الفهرس 
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Abstract
Stroke is the second leading cause of death and the leading cause of disability worldwide. Stroke is a sudden loss of cerebral blood flow caused either by occlusion (85% of cases) or rupture of the cerebral artery manifesting with focal neurological deficit. One-third of stroke patients are younger than 65 years of age and two-thirds are older. Stroke can have both immediate and ongoing physical consequences of disability, and mortality represents the most relevant clinical outcomes.
In Egypt (2014), according to recent estimates, the overall prevalence rate of stroke is high with a crude prevalence rate of 963/ 100 000 inhabitants. The official national statistics indicate that diseases of the circulatory system, including stroke, are the primary cause of death in Egypt and account for one third of all deaths. Stroke accounts for 6.4% of all deaths and thus ranks 3rd after heart disease andgastrointestinal diseases, and followed closely by cancer (6.1%).
According to WHO (2015), stroke is one of the three major causes of death in the world among other dangerous diseases such as cancer and heart diseases. In the United States approximately 5 million people have experienced stroke, and consequently neurological deficit, and two-thirds of this deficit is severe. Stroke is the fifth leading cause of death, but it remains the first cause of disability in the USA. By the year 2020, stroke and coronary artery disease together areexpected to be the leading causes of lost healthy life years worldwide. By 2030 there will be almost 1million stroke deaths and 70 million stroke survivors globally.
Stroke rehabilitation is a dynamic process with the overall aim of reducing stroke-related disability. There is substantial evidence in support of the multidisciplinary team (MDT) for effective delivery of stroke rehabilitation. They provide an organized package of care through a cyclical process involving assessment, goal setting, intervention and reassessment which is typical of stroke rehabilitation. Comprehensive rehabilitation programs appear to improve functional recovery over standard care in terms of speed and extent of recovery.
The critical period to commence rehabilitation after stroke has been poorly defined due to the complexity of trials at an early phase of stroke. Although early mobilization has been recommended in many guidelines, limited evidence is available to guide the practice of rehabilitation.
Early rehabilitation including early physiotherapy and the therapy of early mobilization in the ICU have been proven to give advantages to both patients and society. Several studies have reported the positive effects of early mobilization such as: enhanced muscle strength, shorter time of delirium, more ventilator free days, and decreased hospital acquired infections, decreased ICU and hospital length of stay, increased discharge to home, improved quality of life, and reduced costs.
The aim of the current study is to assess the effect of implementing early rehabilitation intervention on the functional ability of patients with acute stroke.
Research hypothesis: patients with acute stroke who are subjected to early rehabilitation intervention exhibit higher functional ability than those who are not subjected.
A quasi experimental research design was used in this study.
This study was conducted in two university hospitals namely: Alexandria Main University Hospital (AMUH) and Elhadara University Hospital
- Three intensive care units from (AMUH) including; the casualty intensive care unit (Unit I: 15 beds), and the general intensive care units (Unit II, 12 beds and Unit III: 16 beds)
- One intensive care unit from Elhadara University Hospital ;the Stroke intensive care unit including (6 beds)
Subjects:
- A convenience sample of 50 adult critically ill patients (aging 18 to 65 years old) with acute stroke and admitted within 24 hours of symptoms onset to the previously mentioned settings were included in the study.
Tools: Two tools were used in this study for data collection.
Tool I: Stroke assessment scales:This tool includes two parts:
Part I:Patients characteristics: which was developed by the researcher after reviewing the related literature andPart II:Stroke assessmentscales: which was adopted from Sun, Yue, Leung, Chan (2016)and includes two scales:
Scale I : National Institutes of Health Stroke Scale (NIHSS)to assess acute stroke-related neurological deficitand severity, and Scale II : Oxford Classification of Stroketo determine site of affection.
Tool II: Functional ability assessment scales: This tool includes two parts:
Part I:Physiological parameters developed by the researcher after reviewing the related literature.
Part II:Functional ability assessment scales:which include three scales:Scale I: Muscle strength assessment scaleadopted from Rhesti, Huriani (2015), to assess muscle strength response to the early rehabilitation intervention for the extremities. Scale II: Modified Ranking Scale (MRS)adopted from Rankin (1957), to assess the degree of motor affection and the level of disability, Scale III: Barthel Index Scale adopted from Mahoney, Barthel (1965). To assess the ability of patient with acute stroke to perform activity of daily living (ADL).
- An official letter from the Faculty of nursing was sent to the hospitals’ administrative authorities. Permission to conduct the study was obtained from the administrative authorities of the previously mentioned settings after explanation of the aim of the study.
Part I in both toolswere tested for content validity by five experts in the related field including two professors in critical care and emergency nursingdepartment, one professor in medical surgicalnursing department,one professor in critical care and emergency medicineand one assistant professor in neuropsychatry medicine andthe necessary modifications were done accordingly.
- Part II in Tool I was tested for reliability for (NIHSS) and proved to be reliable (r=0.5–0.8), and part II in tool II was proved to be reliable as follows: BI (r= 0.99), and other scales (MRS MSAS) were tested for reliability and proved to be reliable in the current study, (r=0.88, and r =.927 respectively).
- Written informed consent was obtained from each patient or responsible person (if the patient was unconscious) after providing them with an explanation of the aim of the study and prior to data collection.
- The confidentiality of responses was assured; voluntary participation and right to refuse to participate in the study were emphasized to subjects.
Data were collected as follows:
• All newly admitted patients with acute stroke (within 24 hrs) were assessed by the researcher for meeting the inclusion criteria.
• Patients who meet the inclusion criteria were assigned to two groups (25 patients each group) A the control group and group B the study group.
• For both groups, patients characteristics (patient’s demographic data,and clinical data) and stroke assessment scales were obtained and recorded by the researcher usingtool I, and functional ability was assessed using part II in tool II on admission to obtain a baseline data.
• group A, the control group, received the routine care for stroke patients in ICU including (changing patient position once or twice per shift, and ROM exercises applied by physiotherapy nurse based on request from the ICU physician starting from the 5th day of ICU admission.
• group B, the study group, received early rehabilitation intervention
• Data were collected by the researcher during three consecutive months from 10th of July to 10th of September 2019.
Result of the study:
• Findings of the study showed statisticalsignificant differences between patients in the control group who received the routine care of acute stroke patients in the intensive care units, and patients in the study group who received the early rehabilitation interventionincluding range of motion exercises and early mobilization in bed and out of bed activities from the first 24 hours of admission ,and an improvement in the total score of the functional ability scales ofpatients in the study group compared to a decrease inpatients in the control group .Therefore finding of the current study support the study hypothesis.
• As regard Degree of disability,a statistical significant difference was noted between the 2 groups, an increase in the degree of disability in patients in the control group after receiving the routine intervention compared to adecrease in patients in the study group in the 7th and 14th days after receiving the early rehabilitation intervention.
• Regarding the activity of daily living. A decrease in the degree of independency of patients in the control group compared to an increase in patients in the studygroup as regards feeding, bathing, grooming, toilet use, and transferring from bed to chair and back, mobility and the difference between the two groups was statistically signifecant.
• In relation to muscle strength assessment ,a statistical significant difference was noted between both group manifested by decrease in the muscle strength ofthe upper and lower extremitiesto patients in the control groupafter receiving routine interventionin the 7th and 14th dayswhile an increase in patients in the study group after receiving the early rehabilitation intervention. Moreover, a statistically significant difference was found between patients in the control and study groups as regards total functional abilityin the 7th day and 14th day after receiving the early rehabilitation intervention.
Based on the findings of this study, it is recommended:
- To developevidence based protocols regarding the early rehabilitation intervention for acute stroke patients in collaboration with other ICU health care team members.
- Toensure the availability of adequate staff to maintain adequate nurse/patient ratio in the three different shifts for the initiation and the follow up early rehabilitation and mobilization activity
- To conduct in- service training programs for critical care nurses regarding rehabilitation intervention of acute stroke patients.
- To establishfixed routine rehabilitation intervention for patients with acute stroke during all nursing shifts
- To incorporate the concept of early rehabilitation intervention in the under graduate nursing curriculum.
- To providecritical care nurses with learning facilities such as up to date scientific journals, books, posters, in addition to access to internet to promote self learning regarding the early rehabilitation intervention of critically ill patients.
- To determine the public health implications of early rehabilitation intervention, including its effect on health care utilization, cost of care and mortality rate.