ay i4.1 Introduction
As this dissertation has shown, physical inactivity is a major risk factor for cardiovascular disease and reoccurrence of stroke. Cardiovascular rehabilitation of stroke enables the patient not only to move better but to have a quicker recovery and prevent secondary reoccurrence. This is due not only to the modification of risk factors and improvement in patient fitness but the fact that appropriately planned exercises induce adaptive neuroplasticity. Cardiovascular rehabilitation can therefore be of great value to Irish society in helping stroke victims reclaim their former lives and even change their lifestyles for the better, while reducing the occurrence of secondary stroke and other comorbid conditions. However, the majority of stroke patients spend their time immobile in medical facilities, which can hinder their recovery. Services in Ireland are currently inadequate for stroke patients, and as this dissertation has shown cardiovascular rehabilitation for stroke patients is not being fully recognised for its potential to help patients recover from this common condition. Stroke is on the rise in the western world and it is therefore imperative the government recognise the importance of providing up-to-date evidence-based services that will prevent many patients from suffering needless disabilities and also prevent secondary reoccurrence.
4.2 Recommendations
The following recommendations can be made by this study following analysis of the research:
• More specialised stroke units are needed overall in Ireland. These units should make cardiovascular rehabilitation, which is currently under-utilised and not easily accessible, available to post-stroke patients as a matter of course. A cardiovascular rehabilitation model of care that not only operates within hospital settings but also in the context of out-of-hospital community settings needs to be established.
• A greater knowledge base in cardiovascular rehabilitation is needed in Ireland with clear guidelines and baseline assessment criteria for staff.
• Irish physiotherapists should not use ad hoc mixed approaches but employ approaches based on the latest up-to-date evidence. Cardiovascular rehabilitation programmes should not be used in a piecemeal fashion but meet evidence-based guidelines and it should be used consistently over a number of months.
• Cardiovascular rehabilitation programmes should be tailored and modified to suit patients according to their level of impairment and co-morbidities.
• Cardiovascular rehabilitation programmes should be comprehensive, including not only physical activities but lifestyle changes, drug therapy and education.
• Education in cardiovascular rehabilitation for stroke patients should be provided more widely in universities and in continued training for physiotherapists, while nurses and other personnel should also receive training in this area.
• In general, physiotherapists need to be made more aware of up-to-date information and research on cardiovascular rehabilitation and the importance of exercise-based approaches in general. Perceptions of physiotherapists that cardiovascular rehabilitation is not suitable for patients with moderate-severe disability is a barrier to the recovery of these patients.
• There are not enough physiotherapists employed to cope effectively with the level of patients and more are needed.
• Cardiovascular rehabilitation should be made available to patients on a continuing basis post-discharge through the community. It should be ensured that there is a smooth transition from the hospital to the community in terms of services.
• The government must therefore fund provision of spaces with appropriate equipment in the community.
• New programmes for cardiovascular rehabilitation of stroke patients should link up with existing programmes for cardiac patients.
• There should be clear communication with stroke patients and their families/carers about the importance of cardiovascular rehabilitation and why it should be continued post-discharge
• Further studies of cardiovascular rehabilitation interventions are needed to confirm previous research findings and to help in establishing programmes that suit a variety of stroke patients such as those suffering from varying types of stroke and with a varying range of functional ability.
• Apart from Lennon et al. (2006) Irish research is lacking. No PhD theses dealing with the topic from Irish universities were identified by the researcher. More qualitative and quantitative research is needed to understand how cardiovascular rehabilitation works in an Irish context and what measures need to be taken so that cardiovascular rehabilitation can be provided as a service throughout the country.
• There should also be more research into the effects of cardiovascular rehabilitation on patients with moderate-severe impairment and how it can successfully be carried out, with modifications as required, as there is major concern amongst physiotherapists regarding this area.
• There should also be more research carried out worldwide to clarify further the effects of aerobic exercise on brain plasticity in stroke patients.
• In general, information should be provided to stroke victims and the public on the importance of aerobic exercise as well as how it can be carried out safely and effectively.
4.3 Final Conclusions
Previous studies have indicated the close link between stroke and cardiovascular disease, which have the same risk factors. Cardiovascular rehabilitation has been demonstrated to not only help patients recover more quickly and stimulate adaptive neuroplasticity, but to give them greater independence and quality of life, while also reducing the chance of another stroke as well as various comorbidities. But while cardiovascular rehabilitation has been recognised as a vital factor in disease management and secondary prevention, it has not been widely implemented in Ireland. As indicated by this study, conventional rehabilitation in Ireland incorporates various ad hoc approaches and puts great emphasis on approaches that scholarship now considers outdated, failing to adequate recognise the changing research paradigm. Cardiovascular rehabilitation is therefore underused despite offering stroke patients opportunities to modify risk factors and increase recovery time.
Cardiovascular rehabilitation is available to cardiac patients, but is not readily available to stroke patients due to a range of factors, such as lack of knowledge amongst physiotherapists, lack of programmes, lack of personnel and lack of space. There needs to be major changes in perception for this to happen. Physiotherapists are already aware of the benefits of cardiovascular rehabilitation, but need to be better educated in general regarding the topic to fully realise how essential it is to treatment programmes. Comprehensive evidence-based programmes with clear baseline criteria need to be put in place and linked in with community services, drawing on the expertise of existing cardiac rehabilitation units. Whatever setting cardiovascular rehabilitation occurs in, supervision by qualified personnel is essential and therefore more personnel are needed. Government investment is ultimately needed for services, to increase the number of trained personnel and appropriate spaces with appropriate equipment to allow cardiovascular rehabilitation programmes to be undertaken both in and out of hospital settings. In light of the proven benefits of cardiovascular rehabilitation, such investment could save the government money and therefore perception is perhaps the biggest barrier to this investment, just as the perceptions of physiotherapists that cardiovascular rehabilitation is not suitable for a certain patient cohort is also a barrier to the development of cardiovascular rehabilitation in Ireland. Studies have shown that early intervention is vital and that even severely affected stroke patients can engage in cardiovascular exercise and avail of the benefits.
This study has fulfilled its aim highlighting current attitudes to cardiovascular rehabilitation amongst a sample of physiotherapists in Ireland. It is hoped that this qualitative study will serve as an avenue for further research. Further research into the topic in an Irish context may not help change perceptions by further demonstrating the effectiveness of cardiovascular rehabilitation but can also inform the development of cardiovascular rehabilitation programmes and help set baselines and assessment criteria. As people live a more sedentary lifestyle and with the rise in obesity the risk of stroke in the western world is rising. National stroke strategy must include cardiovascular rehabilitation as a major provision; it is hoped that the Irish government will recognise its importance and facilitate the provision of cardiovascular rehabilitation to stroke patients on a national scale so that the whole population will gain in both health and social terms.
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