Rehabilitation of hemiplegia: indices of assessment and prognosis.
Authors: L J Hurwitz, G F Adams
Journal: BMJ (1972)

Size of the ProblemThe true incidence of cerebrovascular accidents in Britain is not known, because no representative morbidity statistics are kept.The information available is the result of guesswork based on studies of small sections of population.In one from Great Britain76 391 patients were admitted to hospital with cerebrovascular accidents in 1963 from a population of 340,000, an incidence of 1-2 per 1,000 per annum, but the comparable incidence for Middlesex County, Connecticut,7 was 2-3 per 1,000 per annum, giving an adjusted rate for the U.S.A. of 1.7 per 1,000.Statistics from a study in Baltimore78 projected to the whole country yielded an estimate of "500,000 living stroke victims, almost 350,000 (70%0) of them aged 65 and over" in the United States, but the President's Commission79 estimated that there were at least two million people alive in that country in 1964 who had suffered a stroke.An estimate from the office of Population Censuses and Surveys80 states that there are 130,000 people in Great Britain who have significant impairment from stroke.Probably the incidence in both the United Kingdom and United States may be just less than 2 per 1,000 population per annum, and it rises sharply with advancing age especially amongst women.Similar findings have been reported from Denmark.81A family doctor,8" extrapolating his experience in a practice of 2,500 arrived at the same incidence.He found that about five new hemiplegics appear in the practice each year bringing 15-20 hemiplegics of all varieties under his notice annually.Of these he expects 60% "maxi" strokes, 20% "mini" strokes, and 20% miscellaneous cerebrovascular disorders.Applying these figures to a population of 250,000 (the basis for a district hospital) suggests an incidence of 500 strokes per annum, of which 250 will need a lot of help and about 150 will be added to the accumulated number needing continued care each year. Recovery From StrokeWe tend to think of recovery from strokes in three phases: two weeks concerned with survival; eight to twelve weeks of effort to restore activity and independence in walking, standing, and self-care; and two years-the time that may elapse before the full capacity of the patient to participate in normal social activities may be realized.Management at the onset of a major stroke is described elsewhere in this symposium and was also discussed recently.8'Here we are concerned with recovery in the two later stages.Elsewhere a description"4 has been given of the clinical criteria used to assess capacity and define the barriers which may delay recovery and require special consideration in treat- ment.85-90Special aspects of assessment and treatment have also been described in two comprehensive symposia.91-92Two points of rehabilitation which need special emphasis are that initial assessment should be directed towards accepting patients for treatment and not to their rejection, and that the process of recovery is spontaneous and slow.Nerve cells which die do not recover, nor will their connexions remyelinate.Improvement in function occurs partly because damaged tissue regains vitality, and partly because other functions served by healthy brain provide intellectual tricks necessary to compensate for some of what has been lost.Recovery by these mechanisms may account for the improve- ment observed in the first six months after a stroke, but improve- ment may be even more protracted suggesting that there are However, no one seems to have been able, yet, to define criteria of Queen's University and Wakehurst House, City