As I am interested in going into a career in physiotherapy I

As I am interested in going into a career in physiotherapy, I think that researching this topic will give me a different perspective into an area of physiotherapy that I could look at going into in the future, it will give me a better view on different aspects of how physiotherapy can be used. As a physiotherapist I think it would be very rewarding to see patients who were previously severely ill recover step by step which is part of the reason I chose to look into stroke rehabilitation because there are so many issues that can arises from having a stroke which would make it an interesting specialism to study, also the issues will vary from every patient as no stroke is in the same place or of the same severity so the speed of progress patients make would be different and you can see them recover with your support. The role of a physiotherapist can be defined as a person qualified to treat disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise. Recently at my work experience at the Royal Surrey hospital I was able to go onto wards, it was amazing to see the variety of patients the physiotherapist saw ranging from post-op assessment, respiratory issues such as cystic fibrosis or just general muscle weakness prevention because if patients are sat in bed for a long time every day there will be significant muscle wastage which could impact recovery time as they may be to carry out daily tasks safely. At Haslemere hospital I found that there were several generic exercises that could be given out for a variety of musculoskeletal issues which ranged from a fractured fibula to poor balance, this is possible because the patient still had control of their bodies and was fully in control unlike the majority of stroke patients who will have suffered major brain damage which means they have to learn basic activities such as walking from the beginning as if learning it for the first time. I have also had physiotherapy for a few different injuries and it was interesting to see the great variety of methods used during my rehabilitation such as physical manipulation and resistance exercises and I would like to see if the variety was the same for neurological, more specifically stroke patients. It is currently estimated that in the UK an estimated 152,000 people annually have a stroke, that’s nearly one stroke every five minutes or every two seconds worldwide and unfortunately, one in five strokes are fatal (The Stroke Association – Statistics, 2013). Stroke causes about 7% of deaths in men and 10% of deaths in women. There are approximately 1.1 million stroke survivors, with only 3 out of 10 stroke survivors (who need a six-month assessment) receiving the care they need, this leaves over half of the survivor’s dependant on others to carry out day to day life. Therefore, I would like to discover whether physiotherapy is an effective way of improving stroke patients which have a variety of issues and once their problems have been solved does their quality of life increase, as they are not as dependant on other people to take care of them in daily life. There are two main types of stroke these are: 85% are ischaemic strokes, 15% are haemorrhagic strokes of which 10% caused by a primary intracerebral haemorrhage (this occurs within the brain tissue/ventricles), and 5% caused by a subarachnoid haemorrhage (bleeding on the surface of the brain). Transient ischaemic attack (TIA): Sometimes known as a ‘mini-stroke’ or ‘warning stroke’ is another type of stroke however they are not a cause of a stroke only a category. A stroke episode is defined as a transient ischaemic attack if the symptoms such as loss of speech and movement resolve within 24 hours. Ischaemic strokes are the most common type of stroke, they occur when a blood clot blocks the flow of blood and oxygen to the brain. These blood clots typically form in areas where the arteries have been narrowed or blocked over time by fatty deposits known as plaques, this process is known as atherosclerosis (NHS, 2017). As people get older, the arteries can naturally narrow, but certain things can increase the risk of blood clots forming such as lifestyles choices like smoking, obesity, high blood pressure and cholesterol. Strokes have different causes and are known as cerebral haemorrhages or intracranial haemorrhages – are less common than ischaemic strokes. They occur when a blood vessel within the skull bursts and bleeds into and around the brain. The main cause of haemorrhagic stroke is high blood pressure, which can weaken the arteries in the brain and make them prone to split or rupture. (NHS, 2017)Typically, due to the general location of strokes, they mainly cause damage to the part of a brain that controls movement and behaviour. The frontal lobe is responsible for behaviour and motivation, making this the main area damaged during strokes. Other areas of the brain include the parietal lobe which is responsible for movement, sensation and understanding language. The occipital lobe helps you understand what you see whilst the cerebellum is used for balance and coordination, the brain stem is essential for carrying out life functions such as breathing or eating, finally, the temporal lobe controls memory and emotion. Patients may experience weakness or complete paralysis on one side (called hemiplegia), and 76% of stroke survivors have physical issues after suffering a stroke. This will cause their limbs to move in a different way and to feel heavy or numb as the weakness makes them difficult to move. Over three-quarters of stroke, survivors report arm weakness which can make it difficult for people to carry out daily living activities. Whilst almost three-quarters of stroke survivors report leg weakness, which can cause difficulty walking and balancing which may make then dependant on other people or a walking aid which may hinder their recovery as it becomes a safety blanket. Some people have more unusual sensations such as pins and needles, hot and cold sensations or feeling as though water is running down their limb, occasionally this can be painful. There is an increased risk of having problems with a patient’s posture and balance, making it difficult to stay upright and more likely to have a fall. Whilst joints on the affected side, such as a shoulder, may be vulnerable to injury and partial dislocation (called subluxation) or ‘frozen shoulder’, this is when a patient’s shoulder becomes painful and difficult to move. Difficulty Percentage of people affected General movement 80% Arm movement 70% Unable to use an arm 40% Spasticity 19-38% Altered sensation Up to 80% Swallowing 40% Aphasia – language issue 33% Visual problems Up to 66% Depression 29% Dementia 20% Bladder control 50% Bowel control 33% Incontinence 15% In order to tackle a patients numerous problems cause by their stroke they should be placed on specialist stroke units especially as patients placed on these units have been found more likely to be living independently a year after having a stroke than those cared for on other non-specific wards, stroke care and future treatment would see drastic improvement if more hospitals in England had hyper-acute stroke units and more nurses and doctors to provide effective treatment as 4 out of 10 hospitals in the United Kingdom have a shortage of stroke consultants (The Stroke Association, 2017). Hyper-acute stroke unit (HASU) allows rapid assessment of patients; they arrive at the hospital Emergency Department and are assessed by a specialist team at the earliest opportunity to give early treatment and the appropriate level of required, this could be using clot-busting drugs (thrombolysis) if the MRI scan shows they are needed. There are 24/7 monitoring and physiological intervention in a high-dependency bed with a multidisciplinary specialist team on call which includes consultant neurologists, neurosurgeons, interventional radiologists, specialist nurses and therapists to ensure the most effective treatment possible (UCLH NHS, -). Only 77% of patients are taken straight to a stroke unit in England, Wales and Northern Ireland, this means that 23% of people are treated on general wards without stroke specialists early in their treatment but 9 out of 10 stroke patients are cared for on a stroke unit. Some patients receive treatment for their strokes besides physiotherapy however these procedures can be invasive which may not always be the best approach for all patients, especially in elderly patients how already have other medical issues a surgical procedure could be stressful and cause more harm than good. The procedures could include thrombolysis which uses drugs to break down and disperse clots for people who have had an ischaemic stroke. It is licenced to be used up to 4.5 hours from the onset of stroke symptoms, 6 out of 10 stroke patients in England, Wales and Northern Ireland arrived at the hospital after the 4.5-hour time window or had a stroke during sleep so the time could not be calculated. An estimated 1.9 million neurons are lost every minute a stroke is untreated (The Stroke Association, 2017). Another procedure would be a thrombectomy, this is a procedure that mechanically pulls the blood clot out of the brain and approximately 9,000 patients per year may be eligible for thrombectomy. It is shown to reduce the chance of disability after stroke and The National Institute for Health and Care Excellence states that it’s safe and effective. However, there are not enough trained professionals for the service to be rolled out across the UK as the treatment is not fully commissioned yet and almost a third of hospitals have no access to thrombectomy. (The Stroke Association, 2017).The amount of physiotherapy could be increased through an early supported discharge team to provide additional care which would rebuild a patient’s strength faster ultimately giving them more independence in the long run. Early support discharge teams provide an early, intensive rehabilitation service for patients and are starting to be used for stroke patients, the team helps patients to leave hospital more quickly and return to their own homes so that patients can become more independent faster after suffering a stroke. (HRCH NHS, -). A case study for the effectiveness of early supported discharge is Northern Devon Healthcare Trust stroke therapy team who has developed an effective and efficient ESD team for a rurally dispersed population – suffers in rural locations will find it harder to socialise and make appointments as they have little access to public transport which would enable an easier way into hospitals. The service builds on a typical early discharge model with physiotherapists working flexibly across the patient pathway. Care includes a fitness and self-management programme, psychological screening and intervention, vocational support, and integration with other community, health, social care and voluntary services (The Chartered Society of Physiotherapy, 2011). Outcomes included that the length of stay reduced by six days from 22 days to 16 days, saving £833,700, hospital re-admission rates reduced from 6% to 3% through strengthened links with community nurses and 13% more patients returning home as opposed to a care home, saving over £75,500 per person. As recent statistics done by the Stroke Association show that strokes account for 240,456 inpatient episodes of care (The Stroke Association, 2017) costing the NHS £1.7 billion every year in the UK alone. Patients will be seen to by physiotherapists who often work with other professionals to provide a holistic approach to a patient’s recovery, including occupational therapists, speech and language therapists, doctors, nurses and social workers who will work on all aspects of their recovery, not just their mobility. Many patients are also referred to a specialists like a neuro-physiotherapist who is trained to understand the impact of changes caused by damage to the brain and nervous system, unfortunately, stroke causes so much damage as our brains cannot grow new cells to replace the ones that have been damaged (The Stroke Association, 2017). The brain does, however, can unmask neuronal pathways to make up from some loss of brain function and undergo neuroplasticity which is the ability of the brain to change throughout an individual’s life especially if it becomes damaged. Following a stroke, patients will be assessed by a physiotherapist as soon as possible, as people with one-sided paralysis need to be correctly positioned as it is important to prevent spasm or injury, 24 hours after a stroke, patients should be encouraged to get up and about as much as possible. On the other hand, if patients are unable to move, they should be given chest physiotherapy to keep their lungs free of infection, it is important to sit up, as this will help avoid blood clots in their legs, improving breathing and help speed up recovery. Physiotherapy will be used to help the patient learn to use their arms and legs again and regain as much strength and movement as possible. In the early stages, and for people with relatively mild problems, physiotherapy will focus on preventing complications, restoring a large range of movement and increasing a patient’s independence. There will be standard exercise each patient is given to begin with to increase muscle mass and endurance as soon as possible to reduce the negative effects that their stroke has had, after this each patient will be re-assessed to see if any progress has been made so they can be given more specific exercise and target to work on depending on the severity and effected location that the stroke has impacted. The more therapy a person has and the more active they are after a stroke, the better because their muscles are strengthened faster due to a more intensive programme, the sooner basic functions can reign the sooner the patients can be released and transferred into outpatient physiotherapy. Guidelines recommend that while undergoing rehabilitation in hospital, every patient should receive at least 45 minutes of each type of therapy they need per day (The Stroke Association, 2017). There are many ways to practise the exercises the patients are given this is mainly one-to-one, recently on physiotherapy work experience I gained at a hospital there were two physiotherapists for one patient, or can occur in a small group setting which will provide a social aspect to the patients rehabilitation which will help combat feelings of aloneness or depression which could occur from being isolated. Tasks and activities are also given for patients to practice on their own outside of therapy sessions. Patients are given exercises to build up your stamina and stretching exercises to prevent muscle and joint stiffness are also beneficial. The Chartered Society of Physiotherapist has also recommended that seven-day-a-week stroke services, and greater face-to-face time with patients. A New Ambition for Stroke recognises the importance of high-quality rehabilitation services and the key role that physiotherapists play in these teams. During a consultation held they heard from more than 500 stroke survivors, and a key theme was that the patients wanted more physiotherapy both in hospital and after discharge.’ Especially as more recent evidence shows that regular physiotherapy improves mobility and independence in daily living for stroke patients, which strengthens the argument that specialist physiotherapy should be available at all stages of their recovery. Most people recover quickly in the first weeks after their stroke and after about three months, the recovery period usually slows down and plateaus , this could be due to a lack of motivation or lack of physical capability due to the impact of their stroke. This could be prevented by setting goals during the initial treatment stages, a recent study which used 21 patients aged 52-86 years old, found that infrequent goal-setting caused failure to maximize patients’ involvement in sessions. Goal-setting, particularly where patients’ views are elicited and incorporated, involves skill and effort and is influenced by powerful social constraints. Developing detailed knowledge of both practices and constraints may contribute to improving professional practice, guidance and education’ (Parry, 2004).The chartered society of physiotherapist who supports those who deliver physiotherapy care, education and research through professional, educational and trade union services, as well as campaigning on behalf of the profession. The CSP works in partnership with its members and external bodies to achieve and promote excellence in physiotherapy states that ‘The NHS is now exceptional at keeping people alive, but we must do more to ensure the lives that are saved are worth living. Rehabilitation services do that, and it is essential that in the next decade we witness a radical transformation in provisions to ensure no-one misses out’. This is especially important as the prevalence of strokes is expected to increase in future decades due to the increasingly ageing population and the improvements in hyper-acute care resulting in the increased number of individuals surviving their stroke. This means that the treatment given to suffers needs to be effective and efficient. There are several main ways for rehabilitation to occur and these include Bobath, Motor Relearning Programme, Traditional exercises, PNF and the Functional Approach. The Bobath approach is also known as the neuro-developmental treatment and looks at rehabilitating patients based on the brain’s ability to reorganise (neuroplasticity) and it is a multidisciplinary approach, involving Physiotherapists, Occupational therapists and Speech and language therapists. The Bobath approach is used to address problems associated with having a stroke (Wikipedia, 2008). However, a study review researching physical rehabilitation approaches for the recovery of function and mobility following stroke with an objective to determine whether physical rehabilitation approaches are effective in recovery of function and mobility in people with stroke, and to assess if anyone physical rehabilitation approach is more effective than any other approach. Found that no one approach to physical rehabilitation is any more (or less) effective in promoting recovery of function and mobility after stroke. As, evidence indicates that physical rehabilitation should not be compartmentalised or specifically named, but rather should comprise clearly defined, well‐described, evidenced‐based physical treatment. (Pollock A, 2014)

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