Rehabilitación integral post-ictusfactores sociales, impacto a largo plazo y trabajo social de neurologia

Résumé

Introduction: Comprehensive post-stroke rehabilitation (RHB) involves treating in a coordinated and integrated manner all functional deficits that affect the person who has survived a stroke. It is unknown in our environment what the long-term impact of integral RHB is on the functional status of patients. Furthermore, it is not clear whether access to comprehensive RHB is guaranteed within the National Health System, and to what extent it is determined by social factors. Objectives: 1) To know the probability that stroke patients have in our environment have of accessing comprehensive RHB after being indicated by a multidisciplinary team. 2) Analyze the social and environmental factors conditioning access to comprehensive post-ictus rehabilitation. 3) Evaluate the long-term effects of comprehensive rehabilitation on patient functionality. Material and Methods: Two consecutive studies have been carried out, the first of which included 102 patients with ischemic and hemorrhagic stroke admitted to the University Clinical Hospital of Valladolid during 2016, who needed a comprehensive rehabilitation at hospital discharge. Access to integral RHB at three months post-stroke was evaluated in all patients. The association between baseline variables of personal, social and family type, among others, and access to comprehensive post-stroke RHB was analyzed. Finally, a multivariate logistic regression model was performed with the variables that showed association in the bivariate analysis. The second study included 171 consecutive patients hospitalized in 2015 in the Neurology Service with the first ischemic stroke, without previous functional dependence, candidates for comprehensive rehabilitation, who were followed in the long term in the neurological social work consultation of the hospital. The association between baseline variables and access to comprehensive post-stroke RHB was analyzed in a similar way to that performed in the first study. Finally, a multivariate logistic regression model was performed using the score in the Barthel Index at the final visit as a dependent variable, while access to integral RHB, together with the rest of the selected baseline variables, were considered independent variables. Results: In both studies, a similar percentage of access to integral RHB was observed, around 53%. The factors independently associated with access to comprehensive RHB were, in the first study, age (p<0.001), marital status (p=0.007) and the existence of family support (p=0.01). Age and place of residence (rural or urban) were the explanatory factors for access to comprehensive rehabilitation (values adjusted to the rest of the p<0.001 variables were obtained). In the second study, with an average follow-up of 54 months, it was observed that access to comprehensive post-stroke RHB behaved as a predictor of good long-term functional prognosis in the 137 patients who survived to the end of follow-up (OR: 12.441, (95% CI 4.7-32.5), p<0.001). Variables predicting access were: residence in urban environment (OR: 2.957, (95% CI 1.067-8.199), p=0.037), complement with private RHB (OR: 2.890, 95% CI 1.130-7.392), p=0.027), better Rankin at discharge (OR: 22.437, (95% CI 3.247-155.058), p=0.014). Conclusions: Only half of the study population accessed integral RHB. It is evident that the comprehensive RHB post-stroke is associated with a better long-term functional prognosis (5 years), but access to it is conditioned by environmental and social factors such as the place of residence and the possibility of contracting private services, among others. Social Work in neurology plays a key role in the functional recovery of the person after a stroke, resolving the socio-environmental barriers that prevent their access to comprehensive rehabilitative treatment.