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MEDLIB-L  September 2014, Week 3

MEDLIB-L September 2014, Week 3

Subject:

Re: REF?: Rehabilitation Services

From:

Amy Frey <[log in to unmask]>

Reply-To:

Amy Frey <[log in to unmask]>

Date:

Wed, 17 Sep 2014 15:06:34 +0000

Content-Type:

text/plain

Parts/Attachments:

Parts/Attachments

text/plain (469 lines)

A few possibilities:
Title:
Advance care planning in stroke: influence of time on engagement in the process.
Authors:
Green T; Faculty of Nursing, University of Calgary, Calgary, AB, Canada.
Gandhi S; Health Sciences, McMaster University, Hamilton, ON, Canada.
Kleissen T; Faculty of Nursing, University of Calgary, Calgary, AB, Canada.
Simon J; Faculty of Nursing, University of Calgary, Calgary, AB, Canada ; Department of Medicine, University of Calgary, Calgary, AB, Canada.
Raffin-Bouchal S; Faculty of Nursing, University of Calgary, Calgary, AB, Canada.
Ryckborst K; Calgary Stroke Program, Alberta Health Services, Calgary, AB, Canada.
Source:
Patient Preference And Adherence [Patient Prefer Adherence] 2014 Jan 24; Vol. 8, pp. 119-26. Date of Electronic Publication: 20140124 (Print Publication: 2014).
Publication Type:
Journal Article
Language:
English
Journal Info:
Publisher: Dove Press Limited Country of Publication: New Zealand NLM ID: 101475748 Publication Model: eCollection Cited Medium: Print ISSN: 1177-889X (Electronic) Linking ISSN: 1177889X NLM ISO Abbreviation: Patient Prefer Adherence Subsets: PubMed not MEDLINE
Imprint Name(s):
Original Publication: [Auckland, N.Z.] : Dove Press Limited
Abstract:
Purpose: Individuals who experience stroke have a higher likelihood of subsequent stroke events, making it imperative to plan for future medical care. In the event of a further serious health event, engaging in the process of advanced care planning (ACP) can help family members and health care professionals (HCPs) make medical decisions for individuals who have lost the capacity to do so. Few studies have explored the views and experiences of patients with stroke about discussing their wishes and preferences for future medical events, and the extent to which stroke HCPs engage in conversations around planning for such events. In this study, we sought to understand how the process of ACP unfolded between HCPs and patients post-stroke.
Patients and Methods: Using grounded theory (GT) methodology, we engaged in direct observation of HCP and patient interactions on an acute stroke unit and two stroke rehabilitation units. Using semi-structured interviews, 14 patients and four HCPs were interviewed directly about the ACP process.
Results: We found that open and continual ACP conversations were not taking place, patients experienced an apparent lack of urgency to engage in ACP, and HCPs were uncomfortable initiating ACP conversations due to the sensitive nature of the topic.
Conclusion: In this study, we identified lack of engagement in ACP post-stroke, attributable to patient and HCP factors. This encourages us to look further into the process of ACP in order to develop open communication between the patient with stroke, their families, and stroke HCPs.
Contributed Indexing:
Keywords: engagement; health care providers; palliative; qualitative
Entry Date(s):
Date Created: 20140204 Date Completed: 20140204 Latest Revision: 20140210
Update Code:
20140211
PubMed Central ID:
PMC3908836
DOI:
10.2147/PPA.S54822
PMID:
24493922
Database:
MEDLINE with Full Text
Record: 2
Title:
The impact of timing and dose of rehabilitation delivery on functional recovery of stroke patients.
Authors:
Huang HC; Department of Physical Medicine and Rehabilitation, Chiayi Christian Hospital, Taiwan, R.O.C. [log in to unmask]
Chung KC
Lai DC
Sung SF
Source:
Journal Of The Chinese Medical Association: JCMA [J Chin Med Assoc] 2009 May; Vol. 72 (5), pp. 257-64.
Publication Type:
Journal Article
Language:
English
Journal Info:
Publisher: Chinese Medical Association Country of Publication: China (Republic : 1949- ) NLM ID: 101174817 Publication Model: Print Cited Medium: Print ISSN: 1726-4901 (Print) Linking ISSN: 17264901 NLM ISO Abbreviation: J Chin Med Assoc Subsets: MEDLINE
Imprint Name(s):
Original Publication: Taipei, Taiwan : Chinese Medical Association, c2003-
MeSH Terms:
Stroke/*rehabilitation
Female ; Humans ; Male ; Middle Aged ; Occupational Therapy ; Physical Therapy Modalities ; Time Factors
Abstract:
Background: To investigate the impact of both timing and dose of rehabilitation delivery on the functional recovery of stroke patients.
Methods: From chart review, we included 76 patients who were admitted to a regional hospital for first-ever stroke, and who had received multidisciplinary rehabilitation programs including physical therapy (PT) and occupational therapy (OT) at the inpatient department, and continuous rehabilitation therapy at the outpatient department for at least 3 months. The collected data included age, sex, type of stroke (hemorrhage/infarction), onset of stroke, initial motor status by Brunnstrom's motor recovery stages, time to rehabilitation intervention (from onset of stroke), length of stay, existence of aphasia, craniotomy (yes/no), and total units of rehabilitation. Main outcome measures were serial Barthel Index (BI) at initial assessment, 1 month, 3 months, 6 months, and 1 year post-stroke.
Results: Age was inversely correlated with BI and BI improvement at 3 months and 6 months post-stroke. Rehabilitation intervention time from onset was negatively correlated with BI improvement at 1 month and 1 year, and with BI at 1 month, 3 months, 6 months, and 1 year post-stroke. The total units of inpatient PT and/or OT were positively correlated with BI improvement at 1 month, 3 months, and 6 months post-stroke. The total units of PT and/or OT were positively correlated with BI improvement at 3 months and 6 months post-stroke. And the initial BI was positively correlated with BI at 1 month, 3 months, and 6 months post-stroke. The total units of OT can significantly predict BI improvement at 3 months and 6 months post-stroke, while the initial BI capacity can significantly predict BI status at 1 month, 3 months, and 6 months post-stroke.
Conclusion: There is a dose-dependent effect of rehabilitation on functional improvement of stroke patients for the first 6 months post-stroke, and earlier delivery of rehabilitation has lasting effects on the functional recovery of stroke patients up to 1 year.
Entry Date(s):
Date Created: 20090526 Date Completed: 20090903
Update Code:
20131125
DOI:
10.1016/S1726-4901(09)70066-8
PMID:
19467949
Database:
MEDLINE with Full Text
Record: 3
Title:
Timing of initiation of rehabilitation after stroke.
Authors:
Maulden SA; Gassaway J; Horn SD; Smout RJ; DeJong G
Affiliation:
Salt Lake OI Field Office, Department of Veterans Affairs, Salt Lake City, UT
Source:
Archives of Physical Medicine & Rehabilitation (ARCH PHYS MED REHABIL), 2005 Dec; 86 (12): Suppl 2: S34-40. (39 ref)
Publication Type:
journal article - research, tables/charts
Language:
English
Major Subjects:
Stroke -- Rehabilitation
Minor Subjects:
Inpatients; Clinical Assessment Tools; Rehabilitation Centers; Time Factors; Treatment Outcomes; Activities of Daily Living; Length of Stay; Severity of Illness; Prospective Studies; Regression; Data Analysis Software; Middle Age; Aged; Aged, 80 and Over; Female; Male; Funding Source; Human
Abstract:
OBJECTIVE: To study associations between days from stroke symptom onset to rehabilitation admission and rehabilitation outcomes, controlling for a variety of confounding variables. DESIGN: Observational cohort study of 200 consecutive post-stroke rehabilitation patients in each of 6 inpatient rehabilitation facilities. SETTING: Six U.S. inpatient rehabilitation hospitals. PARTICIPANTS: Patients (N=969) with moderate or severe strokes who had days from stroke symptom onset to rehabilitation admission recorded in their medical records. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Discharge total FIM, discharge motor FIM, discharge activities of daily living (ADL) FIM, and discharge mobility FIM scores, as well as rehabilitation length of stay (LOS). RESULTS: Fewer days from stroke symptom onset to rehabilitation admission was associated significantly with better functional outcomes: higher total, motor, mobility, and ADL discharge FIM scores, controlling for confounding variables. For severely impaired patients with stroke in case-mix groups (CMGs) 108-114, the relation was strongest, with F statistics greater than 24.1 for each functional outcome. For patients with moderately severe stroke in CMGs 104-107, fewer days from stroke symptom onset to rehabilitation admission was associated significantly with shorter rehabilitation LOS. CONCLUSIONS: Fewer days from stroke symptom onset to rehabilitation admission is associated with better functional outcomes at discharge and shorter LOS. Copyright (c) 2005 by Elsevier Science (USA).
Journal Subset:
Allied Health; Double Blind Peer Reviewed; Editorial Board Reviewed; Expert Peer Reviewed; Online/Print; Peer Reviewed; USA
Special Interest:
Occupational Therapy; Physical Therapy; Speech-Language Pathology/Audiology
Instrumentation:
Functional Independence Measure (FIM)
ISSN:
0003-9993
MEDLINE Info:
PMID: 16373138 NLM UID: 2985158R
Grant Information:
Supported by the National Institute on Disability and Rehabilitation Research (H133B990005) and the U.S. Army and Material Command (DAMD17-02-2-00032)
Entry Date:
20060707
Revision Date:
20091218
Accession Number:
2009112091
Database:
CINAHL Plus with Full Text
Record: 4
Title:
Stroke rehabilitation patients, practice, and outcomes: is earlier and more aggressive therapy better?
Authors:
Horn SD; DeJong G; Smout RJ; Gassaway J; James R; Conroy B
Affiliation:
Institute for Clinical Outcomes Research, 699 E South Temple, Ste 100, Salt Lake City, UT 84102-1282, [log in to unmask]
Source:
Archives of Physical Medicine & Rehabilitation (ARCH PHYS MED REHABIL), 2005 Dec; 86 (12): Suppl 2: S101-14. (28 ref)
Publication Type:
journal article - research, tables/charts
Language:
English
Major Subjects:
Stroke -- Rehabilitation
Rehabilitation Centers -- Administration
Minor Subjects:
Severity of Illness; Treatment Outcomes; Clinical Assessment Tools; Functional Status; Physical Therapy; Occupational Therapy; Rehabilitation, Speech and Language; Enteral Nutrition; Length of Stay; Prospective Studies; Descriptive Statistics; Fisher's Exact Test; T-Tests; Chi Square Test; Multiple Regression; Data Analysis Software; Aged; Female; Male; Funding Source; Human
Abstract:
OBJECTIVE: To examine associations of patient characteristics, rehabilitation therapies, neurotropic medications, nutritional support, and timing of initiation of rehabilitation with functional outcomes and discharge destination for inpatient stroke rehabilitation patients. DESIGN: Prospective observational cohort study. SETTING: Five U.S. inpatient rehabilitation facilities. PARTICIPANTS: Post-stroke rehabilitation patients (N=830; age, >18 y) with moderate or severe strokes, from the Post-Stroke Rehabilitation Outcomes Project database. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Discharge total, motor, and cognitive FIM scores and discharge destination. RESULTS: Controlling for patient differences, various activities and interventions were associated with better outcomes including earlier initiation of rehabilitation, more time spent per day in higher-level rehabilitation activities such as gait, upper-extremity control, and problem solving, use of newer psychiatric medications, and enteral feeding. Several findings part with conventional practice, such as starting gait training in the first 3 hours of physical therapy, even for low-level patients, was associated with better outcomes. CONCLUSIONS: Specific therapy activities and interventions are associated with better outcomes. Earlier rehabilitation admission, higher-level activities early in the rehabilitation process, tube feeding, and newer medications are associated with better stroke rehabilitation outcomes. Copyright (c) 2005 by Elsevier Science (USA).
Journal Subset:
Allied Health; Double Blind Peer Reviewed; Editorial Board Reviewed; Expert Peer Reviewed; Online/Print; Peer Reviewed; USA
Special Interest:
Occupational Therapy; Physical Therapy; Speech-Language Pathology/Audiology
Instrumentation:
Functional Independence Measure (FIM)
ISSN:
0003-9993
MEDLINE Info:
PMID: 16373145 NLM UID: 2985158R
Grant Information:
Supported by the National Institute on Disability and Rehabilitation Research (H133B990005) and the U.S. Army and Materiel Command (DAMD17-02-2-0032)
Entry Date:
20060707
Revision Date:
20091218
Accession Number:
2009112137
Database:
CINAHL Plus with Full Text
Record: 5
Title:
Post-stroke rehabilitation. A review of the guidelines for patient management.
Authors:
Rosenberg CH; State University of New York (SUNY) at Stony Brook, USA.
Popelka GM
Source:
Geriatrics [Geriatrics] 2000 Sep; Vol. 55 (9), pp. 75-81; quiz 82.
Publication Type:
Journal Article
Language:
English
Journal Info:
Publisher: Advanstar Communications Country of Publication: UNITED STATES NLM ID: 2985102R Publication Model: Print Cited Medium: Print ISSN: 0016-867X (Print) Linking ISSN: 0016867X NLM ISO Abbreviation: Geriatrics Subsets: Core Clinical (AIM); MEDLINE
Imprint Name(s):
Publication: Montvale, NJ : Advanstar Communications
Original Publication: Minneapolis.
MeSH Terms:
Practice Guidelines as Topic*
Stroke/*rehabilitation
Aged ; Female ; Humans ; Male ; Middle Aged ; Reproducibility of Results ; Stroke/epidemiology ; Time Factors ; United States/epidemiology
Abstract:
A comprehensive, intense rehabilitation program is key to successful convalescence for patients who have experienced stroke. A guideline on post-stroke rehabilitation published by the Agency for Healthcare Research and Quality provides clinicians with detailed recommendations for managing patients who have sustained a brain attack. Rehabilitation should begin following diagnosis and after any life-threatening issues have been effectively managed. The key steps include patient management during the acute phase, screening for rehabilitation and choice of setting, managing rehabilitation, and facilitating the patient's transition back into the community. The timeliness of rehabilitation interventions and the intensity of rehabilitation services are important factors in maximizing a patient's functional outcome at hospital discharge and on follow-up.
Entry Date(s):
Date Created: 20001010 Date Completed: 20001010 Latest Revision: 20071115
Update Code:
20131125
PMID:
10997128
Database:
MEDLINE with Full Text
Section:
CME Geriatrics
Evidence-based medicine
Post-stroke rehabilitation: A review of the guidelines for patient management
A comprehensive, intense rehabilitation program is key to successful convalescence for patients who have experienced stroke. A guideline on post-stroke rehabilitation published by the Agency for Healthcare Research and Quality provides clinicians with detailed recommendations for managing patients who have sustained a brain attack. Rehabilitation should begin following diagnosis and after any life-threatening issues have been effectively managed. The key steps include patient management during the acute phase, screening for rehabilitation and choice of setting, managing rehabilitation, and facilitating the patient's transition back into the community. The timeliness of rehabilitation interventions and the intensity of rehabilitation services are important factors in maximizing a patient's functional outcome at hospital discharge and on follow-up.

Rosenberg CH, Popelka GM. Post-stroke rehabilitation: A review of the guidelines for patient management. Geriatrics 2000; 55(Sept.): 75-81.

According to the National Stroke Association (NSA), each year approximately 730,000 Americans experience a new or recurrent stroke, making stroke the nation's third leading cause of death and disability. Of the 570,00 patients who survive, approximately 10% will achieve nearly complete recovery, 25% will recover with minor impairments, and 40% will experience moderate to severe impairments that require special care. Approximately 14% of the survivors will experience a second stroke in the first year following the initial event. Approximately 85% of all strokes are the ischemic type.

Stroke occurs in men and women of all ages, classes, and ethnic origins; age, however, is a key risk factor. According to the NSA, the risk of stroke doubles for each decade after age 55. For adults over age 65, the risk of death from stroke is seven times that of the general population; moreover, two-thirds of all strokes occur in persons over age 65. Stroke kills twice the number of women annually that breast cancer does, and the incidence rate for first stroke among African-Americans is significantly higher than that of white Americans (288 per 100,000 versus 179 per 100,000, respectively).

Successful rehabilitation depends on the amount of damage to the brain, the skill of the rehabilitation team, cooperation of family and friends in the rehabilitation process, and the timing of rehabilitation. Indeed, the sooner rehabilitation is initiated, the more likely it is that patients will regain lost abilities and skills.

Physicians involved in the management of stroke survivors can look for guidance from the "Post-stroke rehabilitation" clinical guideline,(n1) published in 1995 by the Agency for Health Care Policy and Research (now known as the Agency for Healthcare Research and Quality [AHRQ]).

This article examines the guideline from an evidence-based medicine perspective. Our analysis of the literature supports the guideline recommendations that timeliness of rehabilitation interventions and intensity of rehabilitation services provided are important factors in maximizing a patient's functional outcome at hospital discharge and on follow-up. We include a table that outlines the screening process and a figure that can help guide clinicians through key decision-making processes involving rehabilitation and selection of an appropriate setting. A case scenario also is presented to demonstrate use of the guideline.

Case scenario
A 68-year-old right-handed woman was brought to the emergency room by her husband after he found her on the living-room floor of their home with right-sided weakness and slurred speech. Mrs. R had no history of any previous medical problems nor significant surgeries. The examination on admission was remarkable for blood pressure of 142/82 mm Hg, contusion over the right eye, a right-central facial weakness, global aphasia, deviation of the tongue to the right, and right hemiplegia. Blood work for chemistry, hematology, and coagulation was normal. An initial CT of the head was negative. She was anticoagulated with IV heparin then switched to oral warfarin. Subsequent CT of the brain showed a left parietal infarct, and carotid Doppler studies showed high-grade left internal carotid artery stenosis. A vascular surgery team recommended against surgical intervention but asked to see Mrs. R for follow-up after she successfully completed in-patient rehabilitaton.

As Mrs. R's primary care physician, you must determine when to initiate rehabilitation intervention for her. Moreover, collaborating with Mrs. R and her family, you must identify the most appropriate setting that offers post-acute inpatient rehabilitation services.

Background
According to the authors of the poststroke rehabilitation recommendations, the guideline "focuses primarily on the patient with a first stroke who has some degree of hemiparesis, with or without other neurological deficits, and is a candidate for treatment in an interdisciplinary rehabilitation program. Many recommendations also apply, however, to people with multiple strokes and those with limited disabilities who require care by a single rehabilitation discipline. Recommendations cover the period from the time of admission to an acute care hospital through any rehabilitation program and the transition to a community residence."

The purpose of the guidelines, say the authors, is to "assist primary care providers and rehabilitation specialists in the care of patients with disabilities from stroke and to help patients and their families become better informed consumers of rehabilitation services" The target audience includes rehabilitation professionals, neurologists, and primary care physicians including internists, family practitioners, and geriatricians.

Validity of the guideline
The AHRQ post-stroke rehabilitation guideline was developed by a panel of experts and consultants representing the medical and rehabilitation specialties involved in stroke rehabilitation. Medical specialties included family practice, geriatrics, internal medicine, neurology, physiatry, and psychiatry. The participating professional societies nominated potential panel members who were then approved by AHRQ.

The guideline was written by an independent multidisciplinary panel of private-sector clinicians and other selected experts commissioned by AHRQ. The panel used explicit, evidence-based methods and expert clinical judgment to develop specific statements on patient assessment and management of relevant clinical conditions. Preparation of the guideline included extensive literature searches, critical reviews, and syntheses to evaluate empirical evidence and significant outcomes. The recommendations were based primarily on scientific literature, except for instances when such data were incomplete or inconsistent, in which case the authors deferred to consensus of the expert multidisciplinary panel.(n1)

Careful review of the medical literature took place in four stages:

an open forum
review by 44 experts in disciplines involved in stroke rehabilitation
review by an array of professional, provider, insurer, and consumer organizations
and pilot testing by 10 provider organizations that deliver rehabilitation services.
Review articles and observational studies were included if they provided information critical to understanding the natural history of stroke or the effects of rehabilitation. Journal articles cited were published from 1961 to 1994 (most were published in the late 1980s and early 1990s).

Each guideline was rated according to the quality of supporting evidence and according to the degree of consensus among the panel members and expert reviewers (table 1).

The report is divided into four major sections, each of which offers extensive discussion of related variables and issues:

rehabilitation during acute care for stroke (clinical evaluation during acute care, managing complications, early mobilization, and return to self care)
screening for rehabilitation and choosing an appropriate setting (need for accurate program information, threshold criteria for admission to a program [see criteria below], choice of setting)
managing rehabilitation (transition from acute care, comprehensive evaluation of patient status and capabilities, monitoring progress during rehabilitation)
and the transition into the community (family and caregiver functioning, continuity and coordination of patient care, and community supports).
Post-stroke recommendations
According the the AHRQ guideline, post-stroke rehabilitation should begin once the diagnosis has been established and life-threatening problems have been effectively managed. The objective is to quickly mobilize the patient and encourage resumption of self-care activities.

The recommendations about early mobilization of patients are based on research evidence (grade C); recommendations regarding initiating early performance of self-care activities is based on expert opinion. Regarding the latter, the panel believed that the articles referenced demonstrated direct evidence of benefit. Nevertheless, these studies were not randomized controlled trials and panel bias cannot be ruled out.

Screening. Patient status is the key determinant for making a decision about whether rehabilitation is indicated. According to the guideline, threshold criteria for admission to a comprehensive rehabilitation program are:

medical stability
presence of a functional deficit
ability to learn
enough physical endurance to sit supported for at least 1 hour
and the ability to participate actively to some extent in rehabilitation activities.
Determination is made through screening, which should be performed by a person experienced in rehabilitation but who has no direct financial interest in the decision. Screening should occur as soon as the patient's medical and neurologic condition permit.

The key components of the rehabilitation screening examination can be found in the guidelines (table 2).(n1) Patients who meet the threshold criteria and need moderate to total assistance for mobility or for performing basic activities of daily living (ADL) are candidates for an intensive rehabilitation program if they are able to tolerate 3 hours or more of physical activity each day (and a less intensive program if they cannot).(n1)

The guidelines include flowcharts describing the framework for making rehabilitation decisions (figure) and recommendations for selection of the rehabilitation program setting after hospitalization for acute stroke.(n1) These recommendations are based on expert opinion; the research evidence for these recommendations are grade C.

Intensity of the program. According to the guidelines, the evidence suggests (but does not establish) that intense rehabilitation leads to more rapid improvement in function and better long-term outcomes than more slowly paced programs. The evidence also suggests better results in outpatient versus inpatient settings. The panel felt that it was difficult to extrapolate the results of the studies cited to all patient populations or rehabilitation settings. On the other hand, they felt that enough evidence exists to support the maxim that more rehabilitation is better than less, at least for patients with moderate levels of disability.

Review of the literature
Review of the medical literature identified four well-designed studies (grade B)(n4, n5, n6, n7) demonstrating an association between early intervention of therapy following stroke and improved outcome.

In a prospective study of 233 consecutive stroke survivors, Anderson et al demonstrated that a delay in the initiation of rehabilitation services positively correlated with poorer functional outcome.(n5)
Hayes and Carroll showed that early initiation of interdisciplinary rehabilitation shortened the length of stay and improved functional outcome.(n6)
Bourestom(n4) and Shah(n7) reported a positive correlation between improved function and early initiation of interdisciplinary rehabilitation services independent of the severity of stroke or degree of initial functional deficits. (All of these were small randomized trials.)
In a meta-analysis of 36 clinical trials, Ottenbacher and Jannell(n8) showed that patients who underwent an individualized (focused) program of stroke rehabilitation showed significant improvement compared with those who did not undergo such a program. Moreover, performance results improved with early initiation of therapy; younger age also positively affected rehabilitation results.
The guideline authors identified several articles that addressed the association between the intensity of rehabilitation services and functional outcome following stroke.(n10-n14) A critical review of this literature revealed four evidence-based studies at the grade B level.(n10), (n12-n14) Overall, these studies support the AHRQ guideline contention that there is an association between the intensity of rehabilitation services and improved outcomes after a stroke.

One of these studies(n12) (a prospective cohort trial) offered a comparison of outcomes and costs among fracture and stroke patients randomly assigned to rehabilitation hospitals, subacute nursing homes, and traditional nursing homes. The findings showed decreased mortality and improved function in stroke survivors treated in skilled rehabilitation and subacute rehabilitation settings compared with those treated in traditional nursing homes.(n12) Although this was not a randomized trial--patients were directed to a particular rehabilitation setting based on the ability to participate in a higher versus lower intensity program--the analysis adjusted for the preselection bias.

In a nonrandomized prospective trial overseen by Nugent et al, initial and final physical therapy evaluations were performed on 109 consecutive stroke patients admitted to a stroke rehabilitation unit(n14) The researchers analyzed the relationship between the intensity of weight-bearing exercises and a patient's walking ability upon discharge from the unit. They found a dose-response relationship between the intensity of therapy performed and patient functional outcome (ie, the ability to ambulate upon discharge).(n14) In a meta-analysis of nine controlled trials involving 1,051 patients, Kwakkel et al showed that small but statistically significant improvements in activities of daily living and functional outcome parameters were related to the intensity of stroke rehabilitation.(n13)

Resolution of the case
Mrs. R was stabilized and a rehabilitation medicine consultation was obtained. Findings revealed a right central facial palsy, right homonymous hemianopsia, right-sided sensory deficit, global aphasia, dysphagia, and right-sided flaccid hemiplegia with 1/5 motor strength in the upper and lower extremities. She was alert, but due to the aphasia the cognitive evaluation produced incomplete findings. A functional exam revealed bed mobility that required moderate to maximal assistance, transfers that required moderate to maximal assistance, dependence for unsupported standing balance, and maximal ADL assistance. Bedside dysphagia evaluation suggested that Mrs. R aspirated water in the upright and seated position and was therefore at high risk for aspiration pneumonia.

Psychosocial evaluation revealed solid family support. Mrs. R said she lived in a private residence, which featured a flight of steps leading to a front entrance and a ground-floor bedroom. A coordinated program of physical, occupational, and speech therapy services was initiated and 7 days after the stroke Mrs. R was transferred to a hospital-based rehabilitation facility.

During her stay, she received a minimum of 3 hours-a-day of intensive rehabilitation intervention, which included bed mobility, transfer training, gait and balance training, ADL training, dominance retraining (involves teaching the patient to use the nondominant extremity to perform tasks previously undertaken with the dominant extremity), therapeutic exercises, and range-of-motion exercises. A barium swallow radiograph (performed a few days after Mrs. R's admission) had revealed mild delay of the swallowing reflex with no aspiration; at that point, Mrs. R was eligible for a mechanical soft diet that included thin liquids. By the third week of communication therapy (a program of speech therapy integrated with occupational therapy and nursing rehabilitation), Mrs. R learned to gesture when she needed to use the toilet.

Twenty-two days after admission to the inpatient rehabilitation program, Mrs. R was discharged to the home of a family member and arrangements made for home care services. For walking, she required minimal assistance--one person to help her ambulate with the use of a wide-based quad cane and an articulated right ankle-foot orthosis.

Mrs. R continued to have difficulty with manual dexterity, but she was able to use her right upper arm as a gross assist for self-care tasks. Her yes/no reliability was 95% for simple questions, and she was able to use a picture board to facilitate communication interactions. She gained the ability to sign documents with her left hand (through dominance retraining). Family training (education about the implications of stroke) was completed and adaptive equipment was ordered, including a long-handled comb and a reacher to assist with grooming and dressing.

Follow-up conducted 3 months after hospital discharge revealed that Mrs. R. maintained functional gains achieved during her inpatient rehabilitation stay and her communication skills continued to improve.

Discussion
Of the estimated 570,000 Americans who survive a stroke each year, approximately 75% do so with varying degrees of neurologic impairment. Whereas acute neurological impairments frequently resolve spontaneously, persisting disabilities lead to partial or total dependence in ADL in 25 to 50% of stroke survivors. Stroke rehabilitation involves restoration of function after medical and neurologic stability has been achieved. For the patient, the ultimate objective of rehabilitation is the achievement of safe, independent, energy-efficient, and high-quality functioning in the community.

To maximize patient status, a therapeutic program that focuses on bed mobility, sitting balance and tolerance, standing balance and tolerance, transfers, and gait training should be implemented as soon as possible after the event. Mobilizing patients early in the recovery phase helps to prevent development of deep-vein thrombosis, skin breakdown, contractures, and pneumonia.(n2)

The therapeutic program must be individualized and directed at improving strength and motor control, relearning sensorimotor relationships, and improving functional performance. Where indicated, lower extremity orthotics (eg, an ankle-foot orthosis) have proven exceptionally helpful in re-initiating ambulation.(n3) Self-care activities such as eating, grooming, hygiene, and toileting should also be evaluated and encouraged as soon as possible.

Early participation in rehabilitation activities by patients helps them regain a sense of independence and increase strength, endurance, and awareness of their environment. The self-care plan and compensatory strategies facilitate activity progress by teaching adaptive techniques that can be used to overcome disabilities. Early incorporation of appropriate assistive devices (eg, a reacher and special utensils) can expedite functional compensation.

Although it is important that rehabilitation intervention--including transferring the patient to an inpatient rehabilitation facility--is initiated early, selecting the right level of care also is an important consideration. Inpatient post-acute stroke rehabilitation is provided in acute rehabilitation hospital facilities or in a subacute nursing facility. The choice is based upon the patient's medical status (including activity tolerance) and rehabilitation potential.(n1)

Acute inpatient rehabilitation provided in rehabilitation hospitals or rehabilitation units in acute care hospitals is a high-intensity service. Hospital-level rehabilitation requires greater physical and mental effort from the patient.(n12) The best programs use an interdisciplinary team of rehabilitation experts who work collaboratively on a highly coordinated stroke rehabilitation regimen. These experts include nurses, physical therapists, occupational therapists, speech-language pathologists, psychologists, social workers, recreation therapists, and physiatrists (physicians specializing in rehabilitation medicine).

The acute rehabilitation program provides 24-hour nursing service and intensive physician care. A highly coordinated rehabilitation program includes weekly team meetings to assess patient progress, identify barriers, revise rehabilitation goals, and develop a discharge plan. Criteria for referral to acute comprehensive inpatient rehabilitation requires that the patient is medically capable of tolerating at least 3 hours of therapy a day, needs more than minimal assistance for ambulation and self-care, and has adequate cognition and language function (necessary for participation in various therapies).(n9)

Patients who do not meet criteria for admission to an inpatient hospital level program may be eligible for less intensive rehabilitation provided in a subacute skilled nursing facility. Although the term subacute has not been consistently defined, "subacute care" is a rapidly growing segment of the healthcare industry. Subacute programs also use an interdisciplinary team approach to care. They typically offer nursing, physical therapy, occupational therapy, speech therapy, and social services.

In the subacute setting, physician involvement and the patient's involvement in rehabilitation activities is governed by the patient's rehabilitation needs and objectives. At a minimum, therapy is provided 1 hour per day, 5 days per week. The extent of physician participation varies among subacute facilities.(n9)

New directions in stroke rehabilitation
One of the most recent developments in stroke rehabilitation research is constraint-induced movement therapy, or CI therapy, which involves constraining nonparetic limbs in order to force the use of paretic limbs. The new approach was described recently by Leipert and colleagues.(n15) In a controlled prospective randomized trial, the researchers used focal transcranial magnetic stimulation to perform brain mapping of the cortical motor output area that corresponds to the movement of a hand muscle. The size of the area was measured before and after the therapy regimen. Thirteen stroke patients in the chronic stage of their illness underwent a 12-day period of CI therapy, which involved 6 hours per day of exercise using the paralyzed arm. The researchers found that after treatment, "the muscle output area size in the affected brain hemisphere was significantly enlarged, corresponding to a greatly improved motor performance of the paretic limb." Although these findings are promising, they need to be replicated in large randomized, blinded trials before traditional stroke rehabilitation approaches are significantly altered.

Conclusion
Early initiation of rehabilitation services and greater intensity of rehabilitation services following an acute stroke are associated with improved outcomes. Early mobilization is critical and may have an impact upon the stroke survivor's functional abilities and quality of life. Successful outcomes are commonly measured by demonstrated improvement in the patient's functional abilities and whether the patient was able to return to the community. Rehabilitation consultation and a goal-oriented interdisciplinary rehabilitation intervention addressing the patient's functional needs should be initiated as soon as the patient is medically stabilized. Following a stroke, determining the most appropriate post-acute rehabilitation setting for a patient is based upon identifying the intensity of rehabilitation services needed by the patient in order to maximize functional status.

Table 1 Rating of evidence and panel opinion
Legend for chart:

A - Grade/rating
B - Evidence/rationale

       A                               B

A                  Suported by the results of two or more RCTs
                   that have good internal validity, and also
                   specifically address the question of interest
                   in a group of patients comparable to the one
                   to which the recommendation applies (external
                   validity)

B                  Supported by a single RCT meeting the
                   criteria given for "A"-level evidence, by
                   RCTs that only indirectly address the
                   question of interest, or by two or more
                   nonrandomized clinical trials (case control
                   or cohort studies) in which the experimental
                   and control groups are demonstrably similar
                   or multivariate analyses have effectively
                   controlled for group differences

C                  Supported by single non-RCT meeting the
                   criteria given for B-level evidence, by
                   studies using historical controls, or by
                   studies using quasi-experimental designs such
                   as pre- and post-treatment comparisons.

NA                 Recommendation is not addressed by
                   Experimental studies

Expert opinion     Strong consensus. Agreement among 90% or more
                   of panel members and expert reviewers

Consensus          Agreement among 75 to 89% of panel members
                   and expert reviewers

RCT: Randonnized controlled trials

Source: Gresham GE, Duncan PW, Stason WB, et al, Post-stroke
rehabilitation Clinical Practice Guideline, No. 16, Rockville,
MD: U.S. Department of Health and Human Services Public Health
Service, Agency for Health Care Policy and Reasearch AHCPR
Publication N. 95-0662. May 1995.
Table 2 Screening fer post-stroke rehabilitation
Current clinical status
Neurologic deficits
Comorbid diseases
Functional health patterns: nutrition and hydration,
  ability to swallow, bowel and bladder continence, skin
  integrity, activity tolerance, sleep patterns

Special emphases

Functional status prior to stroke
Current functional deficits
Mental status and ability to learn
Emotional status and motivation to participate in rehabilitation
Functional communication
Physical activity endurance

Social and environmental factors

Presence of spouse or significant other
Previous living situation
Ethnicity and native language
Adjustment of patient and family to stroke
Patient and family preferences for and expectations
  of rehabilitation
Extent of support by family or involved others
  (relationships, number, health, availability)
Characteristics of potential postdischarge environments

Standardized instruments

Stroke deficit scale(*)
Measure of disability(*)
Mental status screening test(*)

(*) Also presented in table form in the post-stroke guideline.

Source: Gresham GE, Duncan PW, Stason WB, et al. Post-stroke
rehabilitation. Clinical Practice Guideline, No. 16, Rockville,
MD: U.S. Department of Health and Human Services. Public Health
Service, Agency for Health Care Policy and Reasearch, AHCPR
Publication N. 95-0662. May 1995.
DIAGRAM: Figure Selection of setting for rehabilitation program after hospitalization for acute stroke

References
(n1.) Gresham GE, Duncan PW, Stason WB, et al. Post-stroke rehabilitation. Clinical Practice Guideline, No. 16, Rockville, MD: U.S. Department of Health and Human Services. Public Health Service, Agency for Health Care Policy and Reasearch. AHCPR Publication N. 95-0662. May 1995.

(n2.) Braddom RL, Buschbacher RM, eds. Physical medicine & rehabilitation. Philadelphia: WB Saunders; 1996.

(n3.) Dobkin BH. Neurologic rehabilitation. Philadelphia: EA. Davis; 1996.

(n4.) Bourestom NC. Predictors of long-term recovery in cerebrovascular disease. Arch Phys Med Rehabil 1967; 48(8):415-9.

(n5.) Anderson TP, Bourestom N, Greenberg FR, Hildyard VG. Predictive factors in stroke rehabilitation. Arch Phys Med Rehabil 1974; 55(12):545-53.

(n6.) Hayes SH, Carroll SR. Early intervention care in the acute stroke patient. Arch Phys Med Rehabil 1986; 67(5):319-21.

(n7.) Shah S, Vanclay F, Cooper B. Predicting discharge status at commencement of stroke rehabilitation. Stroke 1989; 20(6):766-9.

(n8.) Ottenbacher K J, Jannell S. The results of clinical trials in stroke rehabilitation research. Arch Neurol 1993; 50(1):37-44.

(n9.) Sandin K J, Mason KD. Manual of stroke rehabilitation. Boston: Butterworth-Heinemann; 1996.

(n10.) Richards CL, Malouin F, Wood-Dauphinee S, Williams JI, Bouchard JP, Brunet D. Task-specific physical therapy for optimization of gait recovery in acute stroke patients. Arch Phys Med Rehabil 1993; 74(6):612-20.

(n11.) Keith RA, Wilson DB, Gutierrez P. Acute and subacute rehabilitation for stroke: a comparison. Arch Phys Med Rehabil 1995; 76(6):495-500.

(n12.) Kramer AM, Steiner JF, Schlenker RE et al. Outcomes and costs after hip fracture and stroke. A comparison of rehabilitation settings. JAMA 1997; 277(5):396-404.

(n13.) Kwakkel G, Wagenaar RC, Koelman TW, Lankhorst G J, Koetsier JC. Effects of intensity of rehabilitation after stroke. A research synthesis. Stroke 1997; 28(8): 1550-6.

(n14.) Nugent JA, Schurr KA, Adams RD. A dose-response relationship between amount of weight bearing exemise and walking outcome following cerebrovascular accident. Arch Phys Med Rehabil 1994; 75(4):399-402.

(n15.) Leipert J, Bauder H, Wolfgang HR, Miltner WH, Taub E, Weiller C. Treatment-induced cortical reorganization after stroke in humans. Stroke 2000; 6:1210-6.

~~~~~~~~
By Craig H. Rosenberg, MD and Gail M. Popelka, MD

Dr. Rosenberg is clinical professor of rehabilitation medicine, State University of New York (SUNY) at Stony Brook; director of rehabilitation medicine at the St. Charles Hospital and Rehabilitation Center, Port Jefferson, NY; and program director for the physical medicine and rehabilitation residency training program, SUNY at Stony Brook School of Medicine.

Dr. Popelka is chief resident and assistant clinical instructor for the physical medicine and rehabilitation residency training program, SUNY at Stony Brook School of Medicine.

Copyright of Geriatrics is the property of Advanstar Communications Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Source: Geriatrics, 2000 Sep; 55(9)
Item Number: 2000069409
Back

-----Original Message-----
From: Medical Libraries Discussion List [mailto:[log in to unmask]] On Behalf Of Stonebraker, Jeanette
Sent: Wednesday, September 17, 2014 10:17 AM
To: [log in to unmask]
Subject: REF?: Rehabilitation Services

Good Morning All!

  This question has me stumped.  My patron wants to know:   if a 3-4 week delay after inpatient rehab for stroke patients would be of detriment  or delay outcomes and recovery?

  All I am finding is that rehab should start as soon as possible during the inpatient period and continue as long as needed, depending on patient needs.  I am not finding any specific references to the month after discharge from an inpatient facility and that is the only time frame she is looking at.

Am I missing something?

Thank you for any assistance you can provide!
Jeanette


Jeanette Stonebraker
Medical Librarian
Levitt Library (IAULVT, HQ4)
Mercy Medical Center
1111 6th Ave
Des Moines, IA 50314
(515) 247-4266


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April 2006, Week 2
April 2006, Week 1
March 2006, Week 5
March 2006, Week 4
March 2006, Week 3
March 2006, Week 2
March 2006, Week 1
February 2006, Week 4
February 2006, Week 3
February 2006, Week 2
February 2006, Week 1
January 2006, Week 5
January 2006, Week 4
January 2006, Week 3
January 2006, Week 2
January 2006, Week 1
December 2005, Week 5
December 2005, Week 4
December 2005, Week 3
December 2005, Week 2
December 2005, Week 1
November 2005, Week 5
November 2005, Week 4
November 2005, Week 3
November 2005, Week 2
November 2005, Week 1
October 2005, Week 5
October 2005, Week 4
October 2005, Week 3
October 2005, Week 2
October 2005, Week 1
September 2005, Week 5
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September 2005, Week 2
September 2005, Week 1
August 2005, Week 5
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July 2005, Week 1
June 2005, Week 5
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June 2005, Week 1
May 2005, Week 5
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May 2005, Week 3
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May 2005, Week 1
April 2005, Week 5
April 2005, Week 4
April 2005, Week 3
April 2005, Week 2
April 2005, Week 1
March 2005, Week 5
March 2005, Week 4
March 2005, Week 3
March 2005, Week 2
March 2005, Week 1
February 2005, Week 4
February 2005, Week 3
February 2005, Week 2
February 2005, Week 1
January 2005, Week 5
January 2005, Week 4
January 2005, Week 3
January 2005, Week 2
January 2005, Week 1
December 2004, Week 5
December 2004, Week 4
December 2004, Week 3
December 2004, Week 2
December 2004, Week 1
November 2004, Week 5
November 2004, Week 4
November 2004, Week 3
November 2004, Week 2
November 2004, Week 1
October 2004, Week 5
October 2004, Week 4
October 2004, Week 3
October 2004, Week 2
October 2004, Week 1
September 2004, Week 5
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September 2004, Week 3
September 2004, Week 2
September 2004, Week 1
August 2004, Week 5
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June 2004, Week 5
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June 2004, Week 3
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May 2004, Week 4
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May 2004, Week 2
May 2004, Week 1
April 2004, Week 5
April 2004, Week 4
April 2004, Week 3
April 2004, Week 2
April 2004, Week 1
March 2004, Week 5
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March 2004, Week 3
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March 2004, Week 1
February 2004, Week 5
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February 2004, Week 3
February 2004, Week 2
February 2004, Week 1
January 2004, Week 5
January 2004, Week 4
January 2004, Week 3
January 2004, Week 2
January 2004, Week 1
December 2003, Week 5
December 2003, Week 4
December 2003, Week 3
December 2003, Week 2
December 2003, Week 1
November 2003, Week 5
November 2003, Week 4
November 2003, Week 3
November 2003, Week 2
November 2003, Week 1
October 2003, Week 5
October 2003, Week 4
October 2003, Week 3
October 2003, Week 2
October 2003, Week 1
September 2003, Week 5
September 2003, Week 4
September 2003, Week 3
September 2003, Week 2
September 2003, Week 1
August 2003, Week 5
August 2003, Week 4
August 2003, Week 3
August 2003, Week 2
August 2003, Week 1
July 2003, Week 5
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July 2003, Week 3
July 2003, Week 2
July 2003, Week 1
June 2003, Week 5
June 2003, Week 4
June 2003, Week 3
June 2003, Week 2
June 2003, Week 1
May 2003, Week 5
May 2003, Week 4
May 2003, Week 3
May 2003, Week 2
May 2003, Week 1
April 2003, Week 5
April 2003, Week 4
April 2003, Week 3
April 2003, Week 2
April 2003, Week 1
March 2003, Week 5
March 2003, Week 4
March 2003, Week 3
March 2003, Week 2
March 2003, Week 1
February 2003, Week 4
February 2003, Week 3
February 2003, Week 2
February 2003, Week 1
January 2003, Week 5
January 2003, Week 4
January 2003, Week 3
January 2003, Week 2
January 2003, Week 1
December 2002, Week 5
December 2002, Week 4
December 2002, Week 3
December 2002, Week 2
December 2002, Week 1
November 2002, Week 5
November 2002, Week 4
November 2002, Week 3
November 2002, Week 2
November 2002, Week 1
October 2002, Week 5
October 2002, Week 4
October 2002, Week 3
October 2002, Week 2
October 2002, Week 1
September 2002, Week 5
September 2002, Week 4
September 2002, Week 3
September 2002, Week 2
September 2002, Week 1
August 2002, Week 5
August 2002, Week 4
August 2002, Week 3
August 2002, Week 2
August 2002, Week 1
July 2002, Week 5
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July 2002, Week 3
July 2002, Week 2
July 2002, Week 1
June 2002, Week 5
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June 2002, Week 3
June 2002, Week 2
June 2002, Week 1
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May 2002, Week 3
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April 2002, Week 5
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April 2002, Week 3
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April 2002, Week 1
March 2002, Week 5
March 2002, Week 4
March 2002, Week 3
March 2002, Week 2
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February 2002, Week 1
January 2002, Week 5
January 2002, Week 4
January 2002, Week 3
January 2002, Week 2
January 2002, Week 1
December 2001, Week 5
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December 2001, Week 3
December 2001, Week 2
December 2001, Week 1
November 2001, Week 5
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November 2001, Week 3
November 2001, Week 2
November 2001, Week 1
October 2001, Week 5
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October 2001, Week 3
October 2001, Week 2
October 2001, Week 1
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August 2001, Week 5
August 2001, Week 4
August 2001, Week 3
August 2001, Week 2
August 2001, Week 1
July 2001, Week 5
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July 2001, Week 3
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July 2001, Week 1
June 2001, Week 5
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June 2001, Week 3
June 2001, Week 2
June 2001, Week 1
May 2001, Week 5
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May 2001, Week 3
May 2001, Week 2
May 2001, Week 1
April 2001, Week 5
April 2001, Week 4
April 2001, Week 3
April 2001, Week 2
April 2001, Week 1
March 2001, Week 5
March 2001, Week 4
March 2001, Week 3
March 2001, Week 2
March 2001, Week 1
February 2001, Week 4
February 2001, Week 3
February 2001, Week 2
February 2001, Week 1
January 2001, Week 5
January 2001, Week 4
January 2001, Week 3
January 2001, Week 2
January 2001, Week 1
December 2000, Week 5
December 2000, Week 4
December 2000, Week 3
December 2000, Week 2
December 2000, Week 1
November 2000, Week 5
November 2000, Week 4
November 2000, Week 3
November 2000, Week 2
November 2000, Week 1
October 2000, Week 5
October 2000, Week 4
October 2000, Week 3
October 2000, Week 2
October 2000, Week 1
September 2000, Week 5
September 2000, Week 4
September 2000, Week 3
September 2000, Week 2
September 2000, Week 1
August 2000, Week 5
August 2000, Week 4
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June 2000, Week 5
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May 2000, Week 5
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May 2000, Week 2
May 2000, Week 1
April 2000, Week 5
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April 2000, Week 3
April 2000, Week 2
April 2000, Week 1
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March 2000, Week 4
March 2000, Week 3
March 2000, Week 2
March 2000, Week 1
February 2000, Week 5
February 2000, Week 4
February 2000, Week 3
February 2000, Week 2
February 2000, Week 1
January 2000, Week 5
January 2000, Week 4
January 2000, Week 3
January 2000, Week 2
January 2000, Week 1
December 1999, Week 5
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December 1999, Week 3
December 1999, Week 2
December 1999, Week 1
November 1999, Week 5
November 1999, Week 4
November 1999, Week 3
November 1999, Week 2
November 1999, Week 1
October 1999, Week 5
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October 1999, Week 3
October 1999, Week 2
October 1999, Week 1
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June 1999, Week 5
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May 1999, Week 1
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April 1999, Week 3
April 1999, Week 2
April 1999, Week 1
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March 1999, Week 4
March 1999, Week 3
March 1999, Week 2
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February 1999, Week 3
February 1999, Week 2
February 1999, Week 1
January 1999, Week 5
January 1999, Week 4
January 1999, Week 3
January 1999, Week 2
January 1999, Week 1
December 1998, Week 5
December 1998, Week 4
December 1998, Week 3
December 1998, Week 2
December 1998, Week 1
November 1998, Week 5
November 1998, Week 4
November 1998, Week 3
November 1998, Week 2
November 1998, Week 1
October 1998, Week 5
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October 1998, Week 3
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October 1998, Week 1
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April 1998, Week 5
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April 1998, Week 2
April 1998, Week 1
March 1998, Week 5
March 1998, Week 4
March 1998, Week 3
March 1998, Week 2
March 1998, Week 1
February 1998, Week 4
February 1998, Week 3
February 1998, Week 2
February 1998, Week 1
January 1998, Week 5
January 1998, Week 4
January 1998, Week 3
January 1998, Week 2
January 1998, Week 1
December 1997, Week 5
December 1997, Week 4
December 1997, Week 3
December 1997, Week 2
December 1997, Week 1
November 1997, Week 5
November 1997, Week 4
November 1997, Week 3
November 1997, Week 2
November 1997, Week 1
October 1997, Week 5
October 1997, Week 4
October 1997, Week 3
October 1997, Week 2
October 1997, Week 1
September 1997, Week 5
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September 1997, Week 2
September 1997, Week 1
August 1997, Week 5
August 1997, Week 4
August 1997, Week 3
August 1997, Week 2
August 1997, Week 1
July 1997, Week 5
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July 1997, Week 1
June 1997, Week 5
June 1997, Week 4
June 1997, Week 3
June 1997, Week 2
June 1997, Week 1
May 1997, Week 5
May 1997, Week 4
May 1997, Week 3
May 1997, Week 2
May 1997, Week 1
April 1997, Week 5
April 1997, Week 4
April 1997, Week 3
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April 1997, Week 1
March 1997, Week 5
March 1997, Week 4
March 1997, Week 3
March 1997, Week 2
March 1997, Week 1
February 1997, Week 4
February 1997, Week 3
February 1997, Week 2
February 1997, Week 1
January 1997, Week 5
January 1997, Week 4
January 1997, Week 3
January 1997, Week 2
January 1997, Week 1
December 1996, Week 5
December 1996, Week 4
December 1996, Week 3
December 1996, Week 2
December 1996, Week 1
November 1996, Week 5
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November 1996, Week 3
November 1996, Week 2
November 1996, Week 1
October 1996, Week 5
October 1996, Week 4
October 1996, Week 3
October 1996, Week 2
October 1996, Week 1
September 1996, Week 5
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September 1996, Week 1
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August 1996, Week 3
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August 1996, Week 1
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July 1996, Week 2
July 1996, Week 1
June 1996, Week 5
June 1996, Week 4
June 1996, Week 3
June 1996, Week 2
June 1996, Week 1
May 1996, Week 5
May 1996, Week 4
May 1996, Week 3
May 1996, Week 2
May 1996, Week 1
April 1996, Week 5
April 1996, Week 4
April 1996, Week 3
April 1996, Week 2
April 1996, Week 1
March 1996, Week 5
March 1996, Week 4
March 1996, Week 3
March 1996, Week 2
March 1996, Week 1
February 1996, Week 5
February 1996, Week 4
February 1996, Week 3
February 1996, Week 2
February 1996, Week 1
January 1996, Week 5
January 1996, Week 4
January 1996, Week 3
January 1996, Week 2
January 1996, Week 1
December 1995, Week 5
December 1995, Week 4
December 1995, Week 3
December 1995, Week 2
December 1995, Week 1
November 1995, Week 5
November 1995, Week 4
November 1995, Week 3
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October 1995, Week 4
October 1995, Week 3
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October 1995, Week 1
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August 1995, Week 1
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July 1995, Week 2
July 1995, Week 1
June 1995, Week 5
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June 1995, Week 3
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May 1995, Week 3
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May 1995, Week 1
April 1995, Week 5
April 1995, Week 4
April 1995, Week 3
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April 1995, Week 1
March 1995, Week 5
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March 1995, Week 3
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March 1995, Week 1
February 1995, Week 5
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February 1995, Week 3
February 1995, Week 2
February 1995, Week 1
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December 1994, Week 5
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December 1994, Week 3
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