Defining the Scope of Rehabilitation Care in Stroke: An Interdisciplinary Perspective
Pub Date: Thursday, September 2, 2010
Author: Margaret Kelly-Hayes, EdD, RN, FAAN, FAHA
Miller EL, Murray L, Richards L, et al; on behalf of the American Heart Association Council on Cardiovascular and Stroke Nursing and the Stroke Council. Comprehensive overview of nursing and interdisciplinary rehabilitation care of the stroke patient: a scientific statement from the American Heart Association. Stroke 2010: published online before print September 2, 2010, 10.1161/STR.0b013e3181e7512b.
For the more than 6.4 million stroke survivors in the United States today, the benefits from organized rehabilitation care are well documented.[1,2] Extensive data have reinforced the belief that stroke rehabilitation is an integral component of stroke treatment and can enhance physical, psychological, social, and vocational potential in survivors with disabilities when the interventions are guided by strong scientific evidence and an effective rehabilitation team. This comprehensive statement provides a broad overview of the assessment, treatment, and care involved in providing nursing and interdisciplinary rehabilitation services to those recovering from stroke. It compliments the previously published guidelines [2,3] by providing a review of the interdisciplinary team approach to rehabilitation, outlining the settings in which rehabilitation can occur, and defining components of care that can enhance recovery for the various phases of stroke. The guideline emphasizes that stroke care not only takes place in inpatient and outpatient rehabilitation settings but also in chronic care settings, including those settings that provide end-of-life care.
Recovery and restoration can occur anytime following stroke with the optimal time being early on. No matter in what setting rehabilitation occurs, the overall principles remain the same. The defining goal in stroke rehabilitation is to maximize recovery by identifying and treating the disabilities caused by the stroke and to restore function whenever possible. Research has shown that patients do better with a well-organized, interdisciplinary approach, in which the standards and focus of treatments to ameliorate deficits are adhered to and that a well-conceived rehabilitation management plan and team carry out the plan of care.
To ground the complexity, focus, and elements of rehabilitation care across the continuum presented in this statement, the International Classification of Functioning, Disability, and Health (ICF) model, developed by the World Health Organization, was chosen as the organizational framework. The ICF model was applied to the domains affected by stroke and to the settings where survivors receive treatment. The framework outlines four major components when approaching the care of a stroke survivor: 1) loss of body functions and structures, 2) activities limitations, 3) participation restrictions, and 4) contextual factors, including personal and environmental variables. The guideline evaluates and summarizes the best available evidence and recommendations for interdisciplinary management of the needs of stroke survivors and their families within the ICF framework during inpatient and outpatient rehabilitation and in chronic care and end-of-life settings.
Similar to previously published guidelines, this scientific statement provides an evidence-based plan for care and is formulated to address the spectrum of neurological deficits experienced by the individual. The recommendations are explicit where possible and supported according to the levels of evidence. In many ways, it builds on the previous published guidelines [2,3] and includes an extensive review of the relevant literature and expert consensus. The recommendations in the guideline refer to all phases of stroke recovery. The unique contribution of each discipline is described in detail as well as the importance of a unified team and evidence-based approach. In turn, this facilitates short- and long-term goal achievement within the most effective system of care.
A highlight of the guideline is the section on families and caregivers. It is well known that families provide approximately 75% of care after the stroke survivor returns home. Evidence is presented about the vital role of family during recovery, including the association of family support with improvements in stroke survivors' physical and overall functional status. Attention is paid to the emotional and physical health of the caregiver and the importance of the family in the care of the stroke survivor across inpatient, outpatient and chronic care settings.
Effective rehabilitation interventions initiated early on after stroke can enhance the recovery process and minimize functional disability. Although there have been dramatic improvements in stroke treatments, a majority of stroke survivors continue to cope with residual deficits. Applying the ICF framework to deliver effective and comprehensive rehabilitation and care is a step forward in providing a uniform structure to guarantee the highest achievable outcomes and excellent care. This statement is an important and timely addition to our evolving understanding of the scope of rehabilitation needs involved in providing comprehensive care after stroke.
- Lloyd-Jones D, Adams RJ, Brown TM, et al. Heart disease and stroke statistics-2010 update: a report from the American Heart Association. Circulation 2010;121:e46-e215.
- Duncan PW, Zorowitz R, Bates B, et al. Management of adult stroke rehabilitation care: a clinical practice guideline. Stroke 2005;36:e100-143.
- Summers D, Leonard A, Wentworth D, et al. Comprehensive overview of nursing and interdisciplinary care of the acute ischemic stroke patient: a scientific statement from the American Heart Association. Stroke 2009;40:2911-2944.
- Schouten LM, Hulscher ME, Akkermans R, et al. Factors that influence the stroke care team's effectiveness in reducing the length of hospital stay. Stroke 2008;39:2515-2521.
- Moriello C, Byrne K, Cieza A, et al. Mapping the Stroke Impact Scale (SIS-16) to the International Classification of Functioning, Disability and Health. J Rehabil Med 2008;40:102-106.
- Dewey HM, Thrift AG, Mihalopoulos C, et al. Informal care for stroke survivors: results from the North East Melbourne Stroke Incidence Study (NEMESIS). Stroke 2002;33:1028-1033.
-- The opinions expressed in this commentary are not necessarily those of the editors or of the American Heart Association --