Physical Medicine and Rehabilitation: Long-Term Consequences of Stroke.

The editor's intent is to address those consequences of stroke that face the patient and family members after hospitalization and therapy have been discontinued. The 21 contributors, however, cover a broad spectrum from risk factors and diagnostic tests to long-term physical and emotional sequelae. The 15 chapters, include epidemiology and recovery, disability, recurrence and prevention, urinary, incontinence, dysphagia, seizures, dementia, and psychological and social consequences. There are 36 to 213 references in each chapter. Of particular interest to the physical therapy practitioner are chapters on spasticity and contracture, lower-extremity disorders, upper-extemity disorders and pain, and orthotics.

The authors differentiate spasticity from muscle tone, but acknowledge that spasticity is often a measure of one or more components of muscle tone. Referenced data supporting and refuting neurophysiologic mechanisms suggested as underlying spasticity are presented. Biomechanical contributors to spasticity, such as elastic and viscous, stiffness, are described, and followed by methods of clinical and laboratory assessment, including the Ashworth Scale. The pharmacologic treatment of spasticity is presented through a table of nine agents, hypothesized mechanisms of action, side effects, and qualitative comments. A brief overview of neurorehabilitative treatment related to spasticity avoids reference to specific approaches; however, motor learning and a task-specific treatment style are mentioned. Intervention efficacy cannot be documented, due to lack of measurement sensitivity, validity, and reliability. The information given about contractures includes pathophysiology, cartilage changes, sites frequently affected, their effect on movement efficiency, and energy consumption. Data of the effects of muscle stretch, including prone lying and serial casting, as it relates to duration of stretch, sacromere composition, and connective tissue remodeling are explained.

The relatively greater upper-extremity as compared with lower-extremity involvement following middle cerebral artery insults is noted with statistics of functional recovery and positive outcomes. There are several upper-extremity disorders covered, including shoulder pain, subluxation, contracture/frozen shoulder, reflex sympathetic dystrophy, shoulder-hand syndrome, brachial plexus injury, and central pain. The relationship among these sequelae, their potential causes, and preventive and corrective intervention (including physical and pharmacologic therapies) are addressed with good use of the available literature. The chapter on disorders of the lower extermity refers to relative differences of stroke due to anterior cerebral artery, middle cerebral artery, internal capsule, and brain-stem lesions. Clinical imaging techniques of the anatomical site, however, have not correlated with clinical signs. Theories of recovery briefly covered include resolution of cerebral edema, collateral circulation, neuronal sprouting, and unmasking. Lower-extremity assessments include the Medical Research Council Scale; Brunnstrom and other descriptions of movement patterns; functional reflections of lower-extremity control through gait parameters such as speed and distance or the degree of assistance of a second person or assistive ambulatory device; and functional measures that encompass far more than lower-extremity control such as Barthel, pulses, and functional independence measures. Although these are potential measures of long-term outcome, no summary outcome data are presented. Mention of treatment techniques is made, with data of successful use of biofeedback and electrical stimulation under certain conditions. As with the upper-extremity disorders, incidence, causes, prevention, and intervention of long-term consequences within the lower extremity are presented. Sections on hip and knee contractures, genu recurvatum, equinovarus, lateral foot pain, fractures, heterotopic ossification, arthritis, and deep vein thrombosis are presented with some outcome data.

Goals for the use and types of both upper-and lower-extremity orthoses are presented. A Canadian study in which 80% of the individuals who were poststroke reported wearing orthoses at least 7 hours a day was cited. The use of electrodynograms, the parameters typically different from normal in the stroke population, and implications of the findings for orthotic choice are addressed. Various materials, joints involved, and intended biomechanical effects, as well as the use of functional electrical stimulation during gait, are described, followed by methods of gait training.

The authors succeed in covering many aspects of life after stroke without preaching a single philosophy. They have cited many references for theory and efficacy. What is disappointing for physical therapy practitioners is the paucity of documentation of impairment and disability at intervals poststroke, and efficacy of specific treatments in altering outcomes that one might expect from a book of this title. This is not the short-coming of the text, but rather of the available body of knowledge.

This book is appropriate for any physical therapy practitioner, novice or experienced therapist or therapist assistant, as well as other health care providers. The novice is offered a concise overview, and the more experienced practitioner is provided a launching point to pursue a more through exploration of the literature. The information will not, however, significantly direct the practitioner in methods of effective intervention.