Monday, January 30, 2012

Neurological and Functional Recovery: The Difference

Having a stroke is one of those medical conditions with a devastating effect on a person as well as for the family. I will not go into detail on this for this article but just to provide a general view a stroke is a medical/neurological condition wherein the brain gets injured due to sudden block of blood flow or due to rupture of a blood supply to it. The effect in terms of what happens to a person is generally affectation of the strength usually on the half side of the body. This is called hemiparesis(partial) or hemiplegia (complete) which is the paralysis of half of the body. i.e affectation of the left upper and left lower limb  or vice versa.

Now just to give a rundown, the cost for medical treatment is definitely something of a blow to any family. It not only disrupts the savings of the family but it may also affect the income especially if the one affected is the breadwinner. Not only that, the family members who will skip work or go on leave also looses their productivity/earnings. Do I need to say more?

Now after the patient becomes stable and is discharged, the question now arises if how much did the patient recover? I will define first neurological recovery. I will simplify this, a patient prior to a stroke has a normal strength on both upper and lower limbs. A Normal grade is 5 over 5(5/5). When the patient has a stroke the left side as an example lost its strength and became poor (2/5). Not only that but also his sensation to touch on the left side decreased by 80 percent. The patient also had difficulty in speaking. All of the above findings show a neurological deficit. If after 4 days of treatment the patient regained his strength from poor (2/5) to fair (3/5), his sensation to light touch improved from 80% less to 50% now while his speech became normal. Those improvements are what we call neurological recovery. See table below.

As for functional recovery, it is the ability of the patient to do activities with or without neurological deficits. Using the example above the patient has initially been fully functional, working, typing, eating, dressing independently etc. He had a stroke wherein he has 2/5 strength, 80% sensory deficit and affected speech. So he became confined to bed, unable to go to the bathroom, feed himself etc. He became fully dependent. Now lets change the situation after 4 days. He still has the same deficit but he is now able to sit by himself, he is able to sit for 30 mins with minimal support, and now able to eat with partial assistance. He has recovered functionally even if his neurological deficit is still the same after 4 days. See table below.

Why am I pointing out these differences? It is because it is often thought that being unable to move a limb means one cannot adapt and become functional. There are patients who had superb neurological recovery as they can move the upper and lower limbs after a stroke and yet are in wheelchair and fully dependent in their activities. While those who have 2/5 lower limbs strength are now able to ambulate with a cane and do self care activities with minimal assistance.

CONCLUSION: The point I am driving is that the functional recovery on an individual is not based solely on the neurological recovery. By undergoing physical rehabilitation and with the proper motivation a patient can recover functionally even with a poor neurological recovery.

Thursday, January 26, 2012

Importance of Physical Therapy

A local advertisment simply says it all, "Mahal ang magkasakit." (Getting sick is expensive). This is especially true for those who got hit by devastating or debilitating conditions such as strokes or similar conditions that affect the physical strength of a patient. Lets try to enumerate the would be expenses: Hospitalization, medicines, laboratory and imaging/diagnostice procedures, and profesional fees for physicians

Now comes the second part of the expenses, upon discharge of a patient and brought home its time to deal with the refitting of the residence to the present needs of the patient. Then one will include continuation of medicine, needed diagnostic test for monitoring and scheduled checkups with their physician.

Now why am I trying to enumerate all of these and yet the title is importance of Physical Therapy. Well simply stating it, a patient who is brought home and has lost the ability to be independent in activities of daily living (walking, dressing, eating, walking, bathing, working etc), needs assistance and caregiving. Which in order to achieve independence partial or complete, needs to undergo physical therapy. Now the other concern is, did physical therapy start while in the hospital or just an afterthought upon dischage?

Unfortunately, this is something that is not sometimes discussed to the patient/relatives and if by any chance discussed, may be considered as a miscellaneous expense and not a required expense. What am I pointing out? If a patient is asked to buy medicines and/or undergo physical therapy, what will the patient/relative do? The patient/relatives may opt to have both but oftentimes will opt to have the medicine and forego the physical therapy. The would be possible reasoning is, "Pwede naman yan pag lumabas na ng hospital" (That can be done already once the patient is discharged).

Again unfortunately, it may be initially less expensive if physical therapy is not done during confinement but how is it in the long run? An article done by Ruth M. Kleinpell, Kathcy Fletcher and Bonnie Jennings in Patient Safety and Quality: An Evidence-Based Handbook for Nurses pointed out the ff:

1. I quote " A dissonance exists between the hospital environment and therapeutic goal for the hospitalized elderly." (This means the goal is to make them medically stable but not functionally recovered upon discharge)
2. By Day 2 deconditioning and functional decline was evident on elderly individuals.
3. Elderly patients who was assessed during confinement showed that from day 2 to discharge, 67% showed no improvement and 10 percent showed further decline.

It then just shows that if an individual further declines in functional status that means, EXTRA care/assistance. Which is equivalent to a caregiver or nurse stay at home. If the patient is fully dependent you might need 2 caregivers in 1 duty shift. Or even to the point that the relative/love one would stop or not work in order to take care of the patient. That is lost productivity not only for the patient but also for the relative taking care of him/her.

And study shows that a deconditioned muscle (due to disuse or non use), needs 2 to 3 times the duration to be strengthened back to its original condition as compared to its deconditioning. So for example, the lower limbs lost its strength for 2 weeks of bedrest/immobility, it will need 4 to 6 weeks before it regains its former strength. And that is for young individuals, what more for elderly or those who became debilitated?

The Evidence Based Review of Stroke Rehabilitation (ESBSR), states that there is strong evidence that greater intensities of physiotherapy and occupational therapy resulted in improved functional outcomes after stroke. This then points to the fact that in the long run, which is the usual duration for those who have a stroke will benefit on early intervention to minimize potential prolonged bedridden and immobilization complications management. These complications, such as bedsores, pulmonary conditions, lower limb edema, joint stiffening, fully dependent on all activities, depression etc, may then prove more costly than having early intervention.

Table 1 shows the effect of prolonged bed rest. (click Table to enlarge)
*Source/Table were it was taken from is noted at end of article.

Conclusion: Patients who had debilitating conditions that affect their functional status during confinement should be assessed properly if early physical therapy intervention is needed or not. Talk to your attending physician so that the recommended Physical Medicine and Rehabilitation specialist can discuss and provide the benefits and consequences or early physical/occupational therapy. Know your options so that you can decide on what would be more beneficial for the patient as well as for the love ones.

* Ruth M. Kleinpell, Kathcy Fletcher and Bonnie Jennings in Patient Safety and Quality: An Evidence-Based Handbook for Nurses
Next article would be the difference between neurological and functional recovery.