Hospital Care Of Stroke Patients example essay topic

Introduction Cerebrovascular disease or the term stroke is used to describe the effects of an interruption of the blood supply to a localised area of the brain. It is characterized by rapid focal or global impairment of cerebral function lasting more than 24 hours or leading to death (Hatano, 1976). As such it is a clinically defined syndrome and should not be regarded as a single disease. Stroke affects 174-216 people per 10,000 population in the UK per year and accounts for 11% of all deaths in England and Wales (Mant et al, 2004).

The risk of recurrent stroke within 5 years is between 30-43%. One problem is that the incidence of stroke rises steeply with age and the number of elderly people in the UK is on the increase. To date people who experience a stroke occupy around 20 per cent of all acute hospital beds and 25 per cent of long term beds (Stroke Association, 2004). The British Government now identifies stroke as a major economic burden on the National Health Service (DoH, 2002). Fifty percent of stroke survivors will experience some residual impairment (physical and cognitive), which is devastating to the individual and their families (Rudd et al, 2002).

It is therefore vital for patients and resources that maximum functional recovery is achieved as fast as possible. The physiotherapist has a key role to play in the management of stroke patients, through assessment, prevention strategies, acute management and recovery. This essay aims to critically discuss physiotherapeutic management and examine how it has and may be influenced by a number of factors (e.g. type of organized system for the delivery of post stroke care, setting of therapy, evidence based practice from which National Guidelines are produced etc). The first stage is to outline stroke pathology, of which forms the basis of appropriate management. Pathology There are two major stroke sub groups, those resulting from infarction (ischemic stroke) and those resulting from haemorrhage (intra cerebral and sub arachnoid).

Each of the types can produce clinical symptoms that fulfil the definition of stroke. The types often differ with respect to survival and long-term disability, from recovery in a day to incomplete recovery, severe disability and death (Warlow et al, 2001). Ischemic stroke is the most common type of stroke, which accounts for approximately 85% of all cases (Rudd et al, 2002). It affects 35 people per 100,000 of the population per year (Coull et al, 2004). Ischemic stroke can be caused by a sudden occlusion of arteries supplying the brain, as a result of thrombosis formed directly at the site of occlusion (i.e. thrombotic ischemic stroke), or in another part of the circulation, which eventually obstructs arteries in the brain (i.e. embolic ischemic stroke).

Diagnosis is usually based on neuro-imaging recordings, however, it may not be possible to decide clinically or radiological whether it is a thrombotic or embolic ischemic stroke (Rudd & Wolf, 2002). Intracerebral haemorrhage is a bleeding from one of the brain's arteries into the brain tissue. The lesion causes symptoms that mimic those seen for ischemic stroke. Diagnosis is based on neuro-imaging, which can differentiate it from ischemic stroke. Hypertension is the single most underlying cause of intra cerebral haemorrhage (Poungvarin, 1998). Subarachnoid haemorrhage is characterised by arterial bleeding in the space between the two meninges pi a mater and arachnoid ea (The university of Virginia, 2004).

Typical symptoms are sudden onset of very severe headache, vomiting and usually impaired consciousness. To date there appears to be no single, specific cause of stroke but rather several factors that may increase the risk of an individual having a stroke. The causes of the first stroke are generally identical to those that result in subsequent stroke. It is therefore important to identify risk factors in order to provide appropriate management. Risk Factors People with more than one risk factor have an 'amplification of risk', in which multiple risk factors compound their destructive effects creating an overall risk greater than the simple cumulative effect.

Generally, risk factors for stroke can be classified as non-modifiable, potentially modifiable and modifiable (Sacco et al., 1997). Non-modifiable risk factors for stroke include age, gender, family history and ethnicity. For example, age is the single most important risk factor for stroke (National Institute of Neurological Disorders and Stroke -NINDS, 2004). Indeed, for each 10 years after age 55, the stroke rate more than doubles for both men and women (The Stroke Association, 2004). Men have a higher risk for stroke; with the stroke risk for men at 1.25 times that as for women (Sacco, et al, 1997). Potentially modifiable risk factors include diabetes and heart disease (and some controversial factors such as alcohol and drugs) (Goldstein, 2001).

Diabetes is associated with stroke, independently of the various cardiovascular risk factors that usually accompany this disease (hypertension, and obesity) (American Stroke Association (ASA), 2004). Modifiable risk factors include hypertension, smoking, physical inactivity and obesity (Rudd & Wolf, 2002). In middle and late adult life, hypertension is undoubtedly the strongest modifiable risk factor for both ischemic and hemorrhagic stroke (Rothwell, 2004) and is present in 70% of stroke cases. Another powerful modifiable stroke risk factor is smoking, (which amongst other things promotes atherosclerosis) and which almost doubles a person's risk for ischemic stroke (ASA, 2004). As part of therapeutic management a physiotherapist would refer the patient to a smoking cessation program. Ideally, health care providers (including physiotherapists) should screen individuals for risk factors that could lead to cerebrovascular disease and use this opportunity for education.

Given the pathology of stroke and the number of risk factors, it is not surprising that the spectrum of clinical presentations is also extensive (Warlow et al, 2001). It is important to recognise that each person should be considered on an individual basis, as no two cases will present the same (Moser & Ward, 2000). The following section therefore provides an overview. Clinical Presentation The types of disability that follow a stroke depend upon which area of the brain is damaged and may correlate to the patient's neurological deficits with the expected sites of arterial compromise (Warlow et al, 2001). The effects of the stroke will also depend on the patient's general health at the time (Harridge, 2000; Malbut-Shennan, 2000). Disabilities can range from isolated motor or sensory deficits to coma.

The symptoms may occur alone, but they are more likely to occur in combination (Malbut-Shennan, 2002). Predictions as to the outcome of stroke are therefore difficult to determine. Movement and sensory deficits -Paralysis is one of the most common disabilities resulting from stroke. An individual who suffers a stroke in the left hemisphere of the brain will show right-sided paralysis or paresis (weakness) and vice versa (the extent of which will be dependant on an individual's basic organisation of the brain). The paralysis may only affect the face, an arm, or a leg or it may affect one entire side of the body. One-sided paralysis is known as hemiplegia and one-sided weakness, .

Individuals often experience pain, numbness or odd sensations of tingling or prickling in the paralyzed or weakened limbs (i.e. paresthesia). These sensory deficits may hinder the ability to respond to objects or sensory stimuli located on one side of the body known as inattention (neglect). Damage to a lower part of the brain, the cerebellum, can affect the body's ability to coordinate movement (i.e. ataxia) and may lead to problems with body posture, walking and balance. Initiating and controlling movement may also be impaired (Bear et al, 2001). This combination of impairments may impact upon activities of daily living (ADL's) such as walking, dressing and eating. These skills often require the mobility and strength developed during physiotherapy.

However training in ADL's involves the entire rehabilitation team. Cognitive problems -Stroke may induce cognitive problems (e.g. impaired: thinking, awareness, attention span, learning, judgment and memory). Severe cognitive problems may include apraxia (i.e. loss of ability to plan and carry out steps involved in complex tasks) and therefore patients may have problems following a set of instructions (NINDS, 2004). Language impairments, such as the loss in the ability to speak or form words (i.e. dysarthria) and understand speech (aphasia) or written language are experienced by a quarter of all stroke survivors (NINDS, 2004). Cognitive and language impairments may adversely affect an individual's ability to participate in therapy and must be taken into account by the physiotherapist as an important determinant for functional recovery (Hochstenbach et al, 2003). Emotional factors - Many people whom survive a stroke often experience fear, anxiety, frustration and anger (a natural response to trauma).

The most common major emotional concomitant of stroke however, is depression (A ben et al, 2001). Signs of clinical depression include sleep disturbances, change in eating patterns, lethargy, social withdrawal, irritability, fatigue, self-loathing, and suicidal thoughts. It is therefore essential that physiotherapists are aware of this as depression can hamper recovery and rehabilitation (Maclean et al. 2000). Motivation - Stroke patients may loose their motivation for restoring lost function and returning to the community (Dowswell et al, 2000). Physiotherapists who specialise in mental health may help patients overcome these adverse emotional states and focus on functional recovery (Maclean et al.

2000). Functional recovery often depends on the assessment and treatment of stroke patients, which in turn are influenced by various factors other than clinical presentation (e.g. National Service Frameworks, clinical guidance etc). It is therefore essential to outline physiotherapeutic management of stroke patients taking into account these factors. Organisation of Early stroke care -health care provision National Service Framework (NSF) -In 1999 a national survey (Ebrahim & Redfern, 1999) revealed that the hospital care of stroke patients was "a matter of chance", with half of patients receiving less than optimal care. The report estimated that up to 7,000 deaths could be attributed to care deficiency. The NSF for Older People (England) was launched (DoH, 2001) in order to address some of the issues raised.

Standard 5 of the Framework focused on national standards and service models for stroke care. It stated that people should have access to diagnostic services, are treated appropriately by a specialist stroke service and (with carers) participate in a multidisciplinary programme of secondary prevention and rehabilitation. Stroke units - One of the main recommendations of the Framework was that all hospitals caring for people with stroke should have a specialised stroke service by April 2004. The Royal College of Physicians' National Clinical Guidelines on Stroke (2002) recommend that treatment is carried out in a designated stroke unit (DSU). Recent evidence supports this view, as the Stroke Association (TSA) (2004) found that for every 16 stroke patients admitted to a general hospital ward, there will be one extra death compared with those admitted to a DSU. Dedicated Stroke Units differ from general medical wards in that they deal specifically with stroke patients, theoretically offering holistic care from several disciplines.

In spite of overwhelming evidence, only 82% of hospitals in England have a DSU (National Sentinel Stroke Organisational Audit-NSSOA, 2004) and 39 more are needed to achieve the target set by NSF (2002). Variations have also been identified in terms of the care they deliver, treatment strategies, organisation of services and clinical outcomes. However, the benefits of a stroke unit clearly outweigh those of a general hospital ward, particularly in the holistic approach to management by a multidisciplinary team. Multidisciplinary teams (MDT) - Aim to provide seamless holistic care from the immediate post-stroke period throughout all stages of rehabilitation to hospital discharge. The NCGS (RCP, 2004) and DoH, (2001) specify a number of specialists whom should be involved (e.g. a consultant physician, physiotherapist, occupational therapist etc). The". ... precise composition and number for such a team will vary according to the size of the unit and its objectives" (NCGS, p. 16).

However, this ambiguity (e.g. composition, facility size, availability and staffing levels) has possibly contributed to the wide variations in quality of service outlined by the NSSAOA (2004). In addition, according to NSSAOA (2004) the acute phase is often being treated on a general medical ward where resources (e.g. staffing and finances) are not always available to achieve the ideal MDT. Ideal interdisciplinary working involves acknowledging the overlap between professional disciplines, with greater sharing of duties and responsibilities including, collaborative clinical records, closer working practices and shared rehabilitation (Gibbon, 1999). For example, physiotherapists may focus on limb weakness, abnormal tone (flaccid or spastic) and balance, to meet the agreed aim of independent mobility, but would work closely with an occupational therapist in order to achieve this. Research suggests that poor team working can become dysfunctional, hierarchical and hindered by professional boundaries (Strasser et al, 1994). However, In the UK to date, post registration courses in rehabilitation and MDT working are rare.

Regular MDT meetings may be used as a tool to enable the provision of a quality rehabilitation service and to discuss differences and potential problem areas of management, training needs etc. and is considered good practice. A central aim of physiotherapy within the team is to promote the recovery of movement and mobility of the stroke patient. This will involve planning and implementing treatments for the individual patients, based on an assessment of their unique problems. Key elements of these patient specific treatment strategies may entail restoring balance, re-educating mobility and promoting functional movement.

Plans can all be conveyed to the MDT and modified accordingly via written or verbal communication. Recent evidence suggests that this combined expertise improves patient outcome (Stroke Unit Trialists' Collaboration, 2004). The NCGS (2004) recommend that MDT meet at least once a week to exchange information regarding individual patients. However, in reality this may not be practicable, due to lack of resources (e.g. time, staffing levels etc).

Continued education and training programmes - The NSF recommends that all staff in contact with stroke patients should undertake a wide range of training (e.g. covering acute and rehabilitation care, how to address patient and carer needs). It is important that physiotherapists are provided with regular training, to keep up to date with evolving evidence based practices and therefore offer patients the most appropriate treatment. High quality treatment saves lives and reduces disability (NCGS, 2004). Care pathways -Many hospitals now have central medical admission units where early medical stroke care can be guidance driven. Clinical guidelines (i.e. known as care maps, or care pathways) are often used for diagnosis, treatment, prevention of complications and rehabilitation (Pushpangadan et al, 1999).

A care pathway focuses on the practical delivery of multidisciplinary care in the form of a daily written care plan, which highlights any important interventions. It is intended to assist healthcare professionals to achieve pre-specified patient goals efficiently while improving quality of care based on best evidence and guidelines. However, there is debate as to the usefulness of these plans. There is some evidence to suggest that when a care pathway is used the patient may be more likely to have the tests they need, less likely to get an infection and less likely to be re-admitted to hospital (Kwan & Sandercock, 2003). However, others (e.g. Low, 1999; Brooks & Anthony, 2000) suggest that care pathways may be a hindrance to professional advancement, by removing the healthcare professional's autonomy and ability to critically evaluate individual needs. Physiotherapeutic management relies heavily on autonomy and clinical reasoning.

If this is removed poorly developed clinical guidelines may underpin ineffective and possibly dangerous practice (a one size fits all attitude is not appropriate). More research needs to be undertaken in this area. The factors identified above clearly have implications for practice, such as assessment, goal setting and treatment. In parallel to the National framework and in order to improve stroke care nationally, the Royal College of Practitioners (RCP) developed the Intercollegiate Working Party (IP) for Stroke. This led to the production of National Clinical Guidelines for Stroke (NCGS, 2000, 2002, 2004). The guidelines outline current evidence based practice of which can be used by all professionals in the management of stroke patients.

In terms of physiotherapy, the guidelines cover in particular, the use of assessments, team working, goal setting and underlying approaches to therapy (CSP, 2002). Assessment, goal setting and outcome measures Assessment -Each member of the multidisciplinary team should provide thorough and repeated assessment, to ensure problems are not overlooked. A physical and neurological examination establishes the baseline with which all future evaluations are compared and must be the basis for effective determination of the patient's problems (Association Chartered Physiotherapists In Neurology-ACPIN, 2004). The ability to collect specific information during the assessment and efficiently communicate this to other health care providers can significantly affect patient outcomes.

According to Schretzmen (2001, pg 7)". ... time equals brain". Irreversible neural damage occurs shortly after the stroke begins, but secondary damage may be prevented or minimise d if appropriate treatments are initiated. The patient should also be assessed on admission for their needs in relation to moving and handling and risk of developing pressure sores. In terms of prompt assessment and types of treatment, health care provision is dependent on a number of factors (e.g. local adaptations of the NSF, availability and training of staff etc), all of which impact on practice. According to NCGS (2002) patients should be reassessed at appropriate intervals. The CSP's Core Standards (CSP, 2000) suggest that a professional evaluation of a patient should be carried out using standardized measurement instruments to facilitate a more systematic approach and to enable progress to be monitored.

In today's climate of evidence-based practice all physiotherapists should advocate the use of valid, reliable and clinically sensitive outcome measures as a benchmark for goal setting, treatment decisions and effective practice (CSP, 2004). Goal Setting - Physiotherapeutic management involves a problem solving approach to stroke care, in order to set short and long terms goals (where appropriate) which may contribute to the process of rehabilitation (CSP, 2002). Goal setting refers to the identification of, and agreement on, a target that the patient, therapist or team will work towards over a specific period of time (Intercollegiate Working Party, 2000). Research evidence has demonstrated that using goals improves rehabilitation outcome provided that significant patient involvement occurs and that both short and long-term goals are developed. Unfortunately, the research base used has been taken from non-stroke studies, most of which involved small sample sizes and usually in the context of outpatient rehabilitation.

(Wade, 1999). Also different definitions have been used and practice varies according to therapist skills (NCGS, 2004). Therefore, the extent to which these studies can be generalised to stroke is uncertain. According to Ashburn et al, (2000) the process of goal setting itself may highlight several differences in expectations between patients and physiotherapists. Therefore, rehabilitation should always be placed in the context of the patient's own activities and beliefs.

This may be done by incorporating goals that are meaningful to the patient and aimed at promoting independent movement for daily functioning, thus achieving the best possible quality of life and social participation. Nevertheless, an understanding of the term is not always shared by patients and carers (Lawler et al, 1999). Independent walking is often an important ultimate goal, requiring several stages of recovery. Initially, patients may display poor trunk control and are unable to bear weight on the affected extremity.

Care must be taken to set goals which are challenging but achievable (CSP, 2002). Physiotherapeutic management should focus on posture, trunk control, and weight transfer. A short-term goal may include being able to sit out during meal times, with a view to a long-term goal of eating in the dining room with other patients (Wade, 2000). Outcome measures - There is much debate about the selection of appropriate outcome measures for routine clinical use and various instruments are available according to whether a measure of impairment (e.g. Rivermead Motor Assessment), disability (e.g. Barthes Index), or activity limitations and participation restrictions (e.g. London Handicap Scale) is required. A recent survey found that 22% of therapists are not measuring outcomes and that many are using measures not tested for reliability and validity (Lennon et al, 2001). The reasons why remain unclear.

According to the CSP (2001 b) the measurement instrument should be appropriate to the treatment intervention and relevant to the patient. To measure mobility for example, the Rivermead Mobility Index (RMI) or the updated version (MRM I) may be selected. Used correctly both are sensitive enough to provide an objective measurement, from which the amount of assistance required for mobility can be calculated (Johnson & Selfe, 2004). This information can be relayed and utilised within the MDT. Prevention of complications and the physiotherapist Airway, breathing and circulation (ABC) - As with any other medical conditions, the treatment during the acute phase begins with the management of ABC in order to prevent and reduce medical complications. Physiotherapeutic management focuses on chest care.

Therefore, if active rehabilitation is not possible (e.g. impaired consciousness), passive rehabilitation is performed to minimise the risk of bronchopneumonia, a major cause of death among stroke patients (Hiker 2003). For example the physiotherapist will aim to maximis e the patient's position such as side lying or supported high sitting (if tolerable) to help improve oxygen saturation and maintain blood pressure, thereby limiting further neurological damage (Blood pressure Acute Stroke Collaboration-BASC, 2004, Balla, 2000, Chatterton, 2000). Early intervention - Physiotherapists should be aware that many patients may have had impaired physical fitness prior to their stroke. Due to age, for example, many will have experienced a decline in cardio respiratory fitness and muscle function (Harridge 2000, Malbut-Shennan 2000). There is the wide range of options available for treatment of both primary and secondary conditions, the selection of which should be tailored to the individual and centered on evidence-based practice (CSP, 2002). Rehabilitation is aimed at decreasing the consequences of the illness and helping relearn skills that are lost when part of the brain is damaged.

The provision of physiotherapy is a major component of rehabilitation and should commence within 24 hours or as soon as the patient is medically stable (NSF, 2001). The reality is however that only 56% of patients are seen within this time frame (Rudd et al, 2001). Paucity of evidence regarding reasons remains unclear. However, there is very little evidence to support the NSF recommendations in this regard (CSP, 2002). Early physiotherapeutic intervention in the acute phase centers on mobilisation for the prevention of secondary co-impairments e.g. pressure ulcers, deep vein thrombosis and musculo skeletal problems such as contractures and shoulder pain. Exercises may be carried out in bed or on a chair, in order to maintain muscle length and tone (Carr, 2000, Dean, 2000).

Post- stroke shoulder pain - is common (although the a etiology is uncertain) and is associated with poor recovery of arm function. How and when shoulder pain is measured results in different prevalence estimates. However, 80% of patients may be affected within the first year after stroke (Hanger et al, 2000). Physiotherapeutic management utilizes a range of measures to prevent shoulder pain.

These may include, correct positioning (avoiding the use of overhead arm slings, which may encourage uncontrolled abduction) and the use of foam supports (CSP, 2001). Incorrect handling has been found to be a contributing factor of shoulder pain (Dean et al, 2000). Therefore, the physiotherapist should educate other members of the team (including carers) in correct handling techniques. If the shoulder pain is already established according to RCP & CSP (2002) physiotherapeutic management may include high-intensity trans cutaneous electrical nerve stimulation (TENS). However, research as to the benefits of TENS in this situation is lacking. Patients should be assessed for pain on a regular basis, as it is a common secondary impairment and if not addressed, may hinder rehabilitation and long-term functional recovery (RCP & CSP, 2002).

Treatment strategies and the physiotherapist Approaches - In terms of rehabilitation different approaches focus on the modification of impairment and improvement in function within everyday activities. A number of different physiotherapy approaches (e.g. Bobath approach, Motor Re-learning approach, Brunn strom, Rood, Proprioceptive Neuromuscular Facilitation etc) have been developed based on different ideas about how people recover after a stroke. The Bobath approach is used by 90% of the physiotherapists in the UK (SIGN, 2004), which is a problem-solving approach to the assessment and treatment of individuals with disturbances of function, movement and tone. However, previous studies found that physiotherapists favour the Motor Relearning Programme, which focuses on task-orientated strategies, (Carr & Shepherd, 1998, Davidson, 2000).

Several studies (e.g. Pomeroy & Tallis, 2000) have investigated the effectiveness of the different approaches and have found no differences between the approaches in terms of improvement in functional ability. However, others (e.g. Carr & Shepherd, 1998) have found that the Motor Re-learning Programme was more beneficial in terms of improved motor function and reduced stay in hospital as compared with the Bobath programme after the first three months of stroke. It must be pointed out that evaluating treatment approaches is extremely difficult as there are so many confounding factors (e.g. patient characteristics, physiotherapist skills etc). According to Lennon (2001) many physiotherapists follow a more eclectic approach based around each patient's assessed needs and this is the position adopted in the NCGS (2004). Regardless of considerable research efforts on multiple treatment modalities, there is still no single rehabilitation intervention demonstrated unequivocally to aid recovery (Pollock, 2004). Emerging evidence suggests that providing the opportunity to practice functional activities (task-specific training) may result in improved outcomes (Pollock et al, 2004).

As an example physiotherapeutic management aimed at promoting the recovery of postural control (balance during the maintenance of a posture, restoration of a posture or movement between postures) to enable the patient to sit upright, will begin in supine with facilitated movement. As the patient's core stability progresses (to unsupported sitting, through to transferring between the bed and a chair, to standing up), care should be taken that quality is not substituted for quantity. Intensity of therapy - Despite it being suggested that patients should receive as much physiotherapy as can be given (CPS, 2002). Only a few trial have been conducted to test this (e.g. Langhorne et al, 2002; Partridge, 2000, Van der Lee & Snels, 2001 and Kwakkel et al, 1999) and no firm conclusion can be made due to confounding factors (e.g. the services providing extra therapy were also those whom had additional and more qualified staff and whom were better organised).

Many studies were found to methodologically flawed (e.g. small numbers of participants, selection bias etc). After a review of the literature Scottish Intercollegiate Guidelines Network-SIGN (2004) revealed a moderate positive benefit of intense therapy for the fittest 10% of stroke patients. However, no firm conclusion could be made regarding the benefit to the other 90%. In reality people in the acute phases often suffer from fatigue and may not respond well physically to intense therapy, although psychologically they may feel that it is beneficial (Partridge, 2000). The latest guidance suggests that therapy should be provided on a needs basis according to how much the patient is willing or able to tolerate. Nevertheless, It is currently not known whether there is a minimum point at below which there is no benefit at all.

Therefore, once the physiotherapist has helped the patient to increase tolerance, physiotherapeutic management may go on to include gait re-education. Gait Disorders - The physiotherapist should offer gait re-education, which has been found to be beneficial in improving the patients walking ability (e.g. Green et al, 2002). There is some concern that walking aids encourage patients to favour the unaffected limb. What little research there is, suggests that they do not, although these studies have utilised small sample sizes (e.g. Tyson & Ashburn, 1994; Laufer et al 2001). Patient's safety is paramount and as such may require equipment such as walking frames and walking sticks to increase their standing stability and ensure safety. Therefore, physiotherapeutic management should be based on clinical judgment in consultation with the patient and reassess periodically.

A focused training programme such as treadmill training has been found to be beneficial in the treatment of gait disorders. Several studies show that patients not walking independently between 30 days and three months after stroke may benefit from treadmill training (Moseley et al 2004). However, this should only be considered as an addition to conventional therapy and treated actively in accordance with the patient's wishes (NCGS, 2004). It should also be recognised that, standard treadmills are unable to provide body weight support and so their value is limited.

Falls -Risk of falling remains a long-term problem for stroke patients and they may become increasingly susceptible to more serious injury from which rehabilitation is difficult (e.g. fractured neck of femur). A careful appropriate assessment will help identify those at greatest risk and implementation of handling strategies by all members of the team is once again paramount (Warlow et al, 2001). Physiotherapist as educator- Research suggests that patients and carers have little understanding of stroke, risk factors, consequences and types of support available (Forester et al, 2001) Lack of knowledge may result in failure to comply with secondary prevention and also lead to poorer long term psychosocial outcomes (O'Mahony et al, 1997). Information in the form of leaflets, videos etc are not as effective as education plus information (Johnson & Pearson, 2000). Physiotherapists are in a position to provide both. However, future research is required to examine different types of education (CSP, 2002).

Physiotherapeutic management - post discharge - Early discharge has the potential to reduce the risk of distress associated with prolonged hospital stay (Rodgers et al, 1997). However, hospital services should have a protocol and local guidelines for discharge, in order to establish (prior to discharge) whether there is a specialist stroke rehabilitation team in the community or the patient is able to transfer safely and attend a day care centre (Roderick, 2001). A stroke care co-ordina tor is recommended (NSF, 2002) in order to bridge hospital and community based services, taking on the responsibilities for care plans, secondary prevention measures, aiding patients etc. The physiotherapist should provide a full assessment and liaise with the co-ordina tor prior to discharge in order to ascertain the individual's requirements and pre-empty any problems.

The physiotherapist working closely with the occupational therapist will help to determine what equipment and adaptations could increase safety and independence (NCGS, 2004). Carers should receive all necessary equipment and training in moving and handling, to be able to position and transfer the patient safely in the home environment. Ideally, procedures (and funding) should be in place to enable re-assessment to check existing aids, appliances and identify and provide new requirements. The timely and appropriate provision of aids and / or appliances is one of the crucial aspects of stroke care. However, many patients experience multiple waiting lists for essential equipment and adaptations. An investigation of five main equipment services by the Audit Commission (2000) found that there was under investment, low priority afforded by senior managers and geographic variations in people eligible to receive services.

There was also variations in the range and quantity of equipment provided, the time spent waiting for its delivery, and in the number of staff trained. This may result in delay from hospital discharge, which impacts on all services including physiotherapy. There is now considerable evidence to suggest that stroke sufferers require a longer period of support and contact than the few months currently provided by hospital departments (Rudd & Wolfe, 2002). After stroke, patients continually decline and if this decline can be prevented or reversed by longer-term stroke rehabilitation, this may prevent re-admission to hospital and thereby be cost effective (NCGS, 2004). The NSF (2002) recommendation that rehabilitation should continue until maximum recovery has been achieved is a step forward.

However, exactly who will decide this maximum recovery remains a mystery. The physiotherapist should assess any patient with disability at six months or later after stroke for further targeted rehabilitation where appropriate (NCGS, 2004). Whilst at the same time, physiotherapists should encourage independence. One problem is that there is little evidence for specific recommendations for appropriate longer-term physiotherapy provision (CSP, 2002).

Conclusion Ongoing physiotherapeutic management of stroke patients is a dynamic process, incorporating evidence based practice (e.g. issued in the National Clinical Guidelines for Stroke Patients, 2004) and responding to the changes in the health service (e.g. as a result of the National Service Framework for Older People, 2002). Stroke is still a major health problem. However, it has been reliably established that organised multidisciplinary stroke care, such as typically provided in a stroke unit, reduces mortality and institutionalization compared to care provided in a general medical ward. In spite of this evidence the NSF targets have not been met and more stroke units are required.

Physiotherapeutic management sits well within a MDT to maximis e assessment, treatment and general rehabilitation. Together they can provide holistic health care, preventing deaths and minimizing physical (and psychological) disability. However, this is the ideal and only beneficial if the MDT is efficient. Resource limitations (finances, time, staffing levels etc) have a major impact upon the type and efficiency of services provided, resulting in wide variations geographically. Clearly physiotherapeutic practices may be constrained even within a dedicated stroke unit.

In addition there is a shortage of physiotherapists in dedicated stroke units and general rehabilitation units (NSSOA, 2004). More units and resources are required in order to both save lives and minimise the risk of further strokes (which would be cost effective). Physiotherapeutic practices themselves focus on evidence-based guidance such as that of the NCGS (2004) and as such, is therefore continually evolving. Physiotherapists must keep up to date in order to maximis e the benefits of therapeutic management for the patient and be able to critically appraise studies in order to incorporate new knowledge into clinical practice. As part of physiotherapeutic management physiotherapists are required to disseminate information to other team members, patients and carers. However, often provisions for training / education are minimal, again often due to lack of resources.

An increase in awareness and use of clinical guidelines can go some way to standardizing care. The problem arises in that physiotherapists are dealing with individuals each with unique circumstances and clinical presentations (this may explain some of the "methodological flaws" identified in studies, such as confounding factors, small sample sizes etc). Evidence based practice and guidance therefore can never be applied to all situations or patients. Clinical judgment (e.g. such as in the choice of treatment for a particular patient) has to remain the cornerstone of effective therapy, utilizing evidence-based practice where applicable.