Med & Health 2008; 3(1): 1-6

REVIEW ARTICLE

Managing Further Rehabilitation in Longer-Term Stroke

Patients in the Community: A New Approach.
N.A Aziz1, A.A Raymond2
Departments of 1Family Medicine and
Kebangsaan Malaysia, Kuala Lumpur.

Medicine, Faculty of Medicine, Universiti

ABSTRAK
Penyakit angin ahmar (strok) semakin menjadi masalah utama di dalam penjagaan
kesihatan di negara kita disebabkan oleh umur populasi negara yang semakin meningkat.
Keberkesanan rawatan strok di peringkat akut menyebabkan tiga daripada empat pesakit
strok dapat melepasi peringkat akut strok. Doktor dan mereka yang terlibat di dalam
penjagaan strok berpendapat bahawa penjagaan strok lanjutan bermula selepas setahun
selepas serangan strok, memandangkan tempoh ini berhubungkait dengan kebarangkalian
untuk terus hidup selepas mendapat serangan strok. Penjagaan strok lanjutan adalah
kompleks, melibatkan keseluruhan aspek kehidupan pesakit; keperluan fisikal, psikologikal
dan penglibatan ke dalam komuniti. Proses rehabilitasi yang merupakan tunjang utama
penjagaan strok lanjutan seharusnya menumpukan kepada evidence-base untuk menjadi
lebih effektif dan relevan kepada pesakit strok.
Kata kunci:

Rehabilitasi, strok jangka panjang, komuniti

ABSTRACT
Stroke is becoming a major public health issue in our country due to the fact that there is
an increasing life span of our population. Due to advancement of acute management of
stroke, three out of four people will survive beyond the acute phase of stroke. Stroke care
providers are still debating regarding the exact period of the terminology longer-term
stroke; however many agreed that long-term of stroke refers to the period of one year and
thereafter as this period is the determinant for longer-term survival. Management beyond
the first year of stroke is complex, encompasses all aspects of patients life; physical,
psychological and integration into community. Rehabilitation being the cornerstone of
longer-term stroke management should now focused on more evidence-based approach
as to be effective and relevant to the stroke patients.
Key words: rehabilitation, long-term stroke, community

Address for correspondence and reprint requests: Dr Noor Azah Aziz, Department of Family Medicine UKM,
Jalan Yaacob Latiff, Bandar Tun Razak, 56000 Cheras, Kuala Lumpur. Tel: 03 91733333 samb 2846
Fax: 03 91738153 Email: [email protected] / [email protected]

Med & Health 2008; 3(1): 1-6

INTRODUCTION
Stroke is a major public health problem
worldwide. It is the third most common
cause of death after coronary heart
disease and cancer (McKay & Mensah
2004). Looking into worldwide incidence of
stroke, Sarti et al. (2000) found that the
incidence of stroke only differs slightly
between countries, after being standardized for age and sex. The incidence rates
for subjects between the ages of 45 and 84
were between 300 per 100,000 population
and 500 per 100,000 population annually.
In Malaysia, epidemiological data from the
Ministry of Health in 2002 showed that
stroke was one of the top five leading
causes of death in our country, with
mortality rate of 11.9 per 100,000
population (MOH 2002).
Overall, the incidence of stroke,
especially in developed countries, has
shown a declining pattern which largely
appears to be due to control of modifiable
blood pressure, improved dietary habits
and reduced levels of smoking (Hankey
2002). However, the absolute numbers of
strokes will continue to escalate in the
future due to one single factor, the
increasing life span of the world population.
This trend is worrying as a significant
number of survivors will still be below the
retirement age and therefore have many
responsibilities involving families and the
workforce (Royal College of Physician
2005). Given that three out of four people
survive beyond the acute phase, these
individuals may lead a longer life with
impairment and disability as a conesquence of stroke. It is therefore imperative
that stroke clinicians look beyond the acute
phase in order to plan and manage the
needs of longer-term stroke patients for
them to have best quality of life.
Longer-term care of stroke a definition
The Royal College of Physicians (2004)
identifies longer-term care as a period of
three to six months post stroke and

Aziz N.A et. al.

thereafter (Royal College of Physician

2004). In most patients, longer-term care is
the phase which starts soon after transfer
from hospital to community, conversely
others may identify as the completion of
rehabilitation program, including outpatient
therapy or any other therapies that has
been completed. However, amongst stroke
care providers longer-term management is
frequently described as a year or more
after stroke, given the fact that the majority
of prospective cohort studies measuring
prevalence of stroke had used one year
after stroke as a determinant for longerterm survival (Dennis et al. 1993;
Grevenson et al. 1991; Patel et al. 2006).
Above all, longer-term care for stroke
patients is primarily about managing the
consequences of stroke in the best way
possible, as it relates to patients quality of
life and their relationship with their carers
and families, and how best to re-integrate
patients into the community with the
available resources. In recent years there
has been agreement that in overall stroke
management, the major elements of
longer-term
care
comprise
further
rehabilitation, secondary prevention, and
involvement in social function (Wilkinson et
al. 1997; Murray et al. 2003). This review
will address the aspect of further
rehabilitation in longer-term management
of stroke, as this area of management
forms the integral part of overall
management for stroke patients that have
been discharged home to the community.
Longer-term consequences of stroke
Stroke is a major health problem in the
community, with more and more people
surviving and living longer after stroke.
However, only a small number of
community-based studies have looked into
the long-term outcome of stroke patients
and very few have assessed functional
status beyond a year of stroke onset.
Studies that observed survival rates after
stroke, agreed that almost half of the
patients survived one year or longer, and

Further Rehabilitation in Longer-Term Stroke Patients

that the survival rate remained constant up

to five years post stroke (Dennis et al.
1993; Grevenson et al. 1991). Disability
remains prevalent up to three years poststroke, with 23-30% having moderate or
severe disability (Barthel Index < 15 /20).
Patel et al. reported that one in two stroke
survivors will remain inactive (Frenchay
Activities Index less than 15) at one year
after stroke, and a further 30% will require
residential care after the first year of stroke
(Patel et al. 2006). Wilkinson et al. reported
that 46% of stroke survivors needed help
with at least one component of activities of
daily living (ADL) and named spouse,
children and other family members as their
main carers (Wilkinson et al. 1997). These
two studies used different outcomes in
assessing health-related quality of life, but
both concurred that the domains that were
significantly affected by disability were
psychological
well
being
(anxious/
depressed), physical functioning (ADL),
physical mobility, general health and social
functioning.
Murray et al (2003) and McKevitt et al.
(2004), in their reviews of qualitative
interviews with stroke patients living more
than one year in the community, further
explored the nature of problems faced by
longer-term stroke patients. Both studies
suggested that problems at this stage of
stroke were diverse and complex and may
change over time. Both reports have
identified five common domains that were
prevalent at this stage of stroke recovery
which include health and social services,
problems in accessing information, transfer
of care and psychological adjustments.
However, these studies were small-scale
and geographically localized, focussing
more on depth rather than breadth of the
problems, and therefore may be only
applicable to the selected populations. In
summary, there is continuing disability for
more than a year after stroke. However the
provision of therapy-based rehabilitation
services is low. At present there is no
agreed consensus about the benefits of
providing a service for more than one year

Med & Health 2008; 3(1): 1-6

after stroke. Documented benefits from

community intervention studies are rare in
this patient group, as the majority of trials
investigated earlier phases of stroke
recovery.
Further rehabilitation :The need for a
paradigm shift.
The World Health Organization describes
rehabilitation as the combined and
coordinated use of medical, social,
educational and vocational measures for
training and retraining the individual to the
highest level of functional ability (WHO
1998). Stroke rehabilitation aims directly
and indirectly to increase independence
and ability. Not only does it concern
prevention of complication, but rehabilitation encompasses all aspects of the
patients life: physical and psychological
health and integration into the community.
The stroke rehabilitation approach involves
multi-disciplinary team, comprising the
patient, the family, therapists, nurses,
social workers and physicians. As is
evident
from
overall
stroke
care,
rehabilitation starts as early as hours after
stroke and continues up after discharge
and into longer term care which involves inhospital settings to various settings in the
community
(Hankey
2002).
Stroke
rehabilitation is a continuous process
starting as assessment in the stroke unit
and ending only when it no longer
produces any positive effect on the patient
(Mant et al. 2004).
It was initially thought that progress of
stroke patients reached a functional
plateau such that little or no recovery
occurred after a certain period of time and
hence the fixing of three to six months for
formal rehabilitation programmes (Pollack
& Disler 2002). However, current evidence
has demonstrated that stroke survivors
showed late functional improvement, even
after several years post stroke, and those
with continuing decline might be reversed
by further rehabilitation input (Mant et al.
2004). Therefore it is now suggested that

Med & Health 2008; 3(1): 1-6

any patient who has had a stroke reporting

significant disability at six months poststroke should be reassessed and offered
targeted
re-habilitation
to
improve
functional capabilities (Department of
Health 2001).
This emerging evidence in longer-term
rehabilitation has brought about a new
direction on how rehabilitation should be
carried out at this stage after the stroke. It
is now suggested that further rehabilitation
should move away from the activity phase
and address the issue of participation as
defined by Wade and Jong as in Table 1
(Wade & Jong 2000). The overall design of
this table shows that the approach of
rehabilitation towards stroke patients now
encompassed a more holistic approach in
managing patients; whereby rehabilitation
now not only involves intervention to the
disabilities and handicaps but helping the
stroke patient to improve his/her functional
status and to re-integrate into the society.
This is particularly important, as patients
need to learn to be more independent and
try to re-integrate into the community,
rehabilitation should concentrate more on
social and leisure activities that help
improve patients post-stroke functioning
level rather than repetitive functional
exercises that are commonly performed at
present. Several trials have addressed the
issue of leisure and social intervention in
stroke patients residing in the community,
but to this date these studies were small,
so that no significant conclusion should be
made although individual results showed
promising outcome (Drummond & Walker
1995; Logan et al. 1997)).
Trials looking at rehabilitation intervention
at this phase of stroke can be divided into
those concerned with transfer from hospital
to the community and those that were
performed in the community itself. The
Outpatient Service Trialist systematic
review, which looked into 14 community
rehabilitation intervention trials involving
1617 patients within a year of having
stroke, demonstrated reduced risks of

Aziz N.A et. al.

deterioration in ability to the undertake

activities of daily living (ADL) and
significantly improved the performance of
ADL (Outpatients Service Trialist 2002).
The meta-analysis also found that common
features shared by these studies were that
staffs carrying out the intervention were
knowledgeable and had specific interest in
stroke care and that outcomes were
achieved by altering task-associated
behaviour. The exact nature and content of
intervention were not known, as the studies
were heterogeneous in their approach, but
it can be concluded that community
rehabilitation intervention is both feasible
and effective.
On the other hand, there have been a few
studies that have addressed the needs of
stroke patients more than a year after
having a stroke. Two mobility intervention
studies
demonstrated
a
short-term
improvement in treatment effects as
measured in Barthel scores, but these
effects were small and intervention was
conducted in small scale studies with short
intervention periods (Wade et al. 1991;
Green et al. 2002). Studies that looked into
leisure intervention showed similar trends
(Mulders et al. 1989; Werner & Kessler
1996). A Cochrane systematic review is
currently in progress in order to establish
the evidence of the effectiveness of
rehabilitation services more than a year
after a stroke, hoping to provide a
foundation for better services in the future
(Aziz et al. 2006). Without doubt, the
element of further rehabilitation is proven to
be an important aspect in longer-term care
of stroke patients. Consequently there is a
need to look again at this aspect of
management of the longer-term stroke
patients in the community.
CONCLUSION
Management of longer-term stroke patients
consists of inter-related key elements that
are both complex and long-standing.
Awareness of the benefits of combining

Further Rehabilitation in Longer-Term Stroke Patients

Table 1:

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Rehabilitation-framework model of revised ICIDH (ICF) (Wade & Jong 2000, AHCPR 1997)

Term for level of illness

Alternative terms

Comments

Pathology

Disease, diagnosis

Abnormalities or changes in the structure or function

of an organ or organ system

Impairment

Symptoms; signs

Abnormalities or changes in the structure of function

of the whole body

Function;

Abnormalities changes, or restrictions in the

interaction between a person and his or her
environment or physical context (that is, changes in
the quality or quantity of behaviour)

Activity
(previously disability)

Participation (previously
handicap)
Domain for contextual
factors

observed behaviour

Social position and roles

Examples

Changes, limitation, or abnormalities in the position

of the person in their social context.
Comment

Personal

Previous illness, previous

coping strategies,
preferred leisure activities
and hobbies

Primarily attitudes, beliefs and expectations, often

arising from previous experience of illness in self or
others.

Physical

House, local shops,

access to buildings

Primarily local physical structures but also includes

people as carers (not as social partners)

Laws, friends

Primarily legal and local cultural setting, including

patients expectation of important people in their life.

Social

ICIDH International Classification of Impairment, Disability and Handicap

ICF International Classification of Function

these elements of care to provide holistic

management of stroke patients in the
community. Current guidelines on stroke
have set a clear and explicit standard of
care for the components of acute
management, secondary prevention and
an early rehabilitation programme for
stroke patients. Nevertheless, with the
emergence of evidence on longer-term
stroke management especially in the area
of further rehabilitation, a new approach to
the rehabilitation of stroke patients in our
community needs to be considered.
Perhaps what is required now is a new
outlook on the longer-term care of stroke
patients in Malaysia, which involves the
intertwining elements of care and evidence
based medicine described above, which

will fit into our unique social and cultural

way of life.
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