Progress Review Rehabilitation for Stroke: A Review

Transcription

1 363 Progress Review Rehabilitation for Stroke: A Review MARY L. DOMBOVY, M.D., BURTON A. SANDOK, M.D., AND JEFFREY R. BASFORD, M.D. SUMMARY Survivors of stroke are often left with severe mental and physical disabilities, which create a major social and economic burden. Many investigators have attempted to assess the role of rehabilitation in reducing such disability. Few controlled studies provide accurate assessment and documentation of benefit. Because of the presence of multiple variables and inadequate measures of outcome, it is difficult to design studies evaluating the effectiveness of rehabilitation for stroke. It is unclear bow early rehabilitation should begin and what aspects of rehabilitation are important. Intensive rehabilitation is an expensive and limited resource; thus, the ability to identify the subgroup of patients with stroke who are likely to benefit is a critical issue. Although preliminary guidelines for the selection of patients who are appropriate for rehabilitation are given, no uniform criteria reliably differentiate patients who need rehabilitation from those who will recover spontaneously or do poorly. Controlled studies in the practice of rehabilitation for stroke will provide much useful information for patient management. Stroke Vol 17, No 3, 1986 CEREBROVASCULAR DISEASE is the third leading cause of death in the United States. Stroke leaves many of its survivors with mental and physical disabilities, which create a major economic and social burden. 1 Many survivors of strokes receive expensive, time-consuming, and intensive rehabilitation in an attempt to improve independence. Although several investigators have studied the role of rehabilitation in the recovery from stroke, few 27 have provided an accurate assessment and documentation of effectiveness. Current concerns about allocation of health-care services and cost-effectiveness have only reemphasized the need for properly designed research of rehabilitation for stroke. Central issues in rehabilitation for stroke are: How should rehabilitation programs be organized? When should rehabilitation begin? Which patients are likely to benefit from intensive rehabilitation efforts? Where should rehabilitation take place? The purposes of this article are to review the available information and to provide preliminary guidelines for the selection of patients who are most likely to benefit from intensive rehabilitation programs. Cause of Stroke and Its Burden on Society Stroke (cerebral infarction, hemorrhage) is defined as the sudden onset of a focal neurologic deficit due to a presumed local disturbance in the blood supply to the brain. 8 Despite differences in the criteria used to define stroke and in the demographic characteristics of the populations studied, investigators generally agree that in the late 1960s the incidence of stroke was about 1.5 per 1,000 person-years and the prevalence was about 5.0 per 1,000 persons. 9 " 14 More recent data based on the population of Rochester, Minnesota, 15 ' 16 show that From the Department of Neurology and Physical Medicine Rehabilitation, Mayo Clinic and Mayo Foundation, Rochester, Minnesota. Address correspondence to: Burton A. Sandolc, M.D., Mayo Clinic, 200 First Street, S.W., Rochester, Minnesota Received May 15, 1985; revision #1 accepted September 17, although the incidence for stroke has decreased almost 50%, to 0.8 per 1,000 person-years during the period , the prevalence has increased 20%, to 6.0 per 1,000 persons. These observations are expanded on by further epidemiologic data obtained from studies based on the Rochester population from " n - l5-17 The initial 30-day case fatality for stroke is high, averaging 38%. Of patients who survive the acute phase, approximately 50% are alive in 7 years. Other studies are in relatively close agreement with this high rate of survival. 18 " 21 Recently, Garraway et al 13 ' " reported a 16% increase in the 5-year survival after cerebral infarction when the periods and were compared. Soltero et ap noted a gradual decline in mortality from cerebrovascular disease since 1960 and a more accelerated rate of decline since 1968; they attributed these findings to the treatment of hypertension. Residual disability in survivors is difficult to estimate. Variation in subject populations and in the methods used for assessment of disability makes comparison and generalization difficult. Stallones et al 13 estimated that of every 100 survivors of the acute phase of stroke, 10 will return to work without disability, 40 will have "mild" disability, 40 will be severely disabled, and 10 will require institutionalization. Gresham et al 2324 reviewed 148 survivors of stroke from the Framingham cohort and compared their function in several categories (for example, vocational function, social function, ability to perform household tasks, mobility, self-care skills, and institutionalization) with that of age- and sex-matched controls. In each area of comparison, a higher percentage of patients with stroke experienced severe disability. The economic and social impacts of stroke are great. The cost of care plus the loss of earnings due to stroke in the United States is estimated at 7.5 to 11.2 billion dollars per year. 23 In Scotland, it has been estimated that the acute care of patients with stroke alone ac-

2 364 STROKE VOL 17, No 3, MAY-JUNE 1986 counts for approximately 5% of the national health budget. 26 Feigenson et al 27 reported that the initial hospital costs in New York City for patients with acute cerebral infarction in 1977 ranged from $13,052 to $19,285. Costs for rehabilitation after this acute care ranged from $6,000 to $8,000. They believed that the cost of rehabilitation was justified if it decreased the number of patients requiring long-term institutional care, which they estimated at 18,000 to 36,000 per year. The burden on health-care services that this reservoir of disability from stroke creates is likely to increase because of the increasing survival after stroke 15 ' n and the increasing number of elderly persons in the population. 28 Efforts at prevention of stroke, other than the treatment of hypertension, have made little impact on disability from stroke. In addition, attempts to improve the prognosis during the period immediately after stroke by providing intensive-care facilities have been largely unsuccessful. 29 Rehabilitation early after stroke to improve functional ability has been suggested to decrease long-term social and economic costs However, no existing, well-designed, populationbased studies adequately address this cost-benefit equation. Issues in Rehabilitation for Stroke General Principles and Problems Rehabilitation is defined as the combined and coordinated use of medical, social, educational, and vocational measures for retraining a person to the highest possible level of functional ability. 32 In light of this definition, Peszczynski et al 33 of the Joint Committee for Stroke Facilities summarized the accepted and well-established principles of rehabilitation for stroke as follows: 1) prevent or minimize secondary complications, 2) compensate for sensory and perceptual loss, 3) substitute for lost motor function, 4) provide environmental stimulation, 5) encourage socialization, 6) produce a high degree of motivation, 7) enable independent function and home living, and 8) achieve vocational rehabilitation when feasible. Athough there is general agreement that limited physical therapy should begin as soon as possible to prevent complications such as contractures and bed sores, 34 a basic question remains unanswered: is intensive rehabilitation effective for 1) reducing disability after stroke and 2) decreasing long-term social and economic costs? Research in the area of rehabilitation is difficult because of the multiple variables that affect selection and outcome. 33 The studies that have attempted to assess the value of rehabilitation for stroke differ in methods and design, and these differences limit their comparability. Some of the problems that limit comparisons are that most studies are descriptive, and many have inadequately matched or ill-defined control groups. In addition, the subjects are often drawn from selected referrals rather than a defined population, and tests of statistical significance are rarely applied. Another obstacle to evaluating the benefits of stroke rehabilitation is the variability in rehabilitation practice: criteria for patient selection vary among institutions, the interval between the onset of stroke and the commencement of rehabilitation varies both within and between studies, and the duration and type of therapy differ among studies and frequently are poorly described. Finally, measurement of outcome is nonuniform: the variables chosen for assessment differ, multiple indices of functional capacity and activities of daily living are used, and the results are often qualitative or ambiguous. Most studies 18 ' 193I3 «- M that have attempted to address the effectiveness of rehabilitation for stroke for improving function suffer from the above-described problems. The conclusions of these studies differ. Despite these difficulties, if improved functional capacity and disposition are used as end points, these reports suggest that an organized and comprehensive rehabilitation program may be beneficial Timing In 1982, Lind 35 reviewed and attempted to compare seven studies of rehabilitation for stroke 19 ' " 36 ~ 38 ' 43 - x and concluded that spontaneous recovery accounted for most of the noted improvements in functional ability. Because recovery is greatest during the first month after stroke, 56 ' 37 spontaneous recovery clouds the effect that rehabilitation may have on functional gains, particularly the effect of early rehabilitation. Feigenson et al 58 attempted to investigate this issue by comparing the outcomes of patients with similar levels of disability but different intervals to the onset of rehabilitation. They found a higher proportion of dismissals to home among patients who began rehabilitation early than among the other patients. However, they measured disability at the time of admission to the rehabilitation unit and not at identical intervals after stroke. This finding suggests that the severity of stroke in these two patient groups is not equivalent. Although difficult to interpret, two recent studies 39 ' 60 cast further doubt about the importance of early rehabilitation and support the conclusion that patients who begin rehabilitation early are likely to be in better health initially. Type of Program What are the benefits of comprehensive rehabilitation programs in a designated rehabilitation unit compared with efforts in a general medical setting? According to Feldman et al, 36 "The results suggest... that the great majority of hemiparetic stroke victims can berehabilitatedadequately on medical and neurological wards [without formal rehabilitation services] if proper attention is given to ambulation and serf care activities." Although Lind's 55 overall conclusion was that comprehensive rehabilitation offered few advantages, he made two very important observations: 1) although functional improvements attributable to comprehensiverehabilitationmay be slight, they sometimes make the difference between institutionalization and a return home; and 2) carefully selected patients with "margin-

3 REHABILITATION FOR STROKE/Dombovy et al 365 al functional impairment" may benefit from individualized and comprehensive rehabilitation. One of the first controlled studies of rehabilitation for stroke, based on the population of Edinburgh, Scotland, lends further support to the hypothesis that intensive rehabilitation may be effective in a select group of patients. 2 " 5 Patients with stroke were randomized within a few days after onset to either a "stroke unit" or to a medical ward. Functional independence was assessed at dismissal and was found to be greater in the patients in the stroke unit despite similar neurologic deficits in the two groups. This finding suggests that some aspect of the stroke unit, rather than spontaneous recovery alone, was responsible for improvement. The length of hospitalization was shorter for the patients in the stroke unit than for those in the medical wards. Patients in the stroke unit received physical therapy earlier but for a shorter period and were more likely to receive occupational therapy and to receive it earlier. Other important differences between the stroke unit and the medical wards were the presence of rehabilitation nursing, a team approach, and a functionally oriented atmosphere that may have encouraged patients to take a more active role and practice their skills more consistently. Two additional recent population-based controlled trials 6-7 compared the clinical outcome of patients in a special stroke rehabilitation unit with that of patients who received therapy on general medical wards. At both 3 and 12 months after stroke, the percentage of patients living at home was greater for the group who received rehabilitation in a specialized setting. However, differences in independence for activities of daily living were small. Similar to the findings in the Edinburgh study, neither of these two studies could discern what aspects of the stroke rehabilitation ward accounted for the differences in outcome. Also, differences in the methods of patient selection among these trials limit direct comparison of the results. Smith et al, 6 ' in a controlled study of outpatient stroke rehabilitation, found that the degree of improvement correlated strongly with the amount of intensity of therapy. They also found that only a few patients (11% of 1,094 patients admitted to a hospital for stroke) were suitable for intensive outpatient rehabilitation. However, they believed that the treatment was effective and realistic in this selected group. In a recent trial of home-care services for patients with acute stroke, Wade et al 62 noted functional recovery equal to that of patients who received hospital care. There did not appear to be greater stress on families, despite severe initial disability in 27% of the patients managed at home. The suggestion that outpatient rehabilitation and home care are feasible alternatives to hospital rehabilitation may have implications in terms of the future structure of rehabilitation services. Duration of Benefit Only a limited number of studies have studied stroke patients for prolonged periods to assess long-term maintenance of independence. Coughlan and Humphrey 63 noted rather severe degrees of disability in the patients they surveyed, but they provided no data about their status at dismissal. Garraway et al 6 * noted a disappearance of the differences in functional status between patients treated in the stroke unit and those treated in the medical unit at 1 year after dismissal, but Strand et al 7 noted maintenance of these gains. Both authors believed that family education was responsible for the difference. Other studies' 9 ' " ** have also suggested that functional capacity remains relatively stable over time. Further research is needed to determine if functional status is maintained for prolonged periods after rehabilitation in survivors of stroke to be able to assess its effectiveness in reducing long-term social and economic costs. Rehabilitation Potential Although the functional benefits and cost-effectiveness of comprehensive rehabilitation have not been determined, comprehensive rehabilitation may be superior to limited rehabilitation in a subgroup of patients with stroke. Numerous studies have addressed this *issue by attempting to identify prognostic indicators for success or failure in rehabilitation programs. v - " m " 39 ' 67^ Controversy surrounds many of the symptoms, deficits, and other data that have been studied in terms of their usefulness for predicting prognosis after stroke (table 1). However, three recent studies 86 " 88 attempted to develop prognostic indicators or a predictive equation for death and disability after stroke. Allen 84 examined patients 24 hours after stroke and included death as a negative outcome. Thus, many of the indicators may not be applicable in terms of predicting functional outcome. The study by Sheikh et al 87 used retrospective and often incomplete data, and the equation developed by Wade et al 88 was only 55% accurate in predicting functional recovery. These studies have not provided a clinically useful tool to select patients with stroke who are likely to benefit from rehabilitation. The development of clinical criteria to select early (within 7 to 10 days) after stroke the patients who are TABLE 1 Predictors of Functional Outcome After Stroke Negative predictors Possibly negative predictors Coma at onset Incontinence 2 wk after stroke Poor cognitive function Severe hemiparesis or hemiplegia No motor return within 1 mo Previous stroke Perceptual-spatial deficit Neglect or denial syndrome Significant cardiovascular disease Large or deep lesion on computed tomogram Multiple neurologic deficits Hemisensory deficit Left hemiparesis Homonymous hemianopsia Advanced age Language disorder Low premorbid intelligence Lack of spouse or close family members Low socioeconomic class 30 days from onset of stroke to admission

4 366 STROKE VOL 17, No 3, MAY-JUNE 1986 most likely to benefit from comprehensive rehabilitation would have considerable practical value in patient management. The Edinburgh stroke study 3 ' w - * made preliminary steps toward this goal by using a selected subgroup of patients who were conscious and had an established or developing hemiplegia (approximately 25% of all patients with stroke). Patients with a poor prognosis for life and independence and patients who were likely to recover with little or no therapy were excluded. The investigators attempted to refine selection further and administered a clinical examination to the patients at various intervals and classified them into three categories (good, intermediate, or poor) on the basis of prognosis for successful rehabilitation. They noted that care in the stroke unit offered the greatest advantage over care on the medical wards for patients in the intermediate group. Assessment of Outcome As noted, one of the obstacles to developing selection criteria for rehabilitation from stroke is the lack of a uniform and well-defined means of measuring outcome. Generally, measures of functional ability rather than abnormalities on neurologic examination are preferred because patients with similar neurologic findings may perform at different functional levels. 536 " 66 Donaldson et al 91 and Granger 92 believed that outcome scales for rehabilitation must 1) provide an objective description of functional status, 2) be sensitive to allow detection of changed functional status, 3) be simple and reproducible so they can be administered reliably by different professionals, and 4) be standardized to improve communication and evaluation of treatment programs. Functional independence in performing the activities of daily living is measured by many scales, including the Barthel index, 93 ~ 9i the Katz index, 9 * Kenny Self-Care Evaluation, 97 Donaldson Unified Activities of Daily Living Evaluation form, 91 Pulses Profile, 98 and Patient Evaluation Conference System. 99 Additionally, many authors devise their own scales to assess the outcome for rehabilitation. The results of studies are not directly comparable because different scales are based on a patient's ability to perform combinations of different activities. Additionally, the same numerical weight may not be given to a particular activity. Of the three most frequently used scales (Barthel, Katz, and Kenny), the Barthel index seems to have the following advantages: completeness, sensitivity to change, and ease of statistical manipulation. 100 The Rankin classification of dependency 48 has been widely used in the United Kingdom and Europe. It has proved satisfactory for the assessment of dependency after stroke in studies that use medical reviews 15 ' 101 and is compatible with the more objective assessments used in controlled trials of rehabilitation for stroke Compared with the Barthel index, the major advantage of the Rankin scale is its relative simplicity and ease of both application and data retrieval. However, the Rankin scale lacks the detail necessary to detect small changes in function. Guidelines for Selecting Patients No uniform criteria based on controlled studies reliably differentiate the patient with stroke who is likely to benefit from intensiverehabilitationfrom the patient who is likely to do poorly or to recover spontaneously. Yet, rehabilitation is both a limited and an expensive resource that requires such a decision. On the basis of the available data from the above studies, some general comments can be made: 1) decreased alertness, inattention, poor memory, and an inability to learn new tasks or to follow simple commands imply that a patient is not ready or not appropriate for intensive rehabilitation; 2) because of their inability to recognize their deficits and their carelessness toward the neglected side, patients with severe denial or neglect are often difficult to motivate in therapy; 3) significant associated medical problems, particularly cardiovascular disease and degenerative joint disease, may limit a patient's participation in therapy; 4) language difficulties (aphasia) and the degree of weakness may have less of an impact on independence and the return home; 5) the presence of a caring and able spouse may be one of the most significant positive factors in the outcome of rehabilitation; 6) other social and economic factors play important but difficult to define roles; and 7) education of family members may be equally as important asrehabilitationof the patient. Most importantly, when considering rehabilitation, the physician must view the patient with all medical, neurologic, and psychosocial problems as a whole and must not base the decision on the presence or absence of specific deficits. Consultation with a physiatrist or a neurologist specializing in rehabilitation prior to embarking on prolonged, intensive rehabilitation efforts may be helpful in making this determination. When feasible, a short trial of rehabilitation enables one to make a more complete and accurate assessment of a patient's rehabilitation potential. Conclusions The central issue in rehabilitation for stroke remains: does early intensive rehabilitation by reducing functional dependency act to decrease long-term social and economic costs? From this question stem several other important questions: 1) which patients are likely to benefit from intensive rehabilitation and can they be preselected? 2) when should rehabilitation begin? 3) where should rehabilitation take place? and 4) how should rehabilitation programs be organized? Designing controlled studies to evaluate a healthcare service such as rehabilitation is difficult. 35 Valid criteria for outcome need to be established in a setting where multiple variables are interacting. A compromise must be reached to select a limited number of variables to be measured that reflect different areas of outcome. These variables may vary in importance and an "end result" of rehabilitation may be difficult to establish. The sample size needed to reach statistical significance should be determined and subjects drawn from a defined population. Because most rehabilitation centers have primarily a referral practice and may

5 REHABILITATION FOR STROKE/Dombovy et al 367 not have adequate medical record systems, such population-based studies are difficult to implement. Unlike a controlled trial to evaluate the effectiveness of a new drug, controlled studies of rehabilitation for stroke have limitations in inference and generalization. This difficulty arises because of differences in staff, rehabilitation methods, and social and economic settings. General conclusions would be justified only if similar results were found in several studies in different locations. If these problems are to be solved, studies must be designed that include the following criteria: 1) strict definitions and characteristics of specific populations, sample groups, and controls; 2) information concerning timing, duration, quantity, and type of therapy; 3) uniform assessment of patients with measures that have proven validity and reliability; and 4) adequate numbers of comparable patients and controls. Properly designed controlled studies that adhere to clinical and epidemiologic principles in the practice of stroke rehabilitation will provide much useful information about patient care and the organization and delivery of rehabilitation services. Acknowledgment The authors wish to thank Dr. R. G. Siekert for his comments and criticisms regarding this manuscript. References 1. Garraway M, Akhtar AJ: I. Theory and practice of stroke rehabilitation. Recent Adv Geriatr Med 1: 7-20, Garraway WM, Akhtar AJ, Prescott RJ, Hockey L: Management of acute stroke in the elderly: preliminary results of a controlled trial. Br Med J 280: , Garraway WM, Akhtar AJ, Smith DL, Smith ME: The triage of stroke rehabilitation. J Epidemiol Community Health 35: 39-44, Prescott RJ, Garraway WM, Akhtar AJ: Predicting functional outcome following acute stroke using a standard clinical examination. Stroke 13: , Smith ME, Garraway WM, Smith DL, Akhtar AJ: Therapy impact on functional outcome in a controlled trial of stroke rehabilitation. Arch Phys Med Rehabil 63: 21-24, Stevens RS, Ambler NR, Warren MD: A randomized controlled trial of a stroke rehabilitation ward. Age Ageing 13: 65-75, Strand T, Asplund K, Eriksson S, Hagg E, Lithner F, Webster PO: A non-intensive stroke unit reduces functional disability and the need for long-term hospitalization. Stroke 16: 29-34, World Health Organization: Cerebrovascular diseases: prevention, treatment, and rehabilitation. WHO Tech Rep Ser No. 469, 1971, pp Eisenberg H, Morrison JT, Sullivan P, Foote FM: Cerebrovascular accidents: incidence and survival rates in a defined population, Middlesex County, Connecticut. JAMA 189: , Abu-Zeid HAH, Choi NW, Hsu PH, Maini KK: Prognostic factors in the survival of 1,484 stroke cases observed for 30 to 48 months. I. Diagnostic types and descriptive variables. Arch Neurol 35: , Whisnant JP, Fitzgibbons JP, Kurland LT, Sayre GP: Natural history of stroke in Rochester, Minnesota, 1945 through Stroke 2: 11-22, Matsumoto N, Whisnant JP, Kurland LT, Okazaki H: Natural history of stroke in Rochester, Minnesota, 1955 through 1969: an extension of a previous study, 1945 through Stroke 4: 20-29, Stallones RA, Dyken ML, Fang HCH, Heyman A, Seltser R, StamlerJ: I. Epidemiology for stroke facilities planning. Stroke 3: , Wylie CM: The community medicine of cerebrovascular disease. Stroke 1: , Garraway WM, Whisnant JP, Kurland LT, O'Fallon WM: Changing pattern of cerebral infarction: Stroke 10: , Garraway WM, Whisnant JP, Drury I: The continuing decline in the incidence of stroke. Mayo Clin Proc 58: , Garraway WM, Whisnant JP, Drury I: The changing pattern of survival following stroke. Stroke 14: , Ford AB.KatzS: Prognosis after strokes. Parti. A critical review. Medicine (Baltimore) 45: , KatzS,Ford AB.Chinn AB.Newill VA: Prognosis after strokes. Part II. Long-term course of 159 patients. Medicine (Baltimore) 45: , Kottke FJ: Historia obscure hemiplegiae. Arch Phys Med Rehabil 55: 4-13, Haerer AF, Woosley PC: Prognosis and quality of survival in a hospitalized stroke population from the South. Stroke 6: , Soltero I, Liu K, Cooper R, Stamler J, Garside D: Trends in mortality from cerebrovascular diseases in the United States, 1960 to Stroke 9: , Gresham GE, Rtzpatrick TE, Wolf PA, McNamara PM, Kannel WB, Dawber TR: Residual disability in survivors of stroke the Framingham study. N Engl J Med 293: , Gresham GE, Phillips TF, Wolf PA, McNamara PM, Kannel WB, Dawber TR: Epidemiologic profile of long-term stroke disability: the Framingham study. Arch Phys Med Rehabil 60: , Feigenson JS: Stroke rehabilitation: effectiveness, benefits, and cost; some practical considerations (editorial). Stroke 10: 1-4, Carstairs V: Stroke: resource consumption and the cost to the community. In Stroke (Proceedings of the Ninth Pfizer International Symposium), Gillingham FJ, Mawdsley C, Williams AE (eds). Edinburgh, , Churchill Livingstone, Feigenson JS, Feigenson WD, Gitlow HS, McCarthy ML, Greenberg SD: Outcome and cost for stroke patients in academic and community hospitals: comparison of two groups referred to a regional rehabilitation center. JAMA 240: , World Health Organization: The uses of epidemiology in the study of the elderly. WHO Tech Rep Ser No. 706, 1984, pp Garraway WM, Akhtar AJ, Prescott RJ, Hockey L: Evaluating the effectiveness of a stroke unit in the management of acute stroke. Excerpta Medica International Congress Series No. 568, 1982, pp Feigenson JS: Neurologic rehabilitation. In Clinical Neurology. Revised edition, vol 4. Baker AB, Baker LH (eds). Philadelphia, 1-66, Harper & Row Publishers, Lehmann JF, DeLateur BJ, Fowler RS Jr, et al: Stroke: does rehabilitation affect outcome? Arch Phys Med Rehabil 56: , World Health Organization: WHO Expert Committee on Medical Rehabilitation. WHO Tech Rep Ser No. 419, 1969, pp Peszczynski M, Benson F, Collins J, et al: II. Stroke rehabilitation. Stroke 3: , Sharpless JW: Mossman's a Problem-Oriented Approach to Stroke Rehabilitation. 2nd ed. Springfield, Illinois, Charles C Thomas, Publisher, Garraway WM, Prescott R: Limitations of the controlled trial in health care. Health Bull (Edinb) 35: , Feldman DJ, Lee PR, Unterecker J, Lloyd K, Rusk HA, Toole A: A comparison of functionally oriented medical care and formal rehabilitation in the management of patients with hemiplegia due to cerebrovascular disease. J Chronic Dis 15: , Stem PH, McDowell F, Miller JM, Robinson M: Factors influencing stroke rehabilitation. Stroke 2: , Waylonis GW, Keith MW, Aseff JN: Stroke rehabilitation in a midwestem county. Arch Phys Med Rehabil 54: , Feigenson JS, McDowell FH, Meese P, McCarthy ML, Greenberg SD: Factors influencing outcome and length of stay in a stroke rehabilitation unit. Part I. Analysis of 248 unscreened patients medical and functional prognostic indicators. Stroke 8: , 1977

6 368 STROKE VOL 17, No 3, MAY-JUNE FeigensoD JS, McCarthy ML, Greenberg SD, Feigenson WD: Factors influencing outcome and length of stay in a stroke rehabilitation unit. Part 2. Comparison of 318 screened and 248 unscreened patients. Stroke 8: , Anderson TP, McClure WJ, Athelstan G, et al. Stroke rehabilitation: evaluation of its quality by assessing patient outcomes. Arch Phys Med Rehabil 59: , Anderson TP, Baldridge M, Ettinger MG: Quality of care for completed stroke without rehabilitation: evaluation by assessing patient outcomes. Arch Phys Med Rehabil 60: , Brocklehurst JC, Andrews K, Richards B, Laycock PJ: How much physical therapy for patients with stroke? Br Med J 1: , McCann BC, Culbertson RA: Comparison of two systems for stroke rehabilitation in a general hospital. J Am Geriat Soc 24: , Truscott BL, Kretschmann CM, Toole JF, Pajak TF: Early rehabilitative care in community hospitals: effect on quality of survivorship following a stroke. Stroke 5: , Issacs B, Marks R: Determinants of outcome in stroke rehabilitation. Age Ageing 2: , Buchanan JJ: Rapid mobilization of cerebrovascular accident patients. Arch Phys Med Rehabil 37: , Rankin J: Cerebral vascular accidents in patients over the age of 60. II. Prognosis. Scott Med J 2: , Hurwitz LJ, Adams GF: Rehabilitation of hemiplegia: indices of assessment and prognosis. Br Med J 1: 94-98, Bourestom NC: Predictors of long-term recovery in cerebrovascular disease. Arch Phys Med Rehabil 48: , VarmaSK, Mukherjee A, Joshi JB.KaurG: Appraisal of rehabilitation treatment in "stroke" hemiplegics. J Assoc Physicians India 21: , Lowenthal M, Tobis JS, Howard IR: An analysis of the rehabilitation needs and prognoses of 232 cases of cerebral vascular accident. Arch Phys Med Rehabil 40: , Dow RS, Dick HL, Crowell FA: Failures and successes in a stroke program. Stroke 5: 40-47, Miglietta O, Chung TS, Rajeswaramma V: Fate of stroke patients transferred to a long-term rehabilitation hospital. Stroke 7:76-77, Lind K: A synthesis of studies on stroke rehabilitation. J Chronic Dis 35: , Twitchell TE: The restoration of motor function following hemiplegia in man. Brain 74: , Van Buskirk C: Return of motor function in hemiplegia. Neurology (NY) 4: , Feigenson JS, McCarthy ML, Meese PD, et al: Stroke rehabilitation. I. Factors affecting outcome and length of stay an overview. NY State J Med 77: , Johnston MV, Keister M: Early rehabilitation for stroke patients: a new look. Arch Phys Med Rehabil 65: , Novack TA, Satterfield WT, Connor M: Stroke onset and rehabilitation: time lag as a factor in treatment outcome. Arch Phys Med Rehabil 65: , Smith DS, Goldenberg E, Ashburn A, et al: Remedial therapy after stroke: a randomized controlled trial. Br Med J 282: , Wade DT, Langton-Hewer R, Skilbeck CE, Bainton D, Bums- Cox C: Controlled trial of a home-care service for acute stroke patients. Lancet 1: , Coughlan AK, Humphrey M: Presenile stroke: long-term outcome for patients and their families. Rheumatol Rehabil 21: , Garraway WM, Akhtar AJ, Hockey L, Prescott RJ: Management of acute stroke in the elderly: follow-up of a controlled trial. Br Med J 281: , Anderson E, Anderson TP, Kottke FJ: Stroke rehabilitation: maintenance of achieved gains. Arch Phys Med Rehabil 58: , Moskowitz E, Lightbody FEH, Freitag NS: Long-term follow-up of the poststroke patient. Arch Phys Med Rehabil 53: , Anderson TP, Bourestom N, Greenberg FR, Hildyard VG: Predictive factors in stroke rehabilitation. Arch Phys Med Rehabil 55: , Adams GF, McComb SG: Assessment and prognosis in hemiplegia. Lancet 2: , Wylie CM: Age and long-term hospital care following cerebrovascular accidents. J Am Geriatr Soc 12: , Gersten JW: Rehabilitation potential. In Stroke and Its Rehabilitation, Licht S (ed). New Haven, Connecticut, , Elizabeth Licht, Publisher, Van Buskirk C, Webster D: Prognostic value of sensory defect in rehabilitation of hemiplegics. Neurology (NY) 5: , Gordon EE, Drenth V, Jarvis L, Johnson J, Wright V: Neurophysiologic syndromes in stroke as predictors of outcome. Arch Phys Med Rehabil 59: , Haerer AF: Visual field defects and the prognosis of stroke patients. Stroke 4: , Bruell JH, Simon JI: Development of objective predictors of recovery in hemiplegic patients. Arch Phys Med Rehabil 41: , Adler MK, Curtland CC Jr, Acton P: Stroke rehabilitation Is age a determinant? J Am Geriatr Soc 28: , Wylie CM: Age and the rehabilitative care of stroke. J Am Geriatr Soc 16: , Rabkin SW, Mathewson FAL, Tate RB: The relation of blood pressure to stroke prognosis. Ann Intern Med 89: 15-20, Miller LS, Miyamoto AT: Computed tomography: its potential as a predictor of functional recovery in stroke. Arch Phys Med Rehabil 60: , Hyman MD: The stigma of stroke: its effects on performance during and after rehabilitation. Geriatrics 26: , May Hyman MD: Social isolation and performance in rehabilitation. J Chronic Dis 25: 85-97, Hyman MD: Social psychological determinants of patients' performance in stroke rehabilitation. Arch Phys Med Rehabil 53: , Hyman MD: Social psychological factors affecting disability among ambulatory patients. J Chronic Dis 28: , Smith DL, Akhtar AJ, Garraway WM: Proprioception and spatial neglect after stroke. Age Ageing 12: 63-69, Alien CMC: Predicting the outcome of acute stroke: a prognostic score. J Neurol Neurosurg Psychiatry 47: , Wade DT, Hewer RL, Wood VA: Stroke: influence of patient's sex and side of weakness on outcome. Arch Phys Med Rehabil 65: , HertanuJS.DemopoulosJT, Yang WC,Calhoun WF, Fenigstein HA: Stroke rehabilitation: correlation and prognostic value of computerized tomography and sequential functional assessments. Arch Phys Med Rehabil 65: , Sheikh K, Brennan PJ, Meade TW, Smith DS, Goldenbeger E: Predictors of mortality and disability in stroke. J Epidemiol Community Health 37: 70-74, Wade DT, Skilbeck CE, Hewer RL: Predicting Barthel ADL score at 6 months after an acute stroke. Arch Phys Med Rehabil 64: 24-28, Garraway WM, Akhtar AJ, Gore SM, Prescott RJ, Smith RG: Observer variation in the clinical assessment of stroke. Age Ageing 5: , Smith ME, Garraway WM, Akhtar AJ, Andrews CJA: An assessment unit for measuring the outcome of stroke rehabilitation. Occup Ther 40: 51-53, Donaldson SW, Wagner CC, Grcsham GE: A unified ADL evaluation form. Arch Phys Med Rehabil 54: , Granger CV: Health accounting functional assessment of the kmg-term patient. In Krusen's Handbook of Physical Medicine and Rehabilitation. 3rd ed. Kottke FJ, StiUwell GK, Lehmann JF (eds). Philadelphia, , WB Saunders Company, Mahoney FI, Barthel DW: Functional evaluation: Barthel index. Md State Med J 14: 61-65, Granger CV, Dewis LS, Peters NC, Sherwood CC, Barrett JE: Stroke rehabilitation: analysis of repeated Barthel Index measures. Arch Phys Med Rehabil 60: 14-17, Schocning HA, Anderegg L, Bergstrom D, Fonda M, Steinke N, Ulrich P: Numerical scoring of self-care status of patients. Arch Phys Med Rehabil 46: , KatzS, Ford AB, MoskowitzRW, JacksonGA, Jaffe MW: Stud-

7 REHABILITATION FOR STROKE/Dombovy et al 369 ies of illness in the aged: the index of AOL; a standardized measure of biological and psychosocial function. JAMA 185: , Schoening HA, IversenIA: Numerical scoring of self<are status: a study of the Kenny Self-Care Evaluation. Arch Phys Med Rehabil 49: , Muzzio TC, Bunis CT: Functional Limitations: A State of the Art Review. Falls Church, Virginia, Indices, Harvey RF, Jellinek HM: Functional performance assessment: a program approach. Arch Phys Med Rehabil 62: , Gresham GE, Phillips TF, Labi MLC: ADL status in stroke: relative merits of three standard indexes. Arch Phys Med Rehabil 61: , Report of the College Committee, Working Group on Strokes: Stroke Disability in Great Britain. London, Royal College of Physicians, Benjamin J: The Northwick Park ADL Index. J Occupat Thcr 39: , 1976