пациентов, которые находились на амбулаторной реабилитации (табл. 3).

Таблица 3
Динамика показателей социального компонента здоровья пациентов, перенесших инсульт, на фоне амбулаторной реабилитации
№	Показатель		1 группа		Уровень достоверности (p)
					1-2*	1**	2***
1	Степень зависимости от близких, баллы	исх.	2,23±0,7	2,17±0,7	0,719	0,107	0,201
2		2 нед	1,97±0,5	2,40±0,6	<0,01
3	Уровень социализации, баллы	исх.	2,20±0,4	2,03±0,6	0,190	<0,05	0,320
4		2 нед	2,53±0,5	2,20±0,6	<0,05
5	Уровень приверженности к лечению, баллы	исх.	2,10±0,4	1,87±0,6	0,073	<0,01	0,203
6		2 нед	2,47±0,6	1,70±0,5	<0,001
Примечание. * – различия между 1 и 2 группой; ** – различия 1 группы в динамике; *** – различия 2 группы в динамике.

Степень зависимости пациентов от близких и родственников оказалась на 22% выше во 2 группе (p<0,01) в сравнении с группой прошедших амбулаторный этап. При долгосрочной оценке через 6 месяцев показатель самостоятельности в группе пациентов, прошедших амбулаторный этап в сравнении с пациентами 2 группы показал статистически значимую разницу (p<0,05). Степень зависимости у пациентов 2 группы статистически значимо возросла (p<0,05). Это дает право предположить, что амбулаторный этап медицинской реабилитации способствует формированию самостоятельности пациентов и снижает степень зависимости от посторонних в повседневной жизни.
При исходно одинаковом уровне социальной активности спустя две недели с момента наблюдения у пациентов 1 группы определялось статистически значимое (p<0,05) повышение уровня потребности межличностного общения, участия в социальных процессах и проявлении интересов. В то время как у 13% (4/30) пациентов 2 группы по результатам опроса близких, напротив, была отмечена тенденция к снижению социализации, уровня вербального общения, реакции на окружающие изменения. В процессе долгосрочного наблюдения 17%(5/30) пациентов 2 группы на фоне отрицания проблем начали злоупотреблять алкоголем (более 8 литров алкоголя в год и 3-4 дня полной трезвости в неделю).
Показатель уровня приверженности к лечению у пациентов 1 группы оказался выше (p<0,01), чем у пациентов 2 группы, что соответствует распределению пациентов по анализируемым группам – одним из стратификационных критериев рандомизации стало согласие пациента проходить амбулаторный этап реабилитации. Стоит также отметить, что прохождение амбулаторного этапа, и, по всей видимости, положительный эффект от реабилитации, статистически значимо (p<0,05) повышает комплаентность пациентов к лечению в будущем: пациенты начинают понимать основные цели реабилитационного процесса, появляется интерес к достижению еще большего реабилитационного потенциала, новых результатов.
Амбулаторной этап реабилитации направлен на стабилизацию течения основного сосудистого заболевания, адаптацию к повседневным бытовым нагрузкам, уменьшению выраженности двигательных и других постинсультных нарушений. К задачам мультидисциплинарной бригады в рамках отделения реабилитации МО относится выработка со стороны пациентов заместительных компенсаций, приспособлении к дефекту, ликвидации артралгий, коррекции психопатологических проявлений, полном или частичном восстановлении бытовой активности.

Заключение

Наличие амбулаторного этапа восстановительного лечения положительно сказывается на состоянии физического, психического и социального компонента здоровья пациентов, перенесших инсульт. В то же время, даже отсутствие амбулаторной реабилитации характеризуется постепенным снижением уровня боли и тревоги, что можно объяснить активизацией собственных адаптационных механизмов организма человека.
Для достижения реабилитационных целей и задач, поставленных перед пациентом в позднем восстановительном периоде, целесообразно последовательное проведение амбулаторного этапа медицинской реабилитации. При данном методе восстановительного лечения положительный эффект отмечается на 91% (10/11) основных критериев оценки, не оказывая влияния, в краткосрочный период, на зависимость пациента от близких и родственников.
В условиях непрерывной оптимизации и усовершенствования системы здравоохранения возникает потребность в использовании систем реабилитации с целью обеспечения успешной и непрерывной реабилитации на амбулаторном этапе с учетом места нахождения больного, а также возможностей перемещения пациента к месту занятий. Подобные методы позволят обеспечить персонифицированный непрерывный процесс реабилитационного лечения, способствующий достижению максимально возможного уровня самостоятельности пациента, а также сохранить уже достигнутые результаты восстановительного лечения. Одной из таких систем может стать дистанционный этап медицинской реабилитации.
Финансирование. Исследование не имело спонсорской поддержки.
Конфликт интересов. Авторы заявляют об отсутствии конфликта интересов.

About the authors

Vitaly V. Fakhretdinov

Tyumen State Medical University

Author for correspondence.
Email: fahretdinov_vv@mail.ru
ORCID iD: 0000-0001-8375-8244

Russian Federation, 625023, Tyumen region, Tyumen, Odesskaya st., 54

graduate student of the department of the department of the department of public health care and health ICPD

Natalya S. Brynza

Tyumen State Medical University

Email: brynzans@tyumsmu.ru
ORCID iD: 0000-0001-5985-1780

Russian Federation, 625023, Tyumen region, Tyumen, Odesskaya st., 54

MD, associate professor of the department of public health and health care ICPD

Al’bert A. Kurmangulov

Tyumen State Medical University

Email: kurmangulovaa@tyumsmu.ru
ORCID iD: 0000-0003-0850-3422

Russian Federation, 625023, Tyumen region, Tyumen, Odesskaya st., 54

Ph. D., associate professor of the department of the department of public health care and health ICPD

References

1. Luk’yanchuk T.P. The use of exoskeleton and functional electrical muscle stimulation in rehabilitation after a stroke. Avitsenna. 2019; (28): 30-2. (in Russian)
2. Fakhretdinov V.V., Brynza N.S., Kurmangulov A.A. Modern approaches to rehabilitation of patients after stroke. Vestnik Smolenskoy gosudarstvennoy meditsinskoy akademii. 2019; 18(2): 182-9. (in Russian)
3. Vlasova D.Yu., Karpov S.M., Sedakova L.V. Cognitive impairment in patients in the post-stroke period. Uspehi sovremennogo estestvoznaniya. 2013; (9): 126-7. (in Russian)
4. Vincent-Onabajo G.O., Owolabi M.O., Hamzat T.K. Sensitivity and responsiveness of the health-related quality of life in stroke patients-40 (HRQOLISP-40) scale. Disabil Rehabil. 2014; 36(12): 1014-9. doi: 10.3109/09638288.2013.825652
5. Vinogralov O.I., Komarov A.N., Pchelentsev M.V. A multidisciplinary approach to the treatment and rehabilitation of stroke. Effektivnaya farmakoterapiya. 2017; (21): 36-44. (in Russian)
6. Galyaev I.Y., Barabanova M.A., Timchenko L.V., Zhadan O.N. Staging and continuity in rehabilitation of patients with neurosurgical issues. Innovatsionnaya meditsina Kubani. 2018; (1): 6-11. (in Russian)
7. Kurmangulov A.A., Reshetnikova Yu.S., Frolova O.I., Brynza N.S. Introduction of the 5S lean manufacturing methodology in the healthcare system of the Russian Federation. Kubanskiy nauchnyy meditsinskiy vestnik. 2019; 26(2): 140-9. (in Russian)
8. Kurmangulov A.A., Reshetnikova J.S., Bagirov R.N., Frolova O.I., Brynza N.S. Possibilities of visualization as a lean method in the management of medical organizations. Meditsinskiy vestnik Yuga Rossii. 2019; 10(1): 6-12. (in Russian)
9. Srailova K.B., Raimkulov B.N., Raimkulova Kh.B., Bhat N.A., Abubakir U.A. Diagnostic parameters of a sickny syndrome in ischemic stroke. Vestnik Kazakhskogo Natsional’nogo meditsinskogo universiteta. 2019; (1): 210-2. (in Russian)
10. Savchuk E.A., Savchuk E.O., Shevchenko I.V. Types of pain syndromes in stroke patients: clinic, diagnosis, treatment. Vestnik fizioterapii i kurortologii. 2018; 24(1): 127. (in Russian)

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Neurorehabilitation After Stroke From Bedside to the Laboratory and Back

A couple comments on what I can read;

There is no long path to recovery; THERE IS NO FUCKING PATH AT ALL

Predicting recovery is not essential; IT IS A TOTAL FUCKING WASTE OF TIME. 

I can't see the multidisciplinary team being that useful: WITH NO PROTOCOLS EVERYTHING IS JUST GUESSWORK AND HOPE. 

Neurorehabilitation After Stroke - From Bedside to the Laboratory and Back

Manuel A. Anaya

,

Meret Branscheidt

Originally publishedhttps://doi.org/10.1161/STROKEAHA.118.023878Stroke. ;0

 

Implementing a function-based cognitive strategy intervention within inter-professional stroke rehabilitation teams: Changes in provider knowledge, self-efficacy and practice

Once again the stroke survivor is responsible for every piece of their recovery, their doctor is doing nothing. 

Implementing a function-based cognitive strategy intervention within inter-professional stroke rehabilitation teams: Changes in provider knowledge, self-efficacy and practice

• Sara E. McEwen ,
• Michelle Donald,
• Katelyn Jutzi,
• Kay-Ann Allen,
• Lisa Avery,
• Deirdre R. Dawson,
• Mary Egan,
• Katherine Dittmann,
• Anne Hunt,
• Jennifer Hutter,
• Sylvia Quant,
• Jorge Rios,
• Elizabeth Linkewich

• Published: March 11, 2019
• https://doi.org/10.1371/journal.pone.0212988

• Article
• Authors
• Metrics
• Comments
• Media Coverage

• Abstract
• Introduction
• Methods
• Results
• Discussion
• Conclusion
• Supporting information
• Acknowledgments
• References

• Reader Comments (0)
• Media Coverage (0)
• Figures

Abstract

Background

The Cognitive Orientation to daily Occupational Performance (CO-OP) approach is a complex rehabilitation intervention in which clients are taught to use problem-solving cognitive strategies to acquire personally-meaningful functional skills, and health care providers are required to shift control regarding treatment goals and intervention strategies to their clients. A multi-faceted, supported, knowledge translation (KT) initiative was targeted at the implementation of CO-OP in inpatient stroke rehabilitation teams at five freestanding rehabilitation hospitals. The study objective was to estimate changes in rehabilitation clinicians’ knowledge, self-efficacy, and practice related to implementing CO-OP.

Methods

A single arm pre-post and 6-month follow up study was conducted. CO-OP KT consisted of a 2-day workshop, 4 months of implementation support, a consolidation session, and infrastructure support. In addition, a sustainability plan was implemented. Consistent with CO-OP principles, teams were given control over specific implementation goals and strategies. Multiple choice questions (MCQ) were used to assess knowledge. A self-efficacy questionnaire with 3 subscales (Promoting Cognitive Strategy Use, PCSU; Client-Focused Therapy, CFT; Top-Down Assessment and Treatment, TDAT) was developed for the study. Medical record audits were used to investigate practice change. Data analysis for knowledge and self-efficacy utilized mixed effects models. Medical record audits were analyzed with frequency counts and chi-squares.

Results

Sixty-five health care providers consisting mainly of occupational and physical therapists entered the study. Mixed effects models revealed intervention effects for MCQs, CFT, and PCSU at post intervention and follow-up, but no effect on TDAT. No charts showed any evidence of CO-OP use at baseline, compared to 8/40 (20%) post intervention. Post intervention there was a trend towards reduction in impairment goals and significantly more component goals were set (z = 2.7, p = .007).

Figures

  

Why motivating your team via goals, milestones and small wins is so important - Your stroke medical team

Is your stroke medical team motivated to get you 100% recovered? Or do you need to call the stroke hospital president and get them some external motivation? Like keeping their jobs? The SPECIFIC GOAL HERE IS 100% RECOVERY. Do not accept anything less.  Yes,  that is a BHAG(Big Hairy Audacious Goal) of 100% recovery for all survivors. But leaders accept and deliver on such challenges. Do you have leaders or not?

Why motivating your team via goals, milestones and small wins is so important

It’s nearly the end of January. How quickly has that gone?! And how many of you have already let your New Year resolutions fall by the wayside? One of the main reasons we fail to achieve what we set out to is because we often set unrealistic, unachievable goals which we don’t check-in on at regular points.
I sometimes come across this in the workplace too. One of the things we examine on my High Performing Team workshops are the objectives and measures of success at an individual and team level. All too often, the managers I work with struggle to clearly define goals and within this, identify what success looks like at points along the year. This is particularly pertinent when you consider a recent study involving 117,000 managers across 32 different countries. Alan Howard and Max Choi found that leadership skills and management skills directly influence a country’s productivity, even when other relevant measures had also been taken into account.

The importance of being as specific as possible

“The power of specific, ambitious goals to improve the performance of individuals and teams is one of the best documented findings in organizational psychology, and has been replicated in more than 500 studies over the past 50 years” – Donald Sull and Charles Sull

One of the best known of these studies is Edwin Locke’s and Gary Latham’s work on Goal Setting Theory, all about “purposefully directed action”. This theory highlights four ways that specific goals connect to performance outcomes:

1. They direct our attention to what’s important
2. They stimulate our effort to focus on what’s important
3. They challenge us to use our knowledge and skills so that we’re more likely to succeed
4. The more challenging the goal, the more likely it is we’ll draw on our range of skills

A poorly worded objective or goal, therefore, might be “Develop a customer service course about handling difficult people”. A better-worded, specific goal might be, “Develop a half-day course about handling difficult people with first session delivered to 20 call-centre supervisors by 31 March, with evaluation of impact taking place one month later and subsequent report written by 15 May.”

The importance of goal difficulty and range

“Decades of research involving over 40,000 participants has shown that people who set difficult and specific goals outperform people who set vague and non-challenging goals” – Brendon Burchard

Researchers from INSEAD found that people believe it’s easier to achieve a small, incremental goal than it is to maintain the status quo. Across six studies, the researchers consistently found that the brain assesses goal difficulty using a two-step process:

1. We estimate the size of the gap to be bridged by the goal. If the gap is zero, the brain then moves to step two…
2. We assess the context within which the goal needs to be achieved.

A key suggestion from this research is that when setting goals, managers should be aware that status quo goals are less attractive than ones involving a slight increment. In other words, you’re more likely to get better performance by increasing expectations on a previous target than keeping it the same. You do your team members no favours by thinking you’re letting them off by keeping the same targets as last year.
And with this in mind, if a goal is geared around a target such as “Get 10,000 followers on our corporate Twitter account” then you are already setting a person up for potential failure. As Steve J Martin, Noah J Goldstein and Robert B Cialdini suggest in their book The small B!g: Small changes that spark big influence, people are much more likely to achieve target-driven goals if the target is set with a high-low range that averages the same, rather than setting a single, specific goal.
Therefore, that Twitter target of 10,000 followers might now state, “Grow our corporate Twitter account to between 5,000 and 15,000 followers by 31 December 2019”. (Although as an aside, and with my old head of communications hat on, you might be better off setting goals around engagement, likes and shares).

The importance of milestones and small wins

“Great big goals set direction and energize people, but if goals are all you’ve got you are doomed. The path to success is paved with small wins” – BOB SUTON

Agreeing with your staff what success looks like at various points in the year is crucial for maintaining focus, momentum and energy levels. Once success has been defined for various objectives, you can then put this into a milestone plan. This is something I used to do with my team managers and we’d review this every quarter at our away days – celebrating successes and understanding where and why we may have fallen short. The latter was important for tweaking milestones in the subsequent quarters.
This approach is backed up by research published in the American Psychological Association’s Psychological Bulletin. Researchers reviewed 138 studies involving nearly 20,000 people which looked at the effectiveness of interventions designed to prompt people to monitor their goal progress. They found that the more people monitored their progress, the greater the likelihood they would succeed in achieving their goal.
Be careful, however. To make monitoring and milestones effective, you need to ensure you’re not managing too much (micromanagement) or too little (laissez faire). This article by Victor Lipman offers some helpful advice around this.

The importance of sharing and communicating

In a popular article from MIT Sloan Management School, the authors suggest that rather than SMART goals, managers develop FAST goals where:
F = Frequently discussed
A = Ambitous
S =  Specific metrics and milestones
T = Transparent for everyone to see
It’s the ‘T’ that I want to pick up on as one of the common issues I find in teams that are under-performing is where individuals, on the same team, have somewhat contradictory objectives. When these aren’t shared, with everyone knowing what each other’s goals are, conflict and tension can occur. Putting everyone’s objectives in a shared place is one way of making things transparent. Another is talking about individual goals in team meetings, as well as in one-to-one meetings.
Another reason sharing and communicating individual goals across the team is so important is that it enables you to plan for things in advance. Researchers from Penn State University found that when barriers got in the way of people taking action against a goal (action crisis), they then started to devalue the goal which made it more likely they wouldn’t achieve that goal. In other words, it impacted people’s commitment to achieving their objective. However, the researchers found that if the person (or their network of friends and colleagues) were to know ahead of time that an action crisis may be imminent, he or she might be more likely to stick to the goal.
This means that as part of the goal-setting process, thinking about potential barriers to achieving goals in advance is crucial; as is coming up with ways of overcoming these barriers. These can also be discussed at team meetings which helps with the transparency and sharing.

If you’re interested in running my High-Performing Teams workshop in-house, why not contact me to find out more? EMAIL ME HERE

Did you find this post helpful? I’d love to know, so Tweet me, or drop me a note on LinkedIn. If you have any colleagues that you feel should read this, too, please share it with them. I’d really appreciate it.
If you liked this post, you might also like these:

• 7 tips for better performance management
• How to motivate your team (there’s more to know than Maslow!)

Rehabilitation After Hemorrhagic Stroke: From Acute to Chronic Stage

Just useless generic blathering. 

Rehabilitation After Hemorrhagic Stroke: From Acute to Chronic Stage

• Authors
• Authors and affiliations

• Yun-Hee Kim

• Yun-Hee Kim
  • 1
  • 2
  • 3
  Email author

1. 1.Department of Physical and Rehabilitation MedicineSungkyunkwan University School of MedicineSeoulSouth Korea
2. 2.Center for Prevention and RehabilitationHeart Vascular Stroke Institute, Samsung Medical CenterSeoulSouth Korea
3. 3.Samsung Advanced Institute for Health Science and TechnologySungkyunkwan UniversitySeoulSouth Korea

Chapter

First Online: 06 September 2018

Part of the Stroke Revisited book series (STROREV)

Abstract

The ultimate goal of rehabilitation in hemorrhagic stroke does not differ from that in ischemic stroke: to reduce disability, regain independence, and improve quality of life. Due to the lack of studies in this specific population, the rehabilitation principles and practice guidelines for hemorrhagic stroke follow those for ischemic stroke. Stroke is a complex syndrome, and the rehabilitation process therefore requires an integrated program provided by a multidisciplinary team.(Why a multidisciplinary team?)  Although controversy about very early rehabilitation in stroke patients has arisen recently, it is generally accepted that early rehabilitation prevents stroke complications and promotes functional recovery. As stroke has various symptoms, the rehabilitation process should include a comprehensive assessment of motor, cognitive, and communication functions, swallowing, and emotions. Medical complications during rehabilitation affect functional recovery and may even increase the risk of mortality in stroke patients. Thus, preventing stroke complications should be considered not only in the acute phase but also in the chronic phase of stroke. Most spontaneous recovery in stroke patients occurs within 6 months after onset, and a substantial number of patients are left with chronic disabilities. Novel therapies to reduce residual disabilities and improve functional outcomes have attracted much attention recently, with rehabilitation robots, virtual reality, and noninvasive brain stimulation being of particular interest in this field. Researchers and clinicians are attempting to combine these novel therapies with conventional stroke rehabilitation. The gathered evidence may impact future rehabilitative practice.