Acupuncture and transcutaneous nerve stimulation in stroke rehabilitation: a randomized, controlled trial

BACKGROUND AND PURPOSE

In small trials with control groups that receive no intervention, acupuncture has been reported to improve functional outcome after stroke. We studied effects of acupuncture and transcutaneous electrical nerve stimulation on functional outcome and quality of life after stroke versus a control group that received subliminal electrostimulation.

METHODS

In a multicenter randomized controlled trial involving 7 university and district hospitals in Sweden, 150 patients with moderate or severe functional impairment were included. At days 5 to 10 after acute stroke, patients were randomized to 1 of 3 intervention groups: (a) acupuncture, including electroacupuncture; (b) sensory stimulation with high-intensity, low-frequency transcutaneous electrical nerve stimulation that induces muscle contractions; and (c) low-intensity (subliminal) high-frequency electrostimulation (control group). A total of 20 treatment sessions were performed over a 10-week period. Outcome variables included motor function, activities of daily living function, walking ability, social activities, and life satisfaction at 3-month and 1-year follow-up.

RESULTS

At baseline, patients in each group were closely similar in all important prognostic variables. At 3-month and 1-year follow-ups, no clinically important or statistically significant differences were observed between groups for any of the outcome variables. The 3 treatment modalities were all conducted without major adverse effects.

CONCLUSIONS

When compared with a control group that received subliminal electrostimulation, treatment during the subacute phase of stroke with acupuncture or transcutaneous electrical nerve stimulation with muscle contractions had no beneficial effects on functional outcome or life satisfaction.

Home rehabilitation after stroke. Reviewing the scientific evidence on effects and costs

OBJECTIVES

The question addressed here is whether home rehabilitation after stroke is better and/or less expensive than the more conventional alternatives, i.e., rehabilitation during inpatient care, day care, and outpatient visits--alone or in combinations appropriate to disease stage and patient needs. Home rehabilitation is managed by teams of professionals who train patients at home.

METHODS

The scientific literature was systematically searched for controlled studies comparing outcomes and costs of home rehabilitation with the more conventional strategies.

RESULTS

The abstracts of 204 papers were evaluated, from which 89 were selected for greater scrutiny. From the 89 studies, we found 7 controlled studies involving 1,487 patients (6 of the 7 were randomized, 4 of the 6 assessed costs). No statistically significant differences, or tendencies toward differences, were revealed as regards the outcome of home rehabilitation versus hospital-based alternatives. Thus, home rehabilitation was neither better nor worse at improving patients' ability to manage on their own or resume social activities. Depression and reduced quality of life were common in all groups of patients and caregivers, irrespective of the rehabilitation strategy. In the four randomized studies that reported on costs, home rehabilitation was found to be less expensive than regular day care, but not less expensive than conventional strategies even though hospital stay was reduced.

CONCLUSION

The outcomes and costs of home rehabilitation after stroke seem to be comparable to alternative treatment strategies.

Effectiveness of heparin treatment for progressing ischaemic stroke: before and after study

OBJECTIVES

During the acute phase of stroke, symptoms progress in 25% of patients, resulting in a worse outcome. Could heparin treatment improve the situation?

DESIGN

Before and after study. During the first period, no treatment was given to patients with progress of symptoms, whereas heparin was used regularly in the second period. A comparison of outcome was performed.

SETTING

Patients with acute stroke cared for in stroke units of two big emergency hospitals in Stockholm. Besides heparin treatment, the groups were taken care of according to the same basic principles.

SUBJECTS

Consecutive patients admitted to a stroke unit during two periods of time. The first study comprised 314 patients with ischaemic stroke and the second 907.

INTERVENTION

In the treatment period, patients with ischaemic stroke and objectively recognized progression received heparin infusion for at least 5 days.

MAIN OUTCOME MEASURES

Continued progression, length of stay, unaided walking at discharge, discharge destination and mortality.

RESULTS

The progression rate was non-significantly higher in the first period: 28 vs. 21%. One-third continued to progress regardless of treatment given. Patients with progression, treated and untreated alike, had 40% longer stay in the stroke unit compared with stable patients, whereas mortality was unaffected. Treatment did not reduce the proportion of patients who needed aid for walking at discharge (77 vs. 74%) or those who needed further institutionalized care (65 vs. 66%).

CONCLUSION

Progression of focal stroke symptoms still constitutes a serious clinical problem for which heparin has insufficient effectiveness in clinical practice. New therapies, ideally preventive, are needed.

Management of minor head injuries in emergency departments in Sweden. Time for a new strategy?

OBJECTIVE

To study how patients with minor head injuries are currently managed.

DESIGN

Questionnaire to senior residents in emergency departments and data from registers covering all in-hospital care in Sweden.

SETTING

All 92 emergency departments in Sweden.

RESULTS

The response rate to the questionnaire was 100%. In Sweden, 75 emergency departments treat patients with minor head injuries. Four departments are paediatric. General surgeons are the main providers (87%) of care for patients with minor head injuries. All hospitals admit patients with a history of unconsciousness or amnesia. Skull radiography is not used routinely. The estimated use of computed tomography (CT) varies between 2% and 80%, the mean being 22%. The need for CT, or the result thereof, is not the deciding factor for admission. In 1996, 16877 patients were treated as inpatients for minor head injuries, (191/100000 inhabitants). The admission rates varied widely among departments, and the total figures have been constant since 1987. The mean hospital stay was 1.6 days, so a large number of hospital days are consumed. The resources more than cover routine CT investigations for those seeking care, and hospital care for those with abnormal findings or special needs.

CONCLUSION

In Sweden, patients with minor head injuries are routinely admitted to hospital for observation. The estimated use of CT varies considerably. No clinics report using CT to triage patients for admission, a strategy that would be consistent with effectiveness and economic arguments.

How do stroke patients fare when discharged straight to their homes? A controlled study on the significance of hospital follow-up after one month

In our experience, stroke patients discharged straight to their homes sometimes showed marked deterioration. We investigated whether this negative course of events could be prevented by means of follow-up visits entailing extensive testing and resultant measures one month after discharge. The patients in our study included a selection of mild cases with a short length of hospital stay. Forty-six patients returned to the stroke unit on a follow-up visit, and 49 patients made up the control group. The groups were compared after 3 months, by means of questionnaires. The results did not show any definite difference between the groups. However, after 3 months we detected depressions in 13 patients in the study group and in 11 patients in the control group, most of them untreated. The study points to a need for follow-up aimed specifically at detecting depression.

Meta-analysis of increased dose of inhaled steroid or addition of salmeterol in symptomatic asthma (MIASMA)

OBJECTIVE

To examine the benefits of adding salmeterol compared with increasing dose of inhaled corticosteroids.

DESIGN

Systematic review of randomised, double blind clinical trials. Independent data extraction and validation with summary data from study reports and manuscripts. Fixed and random effects analyses.

SETTING

EMBASE, Medline, and GlaxoWellcome internal clinical study registers.

MAIN OUTCOME MEASURES

Efficacy and exacerbations.

RESULTS

Among 2055 trials of treatment with salmeterol, there were nine parallel group trials of >/=12 weeks with 3685 symptomatic patients aged >/=12 years taking inhaled steroid in primary or secondary care. Compared with response to increased steroids, in patients receiving salmeterol morning peak expiratory flow was greater at three months (difference 22.4 (95% confidence interval 15.0 to 30.0) litre/min, P<0.001) and six months (27.7 (19.0 to 36.4) litre/min, P<0.001). Forced expiratory volume in one second (FEV(1)) was also increased at three months (0.10 (0.04 to 0.16) litres, P<0.001) and six months (0.08 (0.02 to 0.14) litres, P<0.01), as were mean percentage of days and nights without symptoms (three months: days-12% (9% to 15%), nights-5% (3% to 7%); six months: days-15% (12% to 18%), nights-5% (3% to 7%); all P<0.001) and mean percentage of days and nights without need for rescue treatment (three months: days-17% (14% to 20%), nights-9% (7% to 11%); six months: days-20% (17 to 23%), nights-8% (6% to 11%); all P<0.001). Fewer patients experienced any exacerbation with salmeterol (difference 2.73% (0.43% to 5.04%), P=0. 02), and the proportion of patients with moderate or severe exacerbations was also lower (2.42% (0.24% to 4.60%), P=0.03).

CONCLUSIONS

Addition of salmeterol in symptomatic patients aged 12 and over on low to moderate doses of inhaled steroid gives improved lung function and increased number of days and nights without symptoms or need for rescue treatment with no increase in exacerbations of any severity.

[Sensitive quality indicators stimulate improvement of care]

For the past four years, 52 of the approximately 80 departments of medicine in Sweden have collected data on key indicators of quality of care with regards to acute myocardial infarction, stroke, anticoagulant treatment, and diabetes. The results are analysed centrally, each department being supplied with feedback in the form of overall results, and comparison of its own values with the respective means. Gradual general improvement has been discernible over time, though there is still room for improvement at some departments. There have been isolated instances of manifest changes in indicator values associated with major departmental reorganisation, probably reflecting real deterioration in quality of care. Thus, indicator monitoring would appear a sensitive means of promoting qualitative improvement.

[Computed tomography as an alternative to observation in brain concussion]

In Sweden, patients with minor head injury (i.e., history of loss of consciousness or posttraumatic amnesia) are routinely admitted for neurological observation. The article reports the results of a small study of current clinical practices at St Göran's Hospital in Stockholm, and briefly reviews published reports of different management strategies. The findings suggest that computed tomography scanning might constitute better management than routine hospitalisation, both medically and economically. However, further investigation from a Swedish perspective is needed before any evidence-based recommendations can be made.

[Home rehabilitation after stroke. Review of the literature]

To find an answer to the question whether domiciliary rehabilitation after stroke is better or cheaper than alternative forms of rehabilitation, a systematic literature review of controlled trials was performed. Three large and two smaller, more preliminary studies of all together a thousand patients were found and regarded methodologically acceptable. Efficacy as regards functional, emotional and qualitative outcome of patients was equivalent for various modes of care. So was the degree of stress, social function and quality of life for the main carers. Home treatment costed less than regular day care but more than routine care including a mixture of outpatient and day care, as considered required. Domiciliary rehabilitation seems to be a good and cost effective alternative for stroke patients who need and cannot manage frequent out-patients visits without ambulance or other exhausting and expensive transports.

Development and evaluation of evidence based risk assessment tool (STRATIFY) to predict which elderly inpatients will fall: case-control and cohort studies

OBJECTIVES

To identify clinical characteristics of elderly inpatients that predict their chance of falling (phase 1) and to use these characteristics to derive a risk assessment tool and to evaluate its power in predicting falls (phases 2 and 3).

DESIGN

Phase 1: a prospective case-control study. Phases 2 and 3: prospective evaluations of the derived risk assessment tool in predicting falls in two cohorts.

SETTING

Elderly care units of St Thomas's Hospital (phase 1 and 2) and Kent and Canterbury Hospital (phase 3).

SUBJECTS

Elderly hospital inpatients (aged > or = 65 years): 116 cases and 116 controls in phase 1,217 patients in phase 2, and 331 in phase 3.

MAIN OUTCOME MEASURES

21 separate clinical characteristics were assessed in phase 1, including the abbreviated mental test score, modified Barthel index, a transfer and mobility score obtained by combining the transfer and mobility sections of the Barthel index, and several nursing judgements.

RESULTS

In phase 1 five factors were independently associated with a higher risk of falls: fall as a presenting complaint (odds ratio 4.64 (95% confidence interval 2.59 to 8.33); a transfer and mobility score of 3 or 4 (2.10 (1.22 to 3.61)); and primary nurses' judgment that a patient was agitated (20.9 (9.62 to 45.62)), needed frequent toileting (2.48 (1.08 to 5.70)), and was visually impaired (3.56 (1.26 to 10.05)). A risk assessment score (range 0-5) was derived by scoring one point for each of these five factors. In phases 2 and 3 a risk assessment score > 2 was used to define high risk: the sensitivity and specificity of the score to predict falls during the following week was 93% and 88% respectively in phase 2 and 92% and 68% respectively in phase 3.

CONCLUSION

This simple risk assessment tool predicted with clinically useful sensitivity and specificity a high percentage of falls among elderly hospital inpatients.

Three new naphthyldihydroisoquinoline alkaloids from Ancistrocladus tectorius

Three new 5--1'-linked naphthyldihydroisoquinoline alkaloids (1-3) have been isolated from the organic extract of Ancistrocladus tectorius. The gross structures of the compounds have been established using 1D and 2D NMR spectroscopy and difference NOE experiments. The absolute stereochemistry of 1, 2, and 3 was determined from CD spectral comparison and chemical degradation. Evidence is presented to show that two of the compounds exist exclusively in the keto form at C-8 of the isoquinoline system (2b, 3b).

Validation of four scales for the acute stage of stroke

OBJECTIVES

To validate whether a simplified scale for the acute stage of stroke--the Scandinavian Stroke Supervision scale--is sufficient for monitoring symptom progression of prognostic importance.

DESIGN

The capacity of the scale was compared to that of the Mathew, Toronto and Fugl-Meyer stroke scales and the Barthel ADL index.

SETTING

The stroke unit of Danderyd Hospital, which cares for a defined population.

SUBJECTS

Fifty noncomatose patients with objectively recorded symptoms at entry were examined over a period of 5 days by one physician (250 ratings/scale). The last 10 patients were also investigated by another doctor in the same manner (50 ratings/scale) and by nurses (50 ratings) the Scandinavian scale only. The amount of time required by each scale was tested in another 10 patients by two nurses (100 ratings/scale).

INTERVENTIONS

Routine investigation and treatment.

MAIN OUTCOME MEASURES

The reliability, validity, time requirement and correlation of the scales were evaluated, as was their ability to reveal progress of symptoms.

RESULTS

All scales were highly significantly correlated. The interobserver agreement was excellent between the physicians but not as good between the physician and the nurses. The prediction of the outcome at discharge and after 3 months was very satisfactory for all of the scales with regard to the whole groups of patients, but none of them could predict the outcome for an individual with certainty. The Scandinavian Stroke Supervision scale was least time consuming, and had the fewest uncertainties expressed by the testers. This scale recorded the progression of slightly fewer symptoms, but did record those with a more serious impact on patient outcome.

CONCLUSION

The time-saving, simplified Scandinavian scale was as reliable and as valid as the other scales, and detected deterioration that was important for patient outcome as satisfactorily as the other scales.

The role of autopsies in medical audit: examples from a department of medicine

Autopsy findings from a representative sample of deaths in a clinic provide an opportunity for regular and systematic revision of medical diagnostics and treatment. A standardized analysis of the collected results can furnish useful figures for comparisons and follow-up. On this basis, new strategies for future improvement of medical care should be outlined. Autopsy results can also be used for medical audit concerning more limited items like the certification of death.