Article Versions
Export Article
Cite this article
  • Normal Style
  • MLA Style
  • APA Style
  • Chicago Style
Research Article
Open Access Peer-reviewed

Effect of Chest Physiotherapy Exercises on Reducing Pulmonary Complications for Patients with Acute Stroke at Assiut University Hospital

Marwa Ali Almasry , Neama Mamdouh Mostafa, Eman Hessien Heggy
American Journal of Nursing Research. 2018, 6(6), 541-546. DOI: 10.12691/ajnr-6-6-23
Received August 25, 2018; Revised October 13, 2018; Accepted October 28, 2018

Abstract

Background: Pulmonary complications after stroke contribute significantly to a poor stroke outcome. Early in hospital pulmonary complications of stroke patients can be reduced by chest physiotherapy exercises .The aim of this study was to evaluate the effect of chest physiotherapy on reducing pulmonary complications among stroke patients. Methodology: A quasi-experimental research design was used in this study. The study was conducted in the neurological departments at Assiut University Hospital. The study included 60 adult stroke patients from the acute stage (2 Days) of admission to the hospital until discharge time. The sample was divided into two equal groups. Study and control group (30 patients each). Two tools used to collect data include, patient assessment sheet, pulmonary complication assessment sheet. Results: In the control group was 66.7% while pneumonia in the study group was 23.3% after the application of physical therapy exercises to the chest. Conclusion: Applying chest physiotherapy exercises had a statistically significant effect on reducing pulmonary complications among study group than the control group. Recommendations: Successful chest-program physiotherapy exercises should be implemented as early as the time of hospitalization for each stroke patient.

1. Introduction

Stroke or brain attack is a decrease or interruption of blood flow through the artery to one or more areas of the brain 1.

Stroke is often followed by complications, which have effects on motor, sensory and autonomic function. It is now generally recognized that many stroke patients have important complications, often life-threatening several months to several years beyond stroke. For example, atelectasis, sleeps apnea, pulmonary embolism and lack of oxygen saturation 2.

Respiratory weakness is a major cause of morbidity and mortality in stroke which causes weak respiratory muscles, decrease vital capacity, ineffective coughing, reduced in chest wall compliance, and excess oxygen in breathing due to respiratory distortion. Atelectasis, pneumonia, and ventilator failure are the most common complications during the first 5 days after stroke 3.

Pneumonia, one of the most common respiratory complications of acute stroke, occurs in approximately 5% to 9% of stroke patients. The incidence of pneumonia is higher in patients with acute stroke and those who need to feed with nasogastric tube. Aspiration is caused by nearly 60% of pneumonia after stroke, usually due to dysphagia 4.

Breathing patterns occur abnormally in about 60% of patients with neurological disorders, including strokes. Underlying causes are heart and respiratory abnormalities. Acute stroke patient usually has abnormal breathing periods, especially when the patient has decreased consciousness or serious stroke 5.

Non-saturation oxygen diagnosed by continuous pulse oximetry is accompanied by increased age, and dysphagia. Poor oxygen ischemia of the brain tissue is the main cause of nerve deficits in the brain, and longer periods of oxygen deprivation produce more extensive and irreversible damage 6.

Chest physiotherapy is a set of treatments that aim to improve respiratory efficiency, promote lungs expansion, strengthen respiratory muscles, and eliminate secretions from the respiratory tract 7.

Chest physiotherapy has been shown during hospital treatment to improve respiratory oxygen, muscle strength, mechanical cough, chest wall movment and lung ventilation, as well as reduce respiratory action and prevent post stroke pulmonary complications 8.

The purpose of chest physiotherapy is to help patients breathe more freely and get more oxygen to the body. Chest exercises include; postural drainage, chest percussion, chest vibration, turning, deep breathing and coughing exercises 9.

Significance of the study

According to Assiut University Hospital records (2017), the stroke patients' flow rate at neurological departments was about 480 cases most of them complained from Pulmonary complications post stroke “but unfortunately the hospital lack complication documentation, this was only observed from our clinical practice”. So this study is considered the first in this geographical location to help such group of patients in an attempt to decrease the incidence of these complications.

Aim of the study:

To evaluate the effect of chest physiotherapy on reducing pulmonary complications among stroke patients.

Study Hypothesis:

The occurrence of pulmonary complications after the application of chest physiotherapy exercises in the study group will be less than those in the control group.

2. Patients and Method

2.1. Study Design

The Quasi-experimental research design was used in this study.


2.1.1. Study Setting

This study was conducted in the neurological departments at Assuit University Hospital.


2.1.2. Study Subjects:

The study included 60 adult stroke patients from the acute stage (2 day) of admission to the hospital until discharge time with age 18-65 years . This sample was divided into two equal groups; study and control groups (30 patients each). The study group who received chest physiotherapy exercises and control group received routine hospital care.


2.1.3. Inclusion Criteria

Ÿ The age ranged between 18-65 years old.

Ÿ Recent admission to hospital after acute phase (two days).

Ÿ The ischemic or hemorrhagic stroke.

Study Tools:

Two tools were used to collect data.

Tool Ι: Patient Assessment sheet:

This tool consists of three parts:

Part 1: Sociodemographic characteristics of the Patient: it was used prior to the implementation of the chest physiotherapy exercise program to selected socio-demographic data for stroke patients which consisted of patient’s name, age, gender, level of education, profession patient diagnosis.

Part 2: Risk factors assessment: this part includes the following items:

A. Present risk factors: this include dysphagia, presence of seizures, urinary catheter, site of lesion, serum albumin, serum BUN, serum hemoglobin and deep venous thrombosis.

B. Past risk factors: this part includes the history of smoking, COPD, asthma, daily productive cough, respiratory infection and weight loss more than10% within 6 month.

Part 3: Medical data: this part was included the following items:

Vital signs: (temperature, pulse, respiration), (WBC) and ABG results: (Paco 2, Pao 2, Sao2).

Tool II. Pulmonary complications assessment sheet:

It was used to assess expected pulmonary complications that might develop among stroke patients. This part was included: Acute respiratory failure, pneumonia, aspiration pneumonia, atelectasis, pulmonary embolism, obstructive sleep apnea and oxygen desaturation.

Chest physiotherapy Exercises program

It developed by researchers based on the content of the best practice statement for chest physiotherapy exercises (it include techniques of chest physiotherapy that involve turning, deep breathing, coughing, postural drainage, percussion, and vibration) for completion and application by the researcher.

2.2. Methods
2.2.1. The Study Was Conducted Through

Ÿ Data were collected at Neurological departments at Assuit University Hospital during the period from November 2017 to April 2018.

Ÿ An official permission was obtained from the head of Assuit University Hospital to conduct the study.

Ÿ The study tools and chest physiotherapy exercises program were formulated after a review of the literature.

Ÿ The content validity was done by 5 expertise in the field of medical surgical nursing and neuroscience field. Tools were designed and tested for reliability by using internal consistency for the tools measured using Cronbach test, the tools proved to be reliable at 0.73.

Ÿ A pilot study was conducted on 10% of the subjects to examine easiness and clarity of the tools; those patients were including in the main study as no modifications were done.

Ÿ Patient's agreement for voluntary participation was obtained after the purpose and nature of the study were explained.

Ÿ Confidential data and anonymity were confirmed and collected using the above-mentioned study tools.

Ÿ The study was conducted during the morning and afternoon shift for stroke patients.

Ÿ After the acute stage of the disease over two days of patient stroke entered into the neurological department; the researcher met each patient separately.

Ÿ The researchers met selected patients. Each patient from both groups (study and control) was fully informed with the purpose and nature of the study. Baseline data were created using the tool I.

Ÿ Patients in the control group were exposed to routine nursing care, while patients in the study group received the chest physiotherapy exercises.

Ÿ The chest physiotherapy was applied by the researchers to study group.

Ÿ Each session took about 30-40min twice a day three times a week until discharge time.

Ÿ Chest physiotherapy has been applied on an individual basis. One of the family members was present in the session to ensure patient support.

Ÿ During the session, each patient was given a "handbook" after reviewing extensive studies, including pictures related to pulmonary complications, and how to avoid complications of theses through the application of chest physiotherapy exercises in clear Arabic.

Ÿ Each session includes the implementation of physiotherapy exercises for the chest as the following methods (turning, deep breathing, coughing, postural drainage, percussion, and vibration).

Ÿ Before the patients have being leaving the hospital. The researcher met the patient to evaluate the medical data of the patients using the tool I Part 3 tool and pulmonary complications sheet for the control and the study group using tool II.


2.2.2. Ethical Considerations

Ÿ Research proposal was approved from the Ethics Committee at the College of Nursing.

Ÿ There is no risk to the subject of study during the application of research.

Ÿ The study followed common ethical principles in clinical research.

Ÿ Oral agreement for voluntary participation has been obtained, after explaining the nature and purpose of this study.

Ÿ The researcher confirmed the confidentiality and anonymity of subjects by coding all data.

Ÿ The patient has the right of refusing to participate or to withdraw from the study without any reasons at any time.

Ÿ The patient's privacy was maintained during collection of data.


2.2.3. Difficulties of the Study

Ÿ Lack of scientific sources that talk about the impact of the application of chest physiotherapy exercise program for stroke patients.

Ÿ The need to apply the exercises twice a day and three times a week was a fatigue and trouble for the researcher.

2.3. Statistical Design

The data were tested for normality using the Anderson-Darling test and for homogeneity variances prior to further statistical analysis. Categorical variables were described by number and percent (N, %), where continuous variables described by mean and standard deviation (Mean, SD). Chi-square test and fisher exact test used to compare between categorical variables where compare between continuous variables by t-test. A two-tailed p < 0.05 was considered statistically significant. All analyses were performed with the IBM SPSS 20.0 software.

3. Results

Table 1 showed that, the highest percentage of the studied sample age was between 51-60 years old. Around half were females in both groups (53.3%). About two third were living in rural areas (60% and 73.3%). And most of them were married (96.7% and 100%). Regarding education it was found that the highest percentages in both groups were read and write (56.7% and 66.7%). By looking at the occupation it was found that the highest percentages in both groups were housewives (50% and 66.7%). Finally as diagnosis it was found that the highest percentages in both groups were having cerebral hemorrhage (46.7% and 53.3%).

Table 2 Regarding present risk factors, the highest percentages in both groups (study and control) were inserted urinary catheterizations and were have right side lesion. Regarding past risk factors, it was found that 33.3% of the control group had history of asthma and 36.7% had history of daily productive cough.

Table 3 demonstrated that there was highly statistically difference between the study and the control groups in temperature monitoring and oxygen saturation and there was statistically significant difference between the study and the control after application of chest physiotherapy regarding pulse monitoring and WBC.

Table 4 founded that there was highly significant difference between study and control groups after applications of chest physiotherapy regarding pneumonia, pulmonary embolism, and there was significant difference between the studied sample as regard aspiration pneumonia, obstructive sleep apnea as well as oxygen desaturation.

4. Discussion

Pulmonary complications are predominant as post stroke complications. The majority of these complications occurred during acute phase hospital stay included respiratory failure, pneumonia, a spiration pneumonia, atelectasis, acute respiratory distress syndrome, obstructive sleep apnea, and pulmonary embolism (PE) from venous thromboembolism (VTE) and oxygen desaturation are frequently happen among stroke patients 10.

Therefore, the application of physiotherapy to the chest in the first week of stroke helps improve respiratory efficiency, promote the expansion of the lungs, strengthen the respiratory muscles, and eliminate the secretions from the respiratory system. The practice of deep breathing was one of the first ways, and later, a variety of manual treatments including percussion, vibration, or changes the patient position every 2 hours to improve breathing pattern 11.

Regarding demographic data the present study showed that the largest proportion of both study and control groups were between 51-60 years of age, this can be caused by physiological changes associated with aging are: decrease in the flexible recoil of the lung, decrease in chest wall compliance, Strength of respiratory muscles. Thus respiratory muscle performance is thus impaired by the age. This result agreed with Runa, 12 who founded that the common secondary complications occurred in the age group (50-60) years.

Yared et al., 13 who conducted a study on stroke patients admitted for inpatient care in Addis Ababa, Ethiopia, they found that men are more likely to develop medical and neurological complications than in women and Finlayson et al., 14 indicated that male sex, was predictors of pulmonary complications in ischemic stroke. In the current study there was a higher female predominance than male.

Consistent with the current study Chen et al., 15 mentioned that ischemic stroke could be a predictor for the lower occurrence of pulmonary complications in all stroke patients than hemorrhagic stroke patients. From the researchers point of view this may be due to these patients had more complications and poor prognosis during the hospitalization than ischemic group.

Related to the present risk factors of pulmonary complications this study showed that the highest percentage in both groups was due to dysphagia, this result from the researcher opinion was due to post-stroke has long been attributed to pharyngeal muscular dysfunction and incoordination, secondary to central nervous system loss of control, these results were in the same line with Gordon et al., 16 who founded the presence of dysphagia in stroke survivors has been associated with increased pulmonary complications. Indwelling urethral catheters were the second risk factors for the developing post stroke pulmonary complications. It is worth mentioning that urinary catheterization also has the ability to contribute indirectly to the occurrence of pulmonary complications. This findings were supported by Jen-Wen et al., 17 who founded that only indwelling urethral catheters were associated with an increased incidence of complications among stroke patients post-acute phase.

Regarding past risk factors, it was found that one third of the control group had history of asthma and more than one third had history of daily productive cough. In contrary with the current study Chumbler et al., 18 found that several factors predispose stroke patients to develop pneumonia older age, diabetes, cognitive impairment, stroke severity because he did not assess this element among the factors leading to the occurrence of post stroke pulmonary complications. In the current study pulmonary complications were clinically diagnosed by a physician and confirmed by vital signs and laboratory investigations.

The findings of the present study indicated that pneumonia significantly reduced in the study group than in the control group. In the same line Tishler et al., 19 they reported that the stroke-associated pneumonia was observed in 587 patients in their study that was conducted from July 2003-March 2007, on 8,251 stroke patients.

Among 30 patients of control group, more than half of patients had pulmonary embolism. In the same line with the study conducted by Brogan et al., 20 who revealed that, the pulmonary embolism occur 55% (n=22) among 51 participants.

Among two-thirds of patients with dysphagia, more than one-fifth of patients suffered from aspiration pneumonia. This study result is consistent with Yaggi et al., 21 who study results revealed that the Incidence rates of aspiration pneumonia post stroke are estimated between 11%-50%.

Among the 30 patients of the control group, nearly three quarters of patients were founded to suffer from sleep apnea. Sulter et al., 22 they also in the same line and reported that among patients with strokes, 60% had obstructive sleep apnea.

The results of the current study showed that oxygen desaturation occur in two fifth of control group. Mozaffarian et al., 23 agreed with the researcher’s result and reported that 63% of stroke patients had at least one episode of oxygen desaturation.

The complications mentioned above repeated more among the stroke patients. So it is necessary to apply chest physiotherapy early as soon as possible from the time of stroke to reduce the risk of developing complications. Regarding the effect of chest physiotherapy on reducing pulmonary complications the present study proved that after applying chest physiotherapy there was a significant difference between two groups related to the complications occurrence. From the researchers point of view this may be due to early applying chest physiotherapy that help in improve respiratory muscle strength, oxygenation, coughing mechanism, chest wall mobility and lung ventilation, as well as decreasing respiratory work and preventing pulmonary complications. In the same line, Elkins and Dentice 24 declared that one approach that has the potential to increase respiratory muscle strength and reduce respiratory complications after stroke is respiratory muscle training as perform repetitive breathing exercise.

5. Conclusion

Applying chest physiotherapy exercises had a statistically significant effect on reducing the pulmonary complications among the study group than the control group.

6. Recommendations

1. Nurses working in the neurological department must include the chest physiotherapy exercises in care of stroke patients and successful chest physiotherapy exercises program should be implemented as early as possibly from time of admission to hospital for each stroke patient.

2. Further studies on larger sample from different geographical areas in Egypt to generalize the results, detect the main aspects of the problem, and gather in depth information about post stroke pulmonary complications.

References

[1]  Karen, R.L (2017). Emergency Neurology. Springer Science & Business Media. p. 360.
In article      
 
[2]  Robert, T, Norine, F, Katherine, S, Norhayati, S, Ricardo, V., and Nerissa, C. (2013). Medical Complication Post Stroke, 801 Commissioners Road East, London, 1 Ontario, Canada, N6C 5J1.
In article      
 
[3]  Birschel, P, Ellul, J, and Barer, D. (2014). Progressing stroke: towardsan internationally agreed definition. Cerebrovasc Disease, 17(2-3): 242-52.
In article      View Article  PubMed
 
[4]  Donnan, G.A, Fisher, M, Macleod, M, Davis, S.M (2015). “Stroke”. Lancet. 371 (9624): 1612-23.
In article      View Article
 
[5]  Ayata, C and Lauritzen, M. (2015). Spreading depression, spreading depolarizations, and the cerebral vasculature. Physiol Rev. 95(3), 953-93.
In article      View Article  PubMed
 
[6]  Badhiwala, J.M, Nassiri, F, Alhazzani, W, Selim, M, Farrokhyar, F, Spears J, Kulkarni, A. (2015). Endovascular thrombectomy for acute ischemic stroke: a meta-analysis. JAMA. 314(17), 1832-43.
In article      View Article  PubMed
 
[7]  Boyt Schell, B and Scaffa, M. (2015). Willard & Spackman’s occupational therapy (12thed.). Baltimore, MD: Lippincott Williams & Wilkins.
In article      
 
[8]  Kisner C, Colby L. A, (2002). Therapeutic exercise: foundations and techniques. 4th ed. Philadelphia: FA Davis Company.
In article      PubMed
 
[9]  Broderick, J. (2016). Interventional management of stroke past, present and future. Retrieved from http://www.upmc.com/Services/stroke-institute/Documents/joseph-broderick.pdf.
In article      View Article
 
[10]  Rincon F S, Ghosh, S, Dey M, Maltenfort M, Vibbert J. (2012). Impact of acute lung injury and acute respiratory distress syndrome after traumatic brain injury in the United States, Neurosurgery, vol. 71, no. 4, pp. 795-803.
In article      View Article  PubMed
 
[11]  Adriana, C, LunardiI, I. C, Celso, R. F. and CarvalhoI. (2011). Postoperative chest physical therapy prevents respiratory complications in patients undergoing esophagectomy Brazilian Journal of Physical Therapy 2 (15).
In article      
 
[12]  Runa, S., A., (2015). the common secondary complications among the stroke patients at CPR, Bachelor of Science in Physiotherapy (B.Sc. PT) Roll No. 1586 Registration No. 1893 Session: 2010-2011 BHPI, CRP, Savar, Dhaka).
In article      
 
[13]  Yared, M, Guta, Z and Adamu, A. (2015). medical and neurological complications among stroke patients admitted for inpatient care in addis ababa, ethiopia, p10, Ethiop Med J, Vol. 53, No.1, INAL ARTICLE.
In article      
 
[14]  Finlayson, O, Kapral, M, Hall, R, Asllani, E, Selchen, D, Saposnik, G (2011). Risk factors, inpatient care, and outcomes of pneumonia after ischemic stroke. Neurology; 77(14): 1338-45.
In article      View Article  PubMed
 
[15]  Chen, C.M, Hsu, H.C, Tsai, W.S, Chang, C.H, Chen, K.H, Hong, C.Z (2012). Infections in acute older stroke in patients undergoing rehabilitation. Am J Phys Med Rehabil; 91(3): 211-9.
In article      View Article  PubMed
 
[16]  Gordon, C, Hewer, R. L, Wade, D. T. (1987). Dysphagia in acute stroke. Br. Med. J. (Clin Res. Ed), 295 (6595), 411-414.
In article      View Article
 
[17]  Jen-Wen, H, Tzong-Horng, T, Hsueh-Wen, C, Chau-Peng, L, Yiu-Chung, L (2005). Incidence and Risk Factors of Medical Complications during Inpatient Stroke Rehabilitation, Chang Gung Med J Vol. 28 No. 1.
In article      
 
[18]  Chumbler, N.R, Williams, L.S, Wells, C.K, Nadeau, S, Peixoto, A. J, (2010). Derivation and validation of a clinical system for predicting pneumonia in acute stroke. Neuroepidemiology. 34(4): 193-9.
In article      View Article  PubMed
 
[19]  Tishler, P.V, Larkin, E. K, Schluchter, M. D. (2003). .Incidence of sleep-disordered breathing in an urban adult population: the relative importance of risk factors in the development of sleep-disordered breathing. Journal of the American Medical Association, 289, 2230-2237.
In article      View Article  PubMed
 
[20]  Brogan, E, Langdon, C, Brookes, K, Budgeon, C, & Blacker, D. (2014). Respiratory infections in acute stroke: Nasogastric tubes and immobility are stronger predictors than dysphagia. Dysphagia, 29, 340-345.
In article      View Article  PubMed
 
[21]  Yaggi, H. K., Concat, J, Kernan, W. N. (2005). Obstructive sleep apnea as a risk factor for stroke and death. New England Journal of Medicine, 343, 2034-2041.
In article      View Article  PubMed
 
[22]  Sulter, G, Elting, J. w, Stewart, R, den Arend A, De Kayser J. (2000). Continuous pulse oximetery in acute hemiparetic stroke. J Neurol Sci; 179: 65-9.
In article      View Article
 
[23]  Mozaffarian, D,Benjamin, E. J, Arnett, D. K, Blaha, M. J and Cushman M.(2015). Heart disease and stroke statistics: report from the American Heart association. Circulation; 27; 131: e 29-322.
In article      
 
[24]  Elkins, M and Dentice, R. (2015). inspiratory muscle training facilitates weaning from mechanical ventilation among patients in the intensive care unite: asystemic review. J physiother. 61: 125-134.
In article      View Article  PubMed
 

Published with license by Science and Education Publishing, Copyright © 2018 Marwa Ali Almasry, Neama Mamdouh Mostafa and Eman Hessien Heggy

Creative CommonsThis work is licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/

Cite this article:

Normal Style
Marwa Ali Almasry, Neama Mamdouh Mostafa, Eman Hessien Heggy. Effect of Chest Physiotherapy Exercises on Reducing Pulmonary Complications for Patients with Acute Stroke at Assiut University Hospital. American Journal of Nursing Research. Vol. 6, No. 6, 2018, pp 541-546. http://pubs.sciepub.com/ajnr/6/6/23
MLA Style
Almasry, Marwa Ali, Neama Mamdouh Mostafa, and Eman Hessien Heggy. "Effect of Chest Physiotherapy Exercises on Reducing Pulmonary Complications for Patients with Acute Stroke at Assiut University Hospital." American Journal of Nursing Research 6.6 (2018): 541-546.
APA Style
Almasry, M. A. , Mostafa, N. M. , & Heggy, E. H. (2018). Effect of Chest Physiotherapy Exercises on Reducing Pulmonary Complications for Patients with Acute Stroke at Assiut University Hospital. American Journal of Nursing Research, 6(6), 541-546.
Chicago Style
Almasry, Marwa Ali, Neama Mamdouh Mostafa, and Eman Hessien Heggy. "Effect of Chest Physiotherapy Exercises on Reducing Pulmonary Complications for Patients with Acute Stroke at Assiut University Hospital." American Journal of Nursing Research 6, no. 6 (2018): 541-546.
Share
  • Table 1. Distribution of the studied sample (study and control groups) regarding socio demographic characteristics
  • Table 2. Distribution of the studied sample (study and control groups) regarding assessment of present and past risk factors
  • Table 3. comparison between the studied sample (the study and the control groups) as regard vital signs and laboratory investigation recording chart
  • Table 4. Comparison between the Study and the Control groups as regard pulmonary complications of stroke
[1]  Karen, R.L (2017). Emergency Neurology. Springer Science & Business Media. p. 360.
In article      
 
[2]  Robert, T, Norine, F, Katherine, S, Norhayati, S, Ricardo, V., and Nerissa, C. (2013). Medical Complication Post Stroke, 801 Commissioners Road East, London, 1 Ontario, Canada, N6C 5J1.
In article      
 
[3]  Birschel, P, Ellul, J, and Barer, D. (2014). Progressing stroke: towardsan internationally agreed definition. Cerebrovasc Disease, 17(2-3): 242-52.
In article      View Article  PubMed
 
[4]  Donnan, G.A, Fisher, M, Macleod, M, Davis, S.M (2015). “Stroke”. Lancet. 371 (9624): 1612-23.
In article      View Article
 
[5]  Ayata, C and Lauritzen, M. (2015). Spreading depression, spreading depolarizations, and the cerebral vasculature. Physiol Rev. 95(3), 953-93.
In article      View Article  PubMed
 
[6]  Badhiwala, J.M, Nassiri, F, Alhazzani, W, Selim, M, Farrokhyar, F, Spears J, Kulkarni, A. (2015). Endovascular thrombectomy for acute ischemic stroke: a meta-analysis. JAMA. 314(17), 1832-43.
In article      View Article  PubMed
 
[7]  Boyt Schell, B and Scaffa, M. (2015). Willard & Spackman’s occupational therapy (12thed.). Baltimore, MD: Lippincott Williams & Wilkins.
In article      
 
[8]  Kisner C, Colby L. A, (2002). Therapeutic exercise: foundations and techniques. 4th ed. Philadelphia: FA Davis Company.
In article      PubMed
 
[9]  Broderick, J. (2016). Interventional management of stroke past, present and future. Retrieved from http://www.upmc.com/Services/stroke-institute/Documents/joseph-broderick.pdf.
In article      View Article
 
[10]  Rincon F S, Ghosh, S, Dey M, Maltenfort M, Vibbert J. (2012). Impact of acute lung injury and acute respiratory distress syndrome after traumatic brain injury in the United States, Neurosurgery, vol. 71, no. 4, pp. 795-803.
In article      View Article  PubMed
 
[11]  Adriana, C, LunardiI, I. C, Celso, R. F. and CarvalhoI. (2011). Postoperative chest physical therapy prevents respiratory complications in patients undergoing esophagectomy Brazilian Journal of Physical Therapy 2 (15).
In article      
 
[12]  Runa, S., A., (2015). the common secondary complications among the stroke patients at CPR, Bachelor of Science in Physiotherapy (B.Sc. PT) Roll No. 1586 Registration No. 1893 Session: 2010-2011 BHPI, CRP, Savar, Dhaka).
In article      
 
[13]  Yared, M, Guta, Z and Adamu, A. (2015). medical and neurological complications among stroke patients admitted for inpatient care in addis ababa, ethiopia, p10, Ethiop Med J, Vol. 53, No.1, INAL ARTICLE.
In article      
 
[14]  Finlayson, O, Kapral, M, Hall, R, Asllani, E, Selchen, D, Saposnik, G (2011). Risk factors, inpatient care, and outcomes of pneumonia after ischemic stroke. Neurology; 77(14): 1338-45.
In article      View Article  PubMed
 
[15]  Chen, C.M, Hsu, H.C, Tsai, W.S, Chang, C.H, Chen, K.H, Hong, C.Z (2012). Infections in acute older stroke in patients undergoing rehabilitation. Am J Phys Med Rehabil; 91(3): 211-9.
In article      View Article  PubMed
 
[16]  Gordon, C, Hewer, R. L, Wade, D. T. (1987). Dysphagia in acute stroke. Br. Med. J. (Clin Res. Ed), 295 (6595), 411-414.
In article      View Article
 
[17]  Jen-Wen, H, Tzong-Horng, T, Hsueh-Wen, C, Chau-Peng, L, Yiu-Chung, L (2005). Incidence and Risk Factors of Medical Complications during Inpatient Stroke Rehabilitation, Chang Gung Med J Vol. 28 No. 1.
In article      
 
[18]  Chumbler, N.R, Williams, L.S, Wells, C.K, Nadeau, S, Peixoto, A. J, (2010). Derivation and validation of a clinical system for predicting pneumonia in acute stroke. Neuroepidemiology. 34(4): 193-9.
In article      View Article  PubMed
 
[19]  Tishler, P.V, Larkin, E. K, Schluchter, M. D. (2003). .Incidence of sleep-disordered breathing in an urban adult population: the relative importance of risk factors in the development of sleep-disordered breathing. Journal of the American Medical Association, 289, 2230-2237.
In article      View Article  PubMed
 
[20]  Brogan, E, Langdon, C, Brookes, K, Budgeon, C, & Blacker, D. (2014). Respiratory infections in acute stroke: Nasogastric tubes and immobility are stronger predictors than dysphagia. Dysphagia, 29, 340-345.
In article      View Article  PubMed
 
[21]  Yaggi, H. K., Concat, J, Kernan, W. N. (2005). Obstructive sleep apnea as a risk factor for stroke and death. New England Journal of Medicine, 343, 2034-2041.
In article      View Article  PubMed
 
[22]  Sulter, G, Elting, J. w, Stewart, R, den Arend A, De Kayser J. (2000). Continuous pulse oximetery in acute hemiparetic stroke. J Neurol Sci; 179: 65-9.
In article      View Article
 
[23]  Mozaffarian, D,Benjamin, E. J, Arnett, D. K, Blaha, M. J and Cushman M.(2015). Heart disease and stroke statistics: report from the American Heart association. Circulation; 27; 131: e 29-322.
In article      
 
[24]  Elkins, M and Dentice, R. (2015). inspiratory muscle training facilitates weaning from mechanical ventilation among patients in the intensive care unite: asystemic review. J physiother. 61: 125-134.
In article      View Article  PubMed