The Management of Acute Stroke.

The Management of Acute Stroke By Allen CMC, Harrison MJG, Wade DT. Baltimore, MD 21211, The Johns Hopkins Univeristy Press, 1989, harback, 215 pp, illus, $55

The authors' stated purpose for the book is to provide a state-of-the-art review of "clinically relevant knowledge concerning acute stroke as well as practical advice on the medical management of patients with acute stroke." The book's purpose are fulfilled in three sections--Cerebrovascular Disease, Clinical Management, and Rehabilitation and Recovery--of six chapters each. In the section on cerebrovascular disease, the clinical anatomy of stroke is presented very effectively using line drawings and images of brain slices from the computed tomography (CT) scanner. Circulatory maps also are used in an effective manner. The mechanisms of cerebral thrombosis and infarction, including post-infraction edema and bio-chemical changes, are addressed.

In the section on clinical management, considerable attention is focused on the differential diagnosis of stroke (versus other intracranial lesions). The authors compare and contrast alternative examination procedures, such as lumbar puncture, CT scanning, magnetic resonance imaging, isotope brain scanning, cerebral angiography, and carotid ultrasound. The illustrations of various procedures contribute substantially to their appreciation. A concern that therapists might have about this section is the emphasis on lesion site. Even clinical tests for such impairments as paresis and neglect appear to be presented for their contribution to lesion identification, rather than vice versa. A few inaccuracies can be found in this section, but they probably reflect the age of the book (first published in 1988 in Great Britain) and the rapid growth of knowledge about stroke, rather than a lack of concern by the authors for correctness.

Physical therapy clinicians will probably find the section on rehabilitation and recovery the most clinically useful. The authors begin by distinguishing among impairment, disability, and handicap. Many comments in this section make direct reference to therapists. Straightforward but nondogmatic statements prevail. Regarding shoulder pain, the authors state that the underlying pathology is uncertain, "but probably it is a simple frozen shoulder." Regarding the initiation of therapy after stroke, the authors state, "There is no evidence that rest is needed at all, and there is some indication that early mobilization speeds recovery. Therefore, every patient should be mobilized as fast as possible, starting immediately after they have had their stroke." The beneficial effects of therapy are listed as identifying underlying problems, advising on equipment and handling techniques, teaching adaptive techniques, providing patient and family support (and information), fostering natural recovery, preventing complications (including "learned disuse"), and increasing neurological recovery. This section closes with the chapters "Going Home to the Family" and "Organization of Stroke Care." This is by far the best-referenced section.

I certainly recommend this book to all therapists who are involved in the acute care of patients who have had strokes. It is easy to understand but not simplistic, and it is short enough not to be overwhelming. I found it a truly excellent publication.

Richard Bohannon, EdD, PT