Neuromotor Rehabilitation in Stroke Treatment Units.

ABSTRACT

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Background: Stroke is the second leading cause of death in the world and the first cause of disability in adults. Its complexity requires comprehensive care provided by a multiprofessional team, implemented in the so-called Stroke Treatment Units (STUs). In view of their relevance and impact on the prognosis, identifying activities developed in the framework of neuromotor rehabilitation is of fundamental importance, information which, at present, is not readily available. Methods: Cross-sectional descriptive study, convenience sampling with the participation of 5 kinesiologists from public health centers in Chile. Information was collected by means of an online survey focused on the work being carried out in the STUs. Data analysis was performed using STATA 15 and ATLAS TI 8.0 software. Results: Initiation and frequency of neuromotor rehabilitation is variable and occurs between 24 and 48 hours after diagnosis. Between one and three daily sessions per user are performed and their duration varies from 25 to 90 minutes. Neuromotor activities are integral and multiprofessional; the approach includes neuromotor, respiratory and cognitive components. Neuromotor activities incorporate facilitation techniques for the most advanced user posture achieved and sensory stimulation, among others. Conclusions: Neuromotor rehabilitation in Chile´s STUs shows different realities in terms of identification, functioning and neurokinetic intervention.

Key words: Stroke, Acute Stroke, Stroke Rehabilitation, Rehabilitation, Hospitalization.

INTRODUCTION

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A cerebrovascular accident, (CVA), is a syndrome characterized   by   the   rapid   development   of focal  neurological  symptoms  as  an  expression of altered brain functions(1,2,3). It is the second leading cause of death worldwide and the most common  first  cause  of  disability  in  adults(4,5). It has a high health burden, which is why in the last 40 years standardized policies and treatments have been developed, especially for its acute phase.(6)

In  Chile  it  is  the  second  specific  cause  of death. Its occurrence is increasing, especially between people over the age of 85(7,8). Survival at the time of hospital discharge is 81.8% and the probability of developing a disability after a stroke is 18% at 6 months(8,9,10).  The degree of disabilities developed are multifactorial, associated, among other factors, with the therapeutic  actions  that  are  applied  in  both acute and chronic conditions.

Previously, users who presented an acute CVA were hospitalized in internal medicine or neurology unit where they shared medical care with a wide range of other clinical conditions. For some years there has been scientific discussion about the usefulness of specialized rehabilitation units11 for these patients. Evidence regarding this point has been favorable(12), which is why today, CVA units are common to find in health services13 in developed countries.

Organized hospital care for CVA is recognized throughout the world as “stroke units”(14), which are units where collaborative and coordinated care is provided by doctors, nurses and therapy specialists in stroke management.

In Chile, the Stroke Action Plan contemplates in its Strategic Objective No. 2, “to increase the annual percentage of highly complex hospitals that  have  a  Functional  Stroke  Treatment Unit”(3),  being  the  origin  of  the  Stroke Treatment Units (UTAC) in Chile. These units are  in  a  geographically  limited  clinical  area with a coordinated interdisciplinary team, that provides all medical and rehabilitation care that the patients require.(15)

Acute phase of CVA management in specialized care units show scientific evidence that supports its implementation in hospitals(3,12,13,14,15). The existence of these units are favorable for the reduction of mortality, independence recovery and rehabilitation. However, it is necessary to detail the therapeutic action in greater depth, starting from the most technical concepts and applicability    in    neuromotor    rehabilitation. We can find an example of this in the clinical guidelines related to CVA, where the guidelines on neuromotor rehabilitation are broad and unspecific, which is why it is necessary to research on this topic, especially from the point of  view  of  professionals  who  are  immersed in these units. The purpose of this study is to describe  the  actions  carried  out  in  the  UTAC of the Chilean public health system regarding neuromotor rehabilitation.

METHOD

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Study Design
Descriptive Cross Section Study

Sample
The sample was determined by convenience. 9 kinesiologists working in public hospitals, in stroke units, in Chile, were invited to participate.
5 kinesiologists were interested in participating and complied with the informed consent.

Procedure
The amount of acute stroke care units in the Chilean public health system were pin pointed, and a total of 9 establishments were identified throughout the country.

The participants were recruited through a telephone call. Those who were interested, received  an  email  with  the  presentation  of the  research  project,  informed  consent,  and approval  letter  from  the  Ethics  Committee. Once the informed consent was sent, a telephone call was made to clarify queries and to send a data collection instrument, which consisted of an  online  survey  which  took  approximately 20 minutes to fill out. The survey was sent to their email and had to be responded within 14 days. To elaborate the survey, information from reviewed literature was retrieved, in order to describe the actions in neuromotor rehabilitation that are carried out in the UTAC in Chile. The survey  consists  of  2  sections,  with  a  total  of 9 questions (4 open and 5 closed questions), which are presented in Table 1. The results of the survey were set out on an excel spreadsheet to subsequently perform a quantitative and qualitative analysis. All procedures respected the ethical standards consistent with the Declaration of Helsinki and were approved by the Reloncaví Scientific Ethics Committee. All participants signed their informed consent prior to data collection.

Table 1. Survey.

Section A: Employment History

Specify place of work and unit in which you care for patients with acute ischemic cerebrovascular disease.

Select members of the professional team working in your unit.

Specify the number of hours per day designated to the care of patients with acute CVD.

Section B: Medical History

Specify the intervention time with a patient with acute CVD (in minutes). Select the number of daily sessions per patients with acute CVD.

Select the time elapsed post CVD to start kinesiological intervention

Select the approach on which your intervention is based.

Briefly describe the assessment you perform in patients with acute CVD (if you use instruments, add name).

Briefly describe a typical session with acute CVD patients.

Statistical analysis
To  analyze  the  closed  questions,  absolute  (n) and relative (%) frequency tables together with the STATA 15 statistical software were used. To analyze the open questions, the statistical software ATLAS TI 8.0 was used.

RESULTS

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The purpose of the study was to describe the actions carried out in neuromotor rehabilitation that are carried out in the UTAC of the Chilean public health system.

- UTAC Identification.

Out of a total of five professional kinesiologists who  participated  in  the  study  (4  women  and 1  man),  only  one  does  recognize  the  name of UTAC, the unit or service where stroke patients in the acute phase are cared for. Other participants  mentioned  their  workplace  using the  names:  neurology  service  or  ward,  acute neurological unit, and medium care unit.

- Organized care and multidisciplinary team.

The five professionals who answered the survey, said that their work team include a neurologist, kinesiologist,   occupational   therapist,   nurse, and speech therapist. The professional Kinesiologists also said that they spent between
4 to 8 hours in the UTAC. This means, that some units have part time kinesiologists and others have full time professionals.

- Neuromotor rehabilitation: Start time and duration of the session in the acute phase.

The start of kinesiological care is variable, 3 participants said that it starts before 24 hours after the stroke diagnosis, and 2 of the participants said that it starts 48 hours after diagnosis. Session durations  vary  from  25  to  90  minutes.  The number of daily sessions is presented in Table 2, which shows that it varies from 1 to 3 sessions, however, the average are 2 sessions per day per patient.

Table 2. Number of daily sessions

Daily Sessions	Frequency	Percentage
Once per day	1	20%
Twice per day	3	60%
Three times per day	1	20%
Total	5	100%

 

- Neuromotor rehabilitation: Intervention approaches and types of exercises in the acute phase.

The   therapeutic   approaches   for   the   sessions are presented in Table 3. The total number of respondents, use the Bobath Concept, Sensory Integration, and finally Kabath techniques, as well as music therapy.

Table 3. Therapeutic approaches.

Approach	Frequency	Percentage
Bobath	5	100%
Sensory integration	4	80%
Kabath	1	20%
Music Therapy	1	20%

 

For the segments which state: “Briefly describe the assessment you provide on patients with acute CVA” and “Briefly describe a typical session with acute CVA patients,” the results are shown in  figures 1  and  2  respectively,  which  show that the assessment carried out is comprehensive in nature and includes kinesiological aspects in collaboration with professionals from the unit team such as a speech therapist and an occupational therapist. They assess the neuromotor, respiratory and cognitive status components, among others.

In a standard session, the professionals include an assessment of the state of consciousness and hemodynamics, the procedures that are mostly repeated, are the management of the respiratory component, cognitive stimulation, exercises focused on the best posture obtained by the patient and sensory stimulation.

Finally, all the participants mentioned that these patients are approached from a multidisciplinary perspective, to favor their evolution from different directions.

DISCUSSION

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- UTAC Identification.

Literature describes a long history of existence of these units, showing positive indicators of prognosis and mortality, thanks to medical management,   having   a   favorable   impact   on brain deficit(16). Álvarez-Sabín(17)       proved the effectiveness in reducing hospital stay, mortality and institutionalization, after the implementation of protocolized and specialized care in 5,843 stroke patients.

According to the National Institute of Neurological Disorders and Cerebrovascular Attacks(18), the development of UTAC is due to advances in intensive therapy and specific stroke treatments. This contrasts with the present research, since there is poor identification and outreach of the UTAC, it is difficult for professionals to have a sense of belonging and recognition. The lack of outreach of UTAC in hospitals, health professionals and in the general population could be a negative factor in timely care after a stroke.
- Organized care and multidisciplinary team. Today,    the    UTAC    favors    organized    and
specialized    care    in    different    medical    and
rehabilitation  disciplines,  which  is  directly related to the recommendations of the American Heart   Association   (AHA)(19),   that   suggested to  join  comprehensive  specialized  post-stroke care, incorporating rehabilitation at proportional intensity and tolerance, and standardized interventions. Evidence suggests that hospital care organized by a multidisciplinary team, compared to conventional care, results in lower mortality rate and greater recovery. This can be explained by the existence of greater experience of the multidisciplinary team, better and more effective medical, nursing and rehabilitation procedures.(14)

In this research, we have observed that in the public health system there are different realities related to post-stroke care. There are hospitals with

an organized care system, and an implemented UTAC, while in other centers the implementation of this unit is emergent or not implemented at all. In relation to the multidisciplinary team of the UTAC, this research identifies the presence of doctors, nurses, physiotherapists, speech therapists and occupational therapists; however, a coordinated labor carried out by professionals, does not take place in all centers.

- Neuromotor rehabilitation: Start time and duration of the session in the acute phase.

Evidence-based practice describes physical rehabilitation as an element of organized stroke care, thus being fundamental in the patient´s functional prognosis. The following aspects are essential in the intervention: to start mobilization or postural change(20,21), frequency(22)  and intensity of rehabilitation(23,24)   and the most effective type of exercises for the rehabilitation balance and functionality(25,26)  rehabilitation.

According to the information provided by the kinesiologists  participating  in  the  survey,  we could observe that rehabilitation care in the acute post-stroke stage varies greatly. We could observe ambiguity regarding the starting time of rehab, which  is  different  to  Bernhardt’s  proposal(27), that mentions that it should start after 24 hours, not immediately,  thus supporting a rest approach for the first 24 hours(22). In this same sense, the AVERT21 study does not recommend a very early and high-dose mobilization within 24 hours after the stroke, since it could reduce the chances of a favorable result at 3 months. On a national level, the current stroke clinical practice guideline(1), stated that the start of therapy will depend on the patient’s clinical conditions and that the start of motor rehabilitation, without considering standing position, can start within the first 24 hours. Evidence is not conclusive, generating uncertainty about the beginning of rehabilitation.

In relation to the frequency and intensity of rehabilitation sessions, the kinesiologists in this survey  reported  great  variability  in  their  care.

The AVERT(23)   study recommends a shorter and more frequent mobilization at the beginning of the CVA, being associated with favorable results at 3 months. Langhorne(22)  suggests that the frequency of rehabilitation in the acute post-stroke period varies between 1 to 6 daily sessions, demonstrating a high variability in the number that patients receive. The ACV clinical guide1 proposes at least
1 session to be performed by each professional of the UTAC rehabilitation team, depending on the patient’s medical condition.

- Neuromotor rehabilitation: Intervention approaches and types of exercises in the acute phase.

The total number of respondents, use the Bobath Concept, secondly, Sensory Integration, and finally Kabath techniques, as well as music therapy. Current evidence describes that rehabilitation exercises in the acute phase should prioritize intensity through the repetition of motor actions, as described by Veerbeek(28), showing strong evidence that physical therapy interventions should favor highly repetitive intensive task-oriented training in all post-stroke phases. In addition, using exercises that favor the activation of the sensory systems,  which  stimulate  significant  responses for somatosensory functions and muscle tone are recommended. According to Saeys(29), the lack of sensory information prevents the estimation of verticality, presenting stroke survivors with fewer options for sensory recovery strategies and balance in the face of disturbances. Perennou(30)   suggests that appropriate somatosensory stimulation makes it possible to recalibrate the biased internal model of verticality.

Cabanas-Valdés(31),   shows   that   core   training exercises, performed on a stable or unstable surface, could be a good rehabilitation strategy helping to improve trunk performance and dynamic balance after stroke. Other promising treatment approaches are action observation therapy and mirror therapy, that aim to improve motor learning and promote neural reorganization by stimulating different afferents and visual feedback patterns(32).

In this research, the use of passive mobilizations is evidenced as a fundamental element of the neuromotor rehabilitation process, strategy that presents limited evidence moving away from rehabilitative management in the acute phase of a stroke based on neuroplasticity, motor control, and specific tasks

CONCLUSION

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The neuromotor rehabilitation actions that are carried out in the Stoke Units of the Chilean public health system present different realities, referring to the beginning of the intervention and its dosage, treatment  approaches  and  types  of  exercises. There is ambiguity in relation to the identification of these units and the sense of belonging of the professionals who work in them. Although all Stroke Units have a professional team, not all of them have organized work.

Study Limitations
The main limitation is the number of professionals surveyed; which were 5 kinesiologists who work in Stroke Units in the countries’ public hospitals. This could be due to the difficulty of obtaining information on the existing UTACs in the country, and to the diversity of denominations, which makes  it  difficult to  identify  professionals  and their relevance to it.

For future research that seek to report on the actions of professionals and the organization of these units, it is suggested that a census be carried out that includes all the UTACs along the country, including public and private health systems. Contributing in this way to new evidence and guidelines related to the subject.

REFERENCES

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1. 1.   Ministerio de salud (MINSAL). Resumen ejecutivo guía de práctica clínica ataque cerebrovascular isquémico en personas de 15 años y más. 2019. Disponible en: https://diprece.minsal.cl/garantias- explicitas-en-salud-auge-o-ges/guias-de-practica- clinica/ataque-cerebrovascular-isquemico-en- personas-de-15-anos-y-mas/resumen-ejecutivo-2/
   
2. 2.   Ministerio  de  Salud  (MINSAL).  Guía  Clínica Auge. Ataque Cerebro Vascular Isquémico en personas de 15 años y más. 2013 (Acceso el 2 noviembre de 2013).
   
3. 3.   Disponible     en:     http://www.repositoriodigital. minsal.cl/handle/2015/476
   
4. 4.   Ministerio   de    Salud   (MINSAL).    Plan    de
   Acción   Ataque   Cerebrovascular.   2°   Edición.
   2014. Disponible: https://diprece.minsal.cl/ garantias-explicitas-en-salud-auge-o-ges/guias- de -pra c t i c a -c l i ni c a / a t a que -c e re brova sc ul a r- isquemico-en-personas-de-15-anos-y-mas/ documentos-relacionados-2/
   
5. 5.   Ouriques Martins S C, Sacks C, Hacke W, Brainin M, de Assis Figueiredo F, Marques Pontes-Neto O, Lavados Germain P M, et al. Priorities to reduce the burden of stroke in Latin American countries. Lancet Neurol. 2019 Jul; 18(7):674–683.
   
6. 6.   Arrazola A, Beguiristain J M, Garitano B, Mar J, Elizalde B. Atención hospitalaria a la enfermedad cerebrovascular aguda y situación de los usuarios a los 12 meses. Rev Neurol. 2005; 40 (6): 326-330.
   
7. 7.   Gallego J, Herrera M, Jericó I, Muñoz R, Aymerich N, Martínez-Vila E. El ACV en el siglo XXI. Tratamiento  de  urgencia.  An  Sist  Sanit  Navar.
   2008; 31(1):15-30.
   
8. 8.   Illanes S, Díaz T V.   Manejo inicial del Ataque cerebrovascular (ACV) isquémico agudo. Los detalles hacen la diferencia. Rev Hosp Clín Univ Chile. 2008; 19: 119 - 26.
   
9. 9.   Lavados P M, Sacks C, Prina L, Escobar A, Tossi C, Araya F, et al. Incidence, 30-day case-fatality rate, and prognosis of stroke in Iquique, Chile: a 2-year community-based  prospective    study    (PISCIS project). Lancet. 2005 Jun; 365(9478):2206-15.
   
10. 10. Doussoulin A, Rivas R, Sabelle C. Egresos hospitalarios   por   enfermedad   cerebrovascular en el período 2001-2010 en el Servicio de Salud Araucanía   Sur.   Rev   Méd   Chile.   2016   May; 144(5):571-576.
    
11. 11. Díez-Tejedor E, del Brutto O H, Álvarez-Sabín J, Muñoz-Collazos M, Abiusi G R P. Clasificación de las enfermedades cerebrovasculares. Sociedad Iberoamericana de Enfermedades Cerebrovasculares. Rev Neurol. 2001 Sept; 33(5):455-64.
    
12. 12.  Garraway M. Stroke rehabilitation units: concepts, evaluation,  and  unresolved  issues.  Stroke.  1985
    Mar; 16(2):178–181.
    
13. 13.  Langhorne P, Williams B O, Gilchrist W, Howie
    K. Do stroke units save lives? Lancet. 1993 Aug;
    342(8868):395-8.
    
14. 14.  Langhorne   P,   de   Villiers   L,   Pandian   J   D.
    Applicability  of  stroke-unit  care  to  low-income and middle-income countries. Lancet Neurol. 2012
    Apr;11(4):341-8.
    
15. 15. Stroke Unit Trialists’ Collaboration. Organised inpatient (stroke unit) care for stroke. Cochrane Database Syst Rev. 2013 Sept; 9: CD000197.
    
16. 16.  Lavados P M, Hoppe W A. Unidades de tratamiento del ataque cerebrovascular (UTAC) en Chile. Rev. méd. Chile. 2005 Nov; 133(11): 1271-1273.
    
17. 17.  Díaz V, Illanes S, Reccius A, Manterola J, Cerda P, Recabarren C, González R. Evaluación de una unidad de tratamiento del ataque cerebral en un hospital universitario. Rev Med Chile. 2006; 134:
    1402-1408.
    
18. 18.  Álvarez-Sabín J, Molina C, Montaner J, Arenillas J, Pujadas F, Huertas F, et al. Beneficios clínicos de la implantación de un sistema de atención especializada  y  urgente  del  ACV.  Med  Clin.
    2004;122(14):528-31.
    
19. 19. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med. 1995 Dec; 333: 1581-7.
    
20. 20.  Powers W J, Rabinstein A, Ackerson T, Adeoye O M,  Bambakidis N C, Becker K, et al.  Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2019;50:e344–e418.
21. 21. AVERT Trial Collaboration Group. Efficacy and safety of very early mobilisation within 24 h of stroke  onset  (AVERT):  a  randomised  controlled trial. Lancet. 2015;386:46–55.
    
22. 22.  Langhorne P, Collier J M, Bate P J, Thuy M N, Bernhardt J. Very early versus delayed mobilization after stroke. Cochrane Database Syst Rev. 2018
    Oct;10: CD006187.
    
23. 23. Bernhardt J, Churilov L, Ellery F, Collier J, Chamberlain J, Langhorne P et al, AVERT Collaboration Group. Neurology. Prespecified dose-response analysis for A
    
24. 24.  Very   Early    Rehabilitation    Trial    (AVERT).
    Neurology. 2016 Jun;86(23):2138-45.
    
25. 25. Pollock A, Gray C, Culham E, Durward B R, Langhorne P. Interventions for improving sit-to- stand ability following stroke. Cochrane Database Syst Rev. 2014 May; 5: CD007232.
    
26. 26.  Van Criekinge T, Saeys W, Hallemans A, Vereeck L, De Hertogh W, Van de Walle P, et al. Effectiveness of additional trunk exercises on gait performance: study protocol for a randomized controlled trial. Trials. 2017;18(1):249.
    
27. 27. Murphy T H, Corbett D. Plasticity during stroke recovery: from synapse to behaviour. Nat Rev Neurosci. 2009 Dec;10(12):861-72.
    
28. 28.  Askim T, Indredavik B, Engen A, Roos K, Aas T,  Mørkved  S.  Physiotherapy  after  stroke:  To what extent is task-oriented practice a part of conventional treatment after hospital discharge?. Physiother Theory Pract. 2013; 29:343–350.
    
29. 29.  Bernhardt J, Collier J M, Bate P, Matthew N, Thuy M N T, Langhorne P. Very early versus delayed mobilization after stroke. Systematic Review and Meta-Analysis. Stroke. 2019 jul; 50(7):178-179.
    
30. 30.  Veerbeek J M, van Wegen E, van Peppen R, van der Wees P J, Hendriks E, Rietberg M, et al. What Is the Evidence for Physical Therapy Poststroke? A Systematic Review and Meta-Analysis. PLoS One.
    2014; 9(2): e87987.
    
31. 31.  Saeys  W,  Herssens  N,  Verwulgen  S,  Truijen S. Sensory information and the perception of verticality in post-stroke patients. Another point of view in sensory reweighting strategies. PLoS One.
    2018 Jun;13(6): e0199098.
    
32. 32.  Perennou  D,  Piscicelli  C,  Barbieri  G,  Jaeger M, Marquer A, Barra J. Measuring verticality perception         after    stroke:    why    and    how?. Neurophysiol Clin. 2014;44(1):25-32.
    
33. 33. Cabanas-Valdés R, Bagur-Calafat C, Girabent- Farrés M, Caballero-Gómez FM, du Port de Pontcharra-Serra H, German-Romero A, et al. Long-term follow-up of a randomized controlled trial on additional core stability exercises training for improving dynamic sitting balance and trunk control  in  stroke  patients.  Clin  Rehabil.  2017
    Nov;31(11):1492-1499.
    
34. 34.  Shih T, Wu C , Lin K, Cheng C, Hsieh Y, Chen C, et al. Effects of action observation therapy and mirror therapy after stroke on rehabilitation outcomes and neural mechanisms by MEG: study protocol for a randomized controlled trial. Trials. 2017; 18:459.