The measurement of the structural disorders after stroke can be carried out by estimating the personal deficit and then generalized as a degree of invalidity. The present study focused on 65 stroke patients. They were follow Ðµ d-up and underwent an early neurorehabilitation course. The analysis of an extensive body of literature and the results obtained from our clinical investigations enabled to discuss the relationship between the elements, e. g., diagnosis, planning, intervention and assessment involved in the management of the neurorehabilitation process. Based on the combination of standardized indices and scales the authors suggest a unified rehabilitation profile enabling them to evaluate and monitor the motor and cognitive deficit. Thus, objective prerequisites are established for determining the priorities, monitoring the efficacy and the possibilities for prognosis of terms and outcome of the conducted rehabilitation training

Havezova, L.

Kostadinova, T.

Yordanova, P.

English

Varna Medical University Press: Journals

Scripta Scientifica Medica, vol. 30(1998), pp. 37-41 Copyright © Medical University, Varna REHABILITATION A F T E R STROKE: TRADITION AND FUTURE L . Havezova, P. Yordanova, T. Kostadinova* Department of Neurology and ^Department of Health Management, Medical University qf Varna, Varna The measurement of the structural disorders after stroke can be carried out by estimating the personal deficit and then generalized as a degree of invalidity. The present study focused on 65 stroke patients. They were follow е d-up and underwent an early neurorehabilitation course. The analysis of an extensive body of literature and the results obtained from our clinical investigations enabled to discuss the relationship between the elements, e. g., diagnosis, planning, intervention and assessment involved in the manage­ment of the neurorehabilitation process. Based on the combination of standardized indices and scales the authors suggest a unified rehabilitation profile enabling them to evaluate and monitor the motor and cognitive deficit. Thus, objective prerequisites are established for determining the priorities, monitoring the efficacy and the possibilities for prognosis of terms and outcome of the conducted rehabilitation training. Key-words: Stroke, disability assessment, Barthel Index, Pulses Profile, Functional Independence Measure, International Classification of Impairments, Disabilities and Handicap The high rate of stroke morbid­ity and mortality as well as the severe social and economic consequences for the patients, their families and the com­munity make the issue of rehabilitation of utmost importance. In September 1995, at the PanEuropean meeting for a consensus on treatment of stroke or­ganized by the regional offices of the WHO for Europe and the European Consulting Council on stroke the fol-Address for correspondence: £ Havezova, Dept. of Neurology, Medical University, 55 Marin Drinov St, BG-9002 Varna, BULGARIA E-mail: neurol@asclep.muvar.acad.bg lowing goals of the treatment of stroke were formulated for Europe (1995-2005): a) drop in lethality in the first month after stroke below 20%; b) pre-vention of stroke relapses and drop in the lethality after the second year be-low 40%; c) increased functional inde-pendence of the survived from stroke above 70% after the third month, and d)increased quality of life (2). Points 3 and 4 in the above quotation mark clearly the role and the importance of rehabilitation in this type of pathology. According to the W H O definition / X L . Havezova, P. Yordanova, T. Kostadinova 1980/ neurorehabilitation is an active process aiming at "fulfilling of the op-timal physical mental and social poten-tial as well as a possibility for the individual's integration in a suitable environment'' (3,8). Having in mind the scientific criteria adopted by the Euro-pean federation of Neurological Sc i -ences ( E F N S ) (June 1997) on neurorehabilitation and the rehabilita-tion standards in their annexes we aimed at suggesting a program for re-habilitation training and problem-situ-ation solving which focus on deficit and are directed towards decreasing disabil-ity in stroke survivors. The need for a multidisciplinary approach to the patients' problems prompted the establishment of a com-plex assessment program of a new type, including possibilities for screening, monitoring and prognosis as well as follow-up of the individual rehabilita-tion program efficiency. In conditions of limited resources in the field of health care it was necessary to make a realis-tic evaluation of the achievements so far by means of the management tools and then define the strategy for the fu-ture. M A T E R I A L AND M E T H O D S Subject to our study were 65 patients (28 males and 37 females) aged 60,3 13,2 and admitted to Second Cl inic of Neurology, Department of Neurology, Medical University of Varna for treatment after stroke, all of them with varying degree of motor, speech and cognitive impairment. Patients with total dependence and those with total recovery were excluded from the studiy. After an early rehabilitation course con-ducted under clinical conditions, the health status of some patients was fol-lowed-up in the neuropsychological consulting room after 1, 3 and 6 months up to one year after the event. Informa-tion data were obtained at the patients4 examination and from structured inter-views with the persons nursing them under home conditions. A l l the patients were tested in the following order: 1. The functional capacity of every participant in the working group was registered at admission, on dis-charge from hospital and followed-up in ambulatory conditions by means of the Barthel Index ( B I ) 2. Pulses Profile (PP) scale char-acterizing the functional deficit of the health and psychosocial status and the communicative abilities of the patient 3. Functional Independence Measure ( F I M ) for the measurement of the global functional deficit 4. McMas te r Heal th Index ( M M H I ) for the quality of life assess-ment 5. Neurorehabilitaion profile in-cluding specialized data bank for pa-tients with organic central brain dis-eases (1) 6. Expert system for diagnosing speech impairment (1,9). 38 Rehabilitation after stroke R E S U L T S AND D I S C U S S I O N The main processes, included in the rehabilitation cycle are: diagnosis, planning, intervention and assessment. The effective management in this con-tinuum is a key issue in making the cor-rect strategic decisions and increasing the quality of the rehabilitation pro-grams (2). The diagnostic process was sub-ject to categorization of four levels in the degree of impairment according to the constellations of the International Classification of Impairments, Disabili-ties and Handicap (8). By means of a more modern B I modification we di-vided the studies patients in three sub-groups according to the degree of pro-nouncement of their motor deficit at a personal level (Fig. 1). This index and its temporal dynamics afterwards was included in our expert program both be-cause of its high significance and its correlation with the remaining indices and scales cited above. Its monitoring during the rehabilitation program in combination with PP enabled us to fol-low the actual possibilities for each in-dividual, the necessity for support and the dynamics in the communicative and psychosocial status. B y means of F I M we managed to enlarge the scope of day-to-day activities characterizing the glo-bal deficit in our patients. The priori-ties in this modern scale are subject to discussion of another publication of ours (4). Severe Moderate Mild disability disability disability Fig. 1. Comparison ofbartel Index before and after rehabilitation An important emphasis in the diagnosis is the measurement of the pa-rameter "quality of life " as a pragmatic functional assessment of the daily physical, psychic and social activity of the individuals determined by his/her ability to live up to the personal stan-dards of filling-up (3). The analysis of the data obtained in our study indicated a significant approximation of the so-cial and emotional status values irre-spective of the differences in evaluation of the physical functional status (Fig. 2). The patients' age was also found to be of importance, those aged 50-65 hav-ing a significantly decreased M M H I as compared to the younger ones. This is particularly true for the part "active uti-lization of leisure time". We observed a correlation between the decreased M M H I values and the degree of depres-sion manifestation even in cases of minimum registered motor deficit. The reduced number of social contacts and 39 L . Havezova, P. Yordanova, T. Kostadinova 0.8 0.6 0.4 0.2 Physical status Social status Emotional status Fig. 2. McMaster Health Index results the poor emotional adaptation decrease considerably this parameter. Our find-ings are in accord with other results published (5,6). The information obtained using the quoted scales and indices is particu-larly topical and useful but still insuffi-cient for the setting up of an adequate rehabilitation program. Having studied the information value of the separate di-agnostic parameters and their impact on the global human functions, we estab-lished a unified neurorehabilitation pro-file as a package of significant mani-festations (1). Our three-years' experi-ence with this model gives us grounds to accept its relevant prognostic value with possibilities for defining priorities when working out the individual recov-ery programs (4). An expert system for aphasic disorders diagnosis was adopted for defining the degree of speech impair-ment (9). It enabled us to monitor the results from the neuropsychological in-vestigations of the speech functions. This diagnosis is of particular impor-tance for conducting the long-term speech rehabilitation. The practical ap-plication of this system is determined not only by the possibilities for diagno-sis and dynamic follow-up of the speech status but also in training conditions through active seeking for specific de-viations during the neuropsychological testing. The combination of method-ological elements from cybernetics, lin-guistics and information theory with the application of dichotomy tests is a dis-40 Rehabilitation after stroke tinctive feature of modern cognitive psychology (8). The improvement of the functional communicative abilities of patients with aphasic disorders w i l l comprise our next step in reducing their disability and enhancing their self-es­teem and adaptation to the environment. R E F E R E N C E S 1. Х а в е з о в а , Л . , К. Т е н е к е д ж и е в , П. Й о р д а н о в а . В: Основни проблеми в неврологията. Под ред. Е . Х а д ж и п е т р о в а . Пловдив, Полиграфия АД, 1994,15-16.- 2. B a r n e s , М. P. Europ. J. Neurol., 4, 1997, No 4, 325-331.- 3. B o w l ­ing, А . Measuring Disease. Buckingham-Philadelphia, Open University Press, 1995, 175-187.-4. H a v e z o v a , L . , D . M i n c h e v , P. Y o r d a n o v a , F . K i r o v . Scr. Sci.Med., 29, 1997, Suppl. 4, 11-16.- 5. K e l l y - H a y e s , M . C . P a i g e . Neurology, 45, 1995, Suppl. 1,820-823.-6. K i n g , R . B . Stroke, 1996, 1467-1472.-7. L i n a c r e , J . M . , A . W. H e i n e m a n n , B . D . W r i g h t , C . V . G r a n g e r , В . B . H a m i l t o n . Arch. Phys. Med. Rehab.. 75, 1994, 127-132.- 8. Wade , D . T . Measurement in Neurological Rehabilitation. Oxford, etc., Oxford University Press, 1992, 4-33.- 9. Y o r d a n o v a , P . , L . H a v e z o v a , D . M i n c h e v , S . T z e k o v . Europ. J. Neurol., 3, 1996, Suppl. 5, p. 123. Рехабилитация след мозъчен инсулт - традиции и бъдеще Л . Хавезова, П. Йорданова, Т. Костадинова* Катедра по неврология и *Катедра по здравен мениджмънт, Медицински университет-Варна Резюме: Обсктивизирането на структурните увреждания след мозъчен инсулт се проявява чрез измерване на персоналния дефицит и глобализира като степен на инвалидност. Базирайки се на богат литературен материал и собствени климатични наблюдения,авторите разглеждат взаимовръзката между отделните елементи (диагностика, планиране, интервенция и оценка), включени в невровъзстановителната програма. На базата на комбинация от стандартизирани индекси и скали авторите създават единен рехабилитационен профил, позволяващ оценяване и мониториране на моторния и когнитивен дефицит, потози начин се създават реални педпоставки за определяне на приоритетите, проследява се ефективността и възможностите за прогнозиране сроковете и изхода от проведения курс възстановително обучение. 41 

REHABILITATION AFTER STROKE: TRADITION AND FUTURE

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REHABILITATION AFTER STROKE: TRADITION AND FUTURE

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