Stroke Rehabilitation: Guidelines for Exercise and Training to Optimize Motor Skill.

Stroke Rehabilitation: Guidelines for Exercise and Training to Optimize Motor Skill Carr JH, Shepherd RB. Philadelphia, PA 19106, Butterworth-Heinemann Inc, 2003, paperback, 310 pp, illus, ISBN: 0-7506-4712-4, $54.95.

In their latest text, Carr and Shepherd focus on rehabilitation guidelines to optimize motor function following stroke. The book does not attempt to be an all-inclusive guide for all therapies dealing with this condition. Instead, its scope is limited to those motions that the author's have determined to be critical to recovery: walking, reaching and manipulation, balance in sitting and standing, and standing up and sitting down.

The book is organized into 3 sections. The first section is an introduction to the text. This introduction is followed by a description of brain reorganization following stroke. The authors cite at least 25 magnetic resonance imaging studies published in the last 15 years to support this description. This first section closes with a description of a stroke unit and how the delivery of physical therapy in these units affects the recovery process.

The second section in the book contains the training guidelines for specific functional tasks. Each chapter focuses on a different function and contains an explanation of normal versus impaired motor performance that is based on biomechanical data from recent literature. These explanations are followed by the actual training guidelines. Therapists looking to expand their interventions may be surprised at the limited number of functional activities actually described. The authors' goal in writing these guidelines has been to use only those exercises and activities that have been proven by clinical research to be effective in achieving functional outcomes. As a result, the actual variations of the tasks, other than to change the difficulty level, are limited.

The literature is cited extensively. In each chapter a table summarizes the pertinent clinical outcome studies of the past decade. Each table contains between 4 to 13 studies. References at the back of the book cite all of these studies so that the reader can explore them further.

Each chapter in section 2 reviews soft tissue stretching and muscle strengthening exercises, which, in the authors' view, are critical to enhancing the performance of the specific function. The chapters close with a listing of measurements with established reliability and functional tests that are standardized for the specific patient activity.

The third section of the book contains appendixes that address impairments, adaptations, and strength training for patients who have had a stroke. There is an in-depth discussion of muscle weakness in stroke, loss of dexterity, and increased reflex activity. The book, however, contains a paucity of information regarding sensory impairments, including cognitive and visual perceptual impairments. Many physical therapists feel that the combination of motor impairment with these sensory deficits make stroke a unique condition to manage; therefore, it is disappointing to see that these guidelines have such a cursory review of sensory impairment.

The authors have succeeded in writing an excellent guideline for exercise in stroke that deals with the functional tasks of balance, walking, standing up and sitting down, and reaching and manipulation. Its scope is limited. It does not substantially cover the very acute phases of stroke, bed mobility comorbidities, and sensory impairments. One important item to remember is that this book is written from the perspective of rehabilitation in Australia. The authors often comment on the length and intensity of programs provided to patients who have had a stroke. Insurance coverage, decreasing length of stays, or HMO-imposed limitations on patient care are not mentioned.

This book does, however, give an easy-to-follow guideline to the therapist who is new to neurorehabilitation. It is an excellent text for physical therapist students and new graduates.

Carolyn Vaillancourt, PT, NCS 

Healthsouth Braintree Rehabilitation Center

Braintree, Ma

Ms Vaillancourt has over 15 years of experience in managing patients across the age span in neurorehabilitation.