Health status of individuals with mild stroke

Impact of first-ever mild stroke on participation at 3 and 6 month post-event: the TABASCO study

PURPOSE

This study focused on the relationships between cognition, participation and quality of life (QoL) among first-ever mild ischemic stroke patients 3 months post-event. We hypothesized that significant correlations exist between cognition, executive functions (EF), QoL and participation; and that EF and QoL will significantly contribute to participation beyond demographics and stroke severity at 3 and from 3 to 6 months post-stroke.

METHODS

A prospective cohort study, recruiting consecutive first-ever stroke patients from a large tertiary hospital. The inclusion criteria were first event, mild stroke (NIHSS ≤ 5), and no previous significant neurological or cognitive impairment. In addition to assessment every 6 month at the hospital, an assessment battery was administered at home 3 months post-stroke.

RESULTS

Participants showed mild to moderate difficulties in cognition and participation (n = 249). Low to moderate correlations were found between cognition and EF with participation (-0.380, p < 0.05; r = 0.460, p < 0.001, respectively); and cognition with QoL (r = 0.421, p < 0.001). EF and QoL contributed significantly to participation at 3 months (R(2) = 0.961) and in addition education at 6 months (R(2) = 0.701).

CONCLUSIONS

Participants after mild ischemic stroke experienced cognitive and EF difficulties that affect their participation and QoL. Further studies are needed of mild stroke survivors to enhance our understanding of the variables that affect participation.

IMPLICATIONS FOR REHABILITATION

The findings of the current study have significant implications for the participation of people after mild stroke in the community. Health care systems in general and rehabilitation programs, in particular, do not consider that these clients need rehabilitation as most of them perform basic daily functions independently. Thus, although cognitive and EF deficits are found in people following even mild stroke, but are not externally apparent, these impairments are mostly neglected by the health care system. Mild stroke has long-term effects in most cases and effect family members as well. The implications of the study's results, as well as those of other studies, emphasize the necessity of follow-up and rehabilitation efforts at home and in the community. These efforts should focus on re-enabling the individual to participate in previous activities as much as possible and on providing support for family members. The strength of this study lies in the large number of participants who were evaluated at home in their natural environments. Studies of this kind are rarely performed in the participants' real-life settings, thus the current study provides an important perspective on the participation of this population in the community.

Quality of life after lacunar stroke: the Secondary Prevention of Small Subcortical Strokes study

BACKGROUND

We sought to describe the course and predictors of quality of life (QOL) after lacunar stroke. We hypothesized that there is a decline in QOL after recovery from lacunar stroke.

METHODS

The Secondary Prevention of Small Subcortical Strokes is a clinical trial in lacunar stroke patients with annual assessments of QOL with the stroke-specific QOL score. The overall score was used and analyzed as a continuous variable (range 0-5). We fit linear mixed models to assess the trend in QOL over time, assuming linearity of time, and adjusted for demographics, medical risk factors, cognitive factors, and functional status in univariable and multivariable models.

RESULTS

Among 2870 participants, mean age was 63.4 years (SD 10.7), 63% were men, 51% White, 32% Hispanic, 36% had college education, 36% had diabetes, 89% had hypertension, and 10% had prior stroke. Mean poststroke Barthel Index (BI) score was 95.4 (assessed on average 6 months after stroke). In the final multivariable model, there was an average increase in QOL of .6% per year, and factors associated with decline in QOL over time included age (-.0003 per year, P < .0001), any college education (-.0013 per year, .01), prior stroke (-.004 per year, P < .0001), and BI (-.0002 per year, P < .0001).

CONCLUSIONS

In this clinical trial of lacunar stroke patients, there was a slight annual increase in QOL overall, and age, level of education, and prior stroke were associated with changes in QOL over time. Multiple strokes may cause decline in QOL over time in the absence of recurrent events.

Modern medical management of acute ischemic stroke

The modern management of patients with ischemic stroke begins by having a system in place that organizes the provision of preventive, acute treatment, and rehabilitative services. In the acute setting, initial evaluation is aimed at rapidly establishing a diagnosis by excluding stroke mimics, distinguishing between ischemic and hemorrhagic strokes, and determining if the patient is a candidate for treatment with intravenous tissue plasminogen activator (IV-tPA, alteplase). In some centers, select patients who do not qualify for administration of IV-tPA may be considered for endovascular intervention. General measures include the use of platelet antiaggregants, treatment of fever, blood pressure management, and continuation of statins if the patient has already been taking them. Post-acute evaluation and management is aimed at secondary prevention and optimizing recovery, including recognition and treatment of post-stroke depression.

Life changed existentially: a qualitative study of experiences at 6-8 months after mild stroke

PURPOSE

To explore experiences of mild-stroke survivors in the context of early supported discharge. The meanings patients attributed to activities and participation in the home recovery process were our main interest.

METHODS

Eight participants (45-80 years) from a randomised controlled study were selected for this sub-study. This purposive sample had received rehabilitation in their homes in the post-stroke acute phase of recovery as part of the larger study. Extensive interview data were analysed using an interpretive strategy and systematic text condensation. Coping theory was included in later stages of analysis.

FINDINGS

The mild-stroke survivors' stories revealed that life had changed profoundly. Differences and similarities in experienced changes were related to: self-perceived health, the body, practical activities, taking part in society, and self-perception. The findings showed the ways in which life changed for mild-stroke survivors, experienced challenges, and survivors' thoughts about the future.

CONCLUSIONS

Mild-stroke rehabilitation should focus more strongly on basic concerns related to self-perceived health, self-perception, and body, since these dimensions seem to complicate daily activities and close relationships. Professionals should also be aware of patients who experience an uncertain situation and unresolved rehabilitation needs, which still can be present 6-8 months after the stroke.

IMPLICATIONS FOR REHABILITATION

When living with mild stroke, entrance to practical and social activities seemed founded on the patients' perception of the body and self as comprehensible or not. Comprehending their own changed body and sense of self seem to be a long-term process when living with mild stroke. It is suggested that long-term follow-up be incorporated in home rehabilitation service, also in the context of early supported discharge. This may contribute to help patient cope more optimally with activities and participation of importance to them.

Response shift recalibration and reprioritization in health-related quality of life was identified prospectively in older men with and without stroke

OBJECTIVES

To prospectively consider evidence for response shift (RS) in health-related quality of life (HRQL) in older men who experienced stroke or remained stroke free. RS is a change in the meaning of self-evaluation; this includes recalibration, reprioritization, and reconceptualization.

STUDY DESIGN

A cohort of 3,983 male World War II Royal Canadian Air Force recruits has been followed since 1948. There were three prospectively determined groups: stroke survivors (n = 168; mean age, 80.1 years); older stroke-free group (n = 254; mean age, 82.8 years); and younger stroke-free group (n = 323; mean age, 74.7 years). The Short Form-36 (SF-36) was used to evaluate HRQL. Longitudinal structural equation models were developed using SF-36 subscales and three latent variables. Measurement invariance over two time points for each of the three groups was evaluated to identify RS.

RESULTS

All RS models had reasonable fit: stroke [root mean square error of approximation (RMSEA), 0.069; 90% confidence interval (CI): 0.052, 0.086], older (RMSEA, 0.055; 90% CI: 0.041, 0.068), and younger (RMSEA, 0.062; 90% CI: 0.051, 0.074). Recalibration of physical function occurred in all three groups. Reprioritization of role limitations due to physical health happened in both stroke-free groups.

CONCLUSION

This study is unique in our ability to prospectively identify RS recalibration and reprioritization in HRQL in aging men with stroke and remaining free of stroke. Changes in the meaning of self-evaluation of HRQL occur not only with stroke but also in men who remain free of stroke.

The Restore4Stroke self-management intervention 'Plan ahead!': rationale and description of the treatment protocol based on proactive action planning

OBJECTIVE

To describe the rationale behind and description of a group-based self-management intervention developed for stroke patients and their partners.

RATIONALE

Based on the assumption that proactive coping strategies are beneficial for the re-uptake of daily life by stroke patients and partners, we developed a new stroke-specific, group-based self-management intervention based on proactive action planning. A first concept of the treatment protocol was developed based on the proactive coping theory, the Health Action Process Approach model, existing interventions and expert consultations. Further adjustments were based on two pilot studies, including addition of solution-based therapeutic techniques.

DESCRIPTION OF THE INTERVENTION

'Plan ahead!' is a 10-week group-based self-management intervention, consisting of six 2-hour sessions in the first six weeks and a 2-hour booster session in the 10th week. It is offered in an outpatient setting by two rehabilitation professionals with experience in group counselling and working with stroke patients. It is provided to groups of four stroke patients living at home (stroke ≥2 months ago) and their partners. The main features are (1) proactive action planning as the main constituent, (2) stroke-specific elements and (3) considering partners as full participants.

DISCUSSION

This stroke-specific intervention is expected to increase the use of proactive action planning and thus improve the participation of stroke patients and their partners. It is innovative in its aim to change behaviour patterns of participants directly, teaching participants a general action planning strategy and considering partners as full participants with their own goals and opportunities.

Optimising outcome assessment to improve quality and efficiency of stroke trials

Substantial progress has been made in treatment of stroke and much of this has been driven by large scale, multi-centre, randomised controlled trials. Although stroke is a frequent cause of mortality, stroke-related disability and functional decline is of equal or greater concern to patients and carers. Thus, to prove efficacy of an intervention for stroke, we need robust methods of describing recovery. Various functional assessment scales are available, the tool recommended as trial end point by many specialist societies and regulatory authorities is the modified Rankin Scale (mRS). We will use the mRS as exemplar to discuss contemporary research around functional assessment for stroke trials, including recent work around structured assessments, assessor training and end point adjudication panels. We will present an overview and critique of these studies and give examples where strategies to improve mRS assessment are impacting on the quality of stroke clinical trials.

Patient-reported measures provide unique insights into motor function after stroke

BACKGROUND AND PURPOSE

Patient-reported outcome measures have been found useful in many disciplines but have received limited evaluation after stroke. The current study investigated the relationship that patient-reported measures have with standard impairment and disability scales after stroke.

METHODS

Patients with motor deficits after stroke were scored on standard assessments including the National Institutes of Health Stroke Scale, modified Rankin Scale, and Fugl-Meyer motor scale, and on 2 patient-reported measures, the hand function domain of the Stroke Impact Scale, which documents difficulty of hand motor usage, and the amount of use portion of the Motor Activity Log, which records amount of arm motor usage.

RESULTS

The 43 participants had mild disability (median modified Rankin Scale=2), moderate motor deficits (Fugl-Meyer motor scale=46 ± 22), and mild cognitive/language deficits. The 2 patient-reported outcome measures, Stroke Impact Scale and Motor Activity Log, were sensitive to the presence of arm motor deficits. Of 21 patients classified as having minimal or no impairment or disability by the National Institutes of Health Stroke Scale or modified Rankin Scale (score of 0-1), 15 (71%) reported difficulty with hand movements by the Stroke Impact Scale score or reduced arm use by the Motor Activity Log score. Furthermore, of 14 patients with a normal examination, 10 (71%) reported difficulty with hand movements or reduction in arm use.

CONCLUSIONS

Patient-reported measures were a unique source of insight into clinical status in the current population. Motor deficits were revealed in a majority of patients classified by standard scales as having minimal or no disability, and in a majority of patients classified as having no deficits.

Self-management: a systematic review of outcome measures adopted in self-management interventions for stroke

Purpose

To systematically review the psychometric properties of outcome measures used in stroke self-management interventions (SMIs) to (1) inform researchers, clinicians and commissioners about the properties of the measures in use and (2) make recommendations for the future development of self-management measurement in stroke.

Methods

Electronic databases, government websites, generic internet search engines and hand searches of reference lists. Abstracts were selected against inclusion criteria and retrieved for appraisal and systematically scored, using the COSMIN checklist.

Results

Thirteen studies of stroke self-management originating from six countries were identified. Forty-three different measures (mean 5.08/study, SD 2.19) were adopted to evaluate self-SMIs. No studies measured self-management as a discreet concept. Six (46%) studies included untested measures. Eleven (85%) studies included at least one measure without reported reliability and validity in stroke populations.

Conclusions

The use of outcome measures which are related, indirect or proxy indicators of self-management and that have questionable reliability and validity, contributes to an inability to sensitively evaluate the effectiveness of stroke self-SMIs. Further enquiry into how the concept of self-management in stroke operates, would help to clarify the nature and range of specific self-management activities to be targeted and aid the selection of existing appropriate measures or the development of new measures.

Income disparity and risk of death: the importance of health behaviors and other mediating factors

BACKGROUND

Income disparities in mortality are profound in the United States, but reasons for this remain largely unexplained. The objective of this study was to assess the effects of health behaviors, and other mediating pathways, separately and simultaneously, including health insurance, health status, and inflammation, in the association between income and mortality.

METHODS

This study used data from 9925 individuals aged 20 years or older who participated in the 1999-2004 National Health and Nutrition Examination Survey (NHANES) and were followed up through December 31, 2006 for mortality. The outcome measures were all-cause and CVD/diabetes mortality. During follow-up 505 persons died, including 196 deaths due to CVD or diabetes.

RESULTS

After adjusting for age, sex, education, and race/ethnicity, risk of death was higher in low-income than high-income group for both all-cause mortality (Hazard ratio [HR], 1.98; 95% confidence interval [CI]: 1.37, 2.85) and cardiovascular disease (CVD)/diabetes mortality (HR, 3.68; 95% CI: 1.64, 8.27). The combination of the four pathways attenuated 58% of the association between income and all-cause mortality and 35% of that of CVD/diabetes mortality. Health behaviors attenuated the risk of all-cause and CVD/diabetes mortality by 30% and 21%, respectively, in the low-income group. Health status attenuated 39% of all-cause mortality and 18% of CVD/diabetes mortality, whereas, health insurance and inflammation accounted for only a small portion of the income-associated mortality (≤6%).

CONCLUSION

Excess mortality associated with lower income can be largely accounted for by poor health status and unhealthy behaviors. Future studies should address behavioral modification, as well as possible strategies to improve health status in low-income people.

Post-stroke depression and functional independence: a conundrum

OBJECTIVES

People who suffer a stroke are at risk of developing post-stroke depression (PSD). Not only does this lower their quality of life but it also increases their risk of another stroke or death. This study aimed to investigate the factors associated with PSD in order to better direct rehabilitation efforts aimed at cutting the incidence of PSD.

MATERIAL AND METHODS

This study was based on all patients admitted to the stroke unit of a hospital in southern Sweden from 1 October 2003 to 30 November 2005. The total number of patients involved was 181. Measures were collected at 2 ± 1 weeks after discharge from hospital, 3 ± 0.5 months after the occurrence of the stroke and 12 ± 1 months after the occurrence of the stroke. Information collected was results from the Center of Epidemiologic Studies Depression Scale and the Barthel Index together with demographic data including age, sex, time since stroke and relationship status.

RESULTS

Those patients involved in the study were mainly men (58-59%) and generally those either married or cohabiting (53-57%). The age of respondents ranged from 32 to 92 years with a mean age of 74.0 (95%CI 72.37-75.63) at 2 ± 1 weeks after discharge. The Barthel Index scores ranged from 15 to 100 with means of between 88.7 and 91.7. Between 15% and 19% of the group were clinically depressed during the time frame of the study. The Barthel Index, measuring functional independence in terms of need for assistance with personal activities of daily living (P-ADL), was consistently associated with PSD.

CONCLUSIONS

The differences found in levels of depression between those with lower functional independence after a stroke compared to those more independent in P-ADL, raise the possibility that attention should be paid to therapeutic rehabilitation for stroke patients to help them recover as much functional independence as possible in order to improve their quality of life and lower their chances of developing PSD.

Rasch validation and predictive validity of the action research arm test in patients receiving stroke rehabilitation

OBJECTIVE

To validate the internal construct and predictive validity of the Action Research Arm Test (ARAT).

DESIGN

Secondary study.

SETTING

Seven medical centers.

PARTICIPANTS

Patients with stroke (N=191).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

The internal construct validity of the ARAT score at pretreatment was examined using Rasch analysis. The predictive validity was examined by the correlations between performance on the ARAT before treatment and scores on the Wolf Motor Function Test, the Motor Activity Log, and the Stroke Impact Scale after treatment.

RESULTS

The 4-point ARAT scale had a disordered rating scale structure. Further Rasch modeling suggested revising the original 4-point scale into a 3-point scale. The 19 items measured 1 construct. The item difficulty hierarchy indicated that excluding the gross subtest, a score of 3 on the first item of any other subtest indicated the highest motor ability, and a score of 1 (the revised lowest rating) on the second item indicated the lowest motor ability. Tasks of "place hand behind head" and "place hand on top of head" showed poor item fit and item bias relevant to participants' ages. The ARAT items can reliably separate participants into 5.44 strata. Moderate to good correlations indicated good predictive validity.

CONCLUSIONS

The ARAT possesses good psychometric properties in stroke patients with mild to moderate motor severity and without severe cognitive impairment, and has evidence of unidimensionality, predictive validity, and reliability. The revised 3-point rating scale is recommended when the ARAT is administered on this population. The "place hand behind head" and "place hand on top of head" tasks misfit the Rasch model's expectations. Future studies are needed in the use of the ARAT on stroke patients with different levels of motor severity or with cognitive impairment.

Implementation of a stroke self-management program: A randomized controlled pilot study of veterans with stroke

Secondary stroke prevention is championed as guideline care; yet there are no systematic programs offered. We developed a stroke self-management program to address this gap and pilot test the program. We conducted a randomized controlled trial at two Veterans Administration (VA) hospital sites where we recruited patients with an acute stroke to receive either the stroke program or an attention-control protocol over a 12-week period following hospital discharge. The stroke program included six sessions that facilitated stroke self management focusing on increasing self-efficacy to recover from stroke and engage in secondary stroke risk factor management. We surveyed outcomes at baseline, 3 and 6 months. We conducted an intention to treat analysis comparing the intervention to the control group on changes of outcomes between baseline and follow-up modeled by a linear model with fixed effects for treatment, visit, and the treatment by visit interaction adjusting for baseline. We recruited 63 participants (33 control and 30 intervention) who were hospitalized with a primary diagnosis of ischemic stroke. We found trends in differences between groups on self-efficacy to communicate with physicians, weekly minutes spent in aerobic exercise, and on dimensions of stroke-specific quality of life. This pilot study demonstrated the feasibility of delivering a stroke self-management program to recent stroke survivors in a healthcare organization. The program also demonstrated improvements in patient self-efficacy, self-management behaviors, specific dimensions of stroke-specific quality of life compared to a group that received an attention placebo program.

Successful treatment of long-term, poststroke, upper-limb spasticity with onabotulinumtoxinA

BACKGROUND AND PURPOSE

Poststroke spasticity often negatively affects functional activities and daily living and frequently is accompanied by pain, abnormal limb postures, and contractures. The purpose of this case report is to describe the long-term benefit of botulinum toxin A in a patient with poststroke spasticity.

CASE DESCRIPTION

A 35-year-old woman with poststroke upper-limb spasticity who had lost function in her left hand was treated with onabotulinumtoxinA and physical therapy. Over 25 months, the patient received a physical therapy and occupational therapy program and received onabotulinumtoxinA injections into muscles of the left hand and arm, significantly reducing tone and facilitating recovery of function. Practical assessments, the Ashworth Scale, and electrophysiology were used to measure changes over time. No functional scales or dexterity scales were used to measure changes.

OUTCOMES

OnabotulinumtoxinA injections were discontinued when treatment goals were attained, and no further improvements were achieved. After more than 2½ years without further onabotulinumtoxinA treatments, the patient maintained range of motion and some functional use and dexterity in her left hand.

DISCUSSION

This case report illustrates the efficacy and long-term benefit of onabotulinumtoxinA, combined with physical therapy and occupational therapy, in the successful treatment of poststroke spasticity.

People's experiences of the impact of transient ischaemic attack and its consequences: qualitative study

AIM

This paper is a report of a study of how people's experiences of transient ischaemic attack affect their perception of their health and their uptake of health maintenance measures.

BACKGROUND

Transient ischaemic attack is a well-recognized warning sign of subsequent stroke, but early diagnosis and management of risk factors can substantially reduce this risk. Even though the physical effects of a transient ischaemic attack are transient, it is known to negatively affect quality of life. However, no qualitative studies have explored the impact of transient ischaemic attack on people's everyday lives.

METHODS

Sixteen participants were recruited from a vascular surgery clinic in a district general hospital in North West England. All had a recent transient ischaemic attack. A qualitative grounded theory study using detailed interviews (n = 21) was conducted.

FINDINGS

Participants experienced conflict between acknowledgement of the transient ischaemic attack as a significant illness episode with implications for their long-term health, and denial of its seriousness. Although they often ignored the initial signs, participants also experienced fear due to increased awareness of their risk of stroke. Often, they believed that they were having a permanent stroke. Many participants were prompted to seek medical advice by a family member or acquaintance. Having a transient ischaemic attack negatively changed their perception of their health and their quality of life, but some also viewed it as a positive event that had warned of their stroke risk and enabled them to take up health maintenance measures.

CONCLUSIONS

Having a transient ischaemic attack permanently changes people's quality of life and their perception of their health, despite the transience of the symptoms. The ability of people to make positive health changes after a transient ischaemic attack to some extent ameliorates the negative effects of being aware of their heightened stroke risk. Their appreciation of their quality of life may also be enhanced. The transience of the symptoms and lack of knowledge of transient ischaemic attacks lead to delays in seeking medical advice.

A pilot study to assess use of passive extension bias to facilitate finger movement for repetitive task practice after stroke

BACKGROUND AND PURPOSE

The purpose of this study was to investigate whether active range of finger motion could be increased through the introduction of passive, external extension joint torques in stroke survivors.

PARTICIPANTS

Five chronic stroke survivors with severe hand impairment resulting from hemiparesis took part in the study.

METHOD

Participants completed 2 experimental sessions in which hand movement and function were assessed. In one session, they wore a custom orthotic glove (X-Glove) that passively supplied extension torques to the joints of the fingers. In the second session, they performed the same tasks as in the other session, but without the glove. Outcome measures consisted of active range of motion, distance of the fingertip from the hand, selected tasks from the Graded Wolf Motor Function Test (GWMFT), and the Box and Blocks (BB) test. Primary results with and without the glove were compared using paired t tests with a Bonferroni correction.

RESULTS

Active range of motion improved significantly by over 50%, from 4.4 cm to 6.7 cm, when the X-Glove was worn (P = .011). The distance of the fingertip from the metacarpophalangeal joint increased by an average of 2.2 cm for 4 of the subjects, although this change was not significant across all 5 subjects (P = .123). No significant differences were observed in the BB or GWMFT whether the X-Glove was worn or not.

DISCUSSION AND CONCLUSION

Introduction of passive extension torque can improve active range of motion for the fingers, even in chronic stroke survivors with substantial hand impairment. The increased range of motion would facilitate therapeutic training of the hand, potentially even in the home environment, although the bulk of the orthosis should be minimized to facilitate interactions with real objects.

Intravenous tissue plasminogen activator for patients with minor ischemic stroke

BACKGROUND

Patients with minor ischemic stroke (MIS) are frequently excluded from thrombolytic therapy. Denial of therapy to these patients, however, remains controversial. We compared outcomes in patients with MIS who received intravenous (IV) tissue plasminogen activator (t-PA) with those who were not treated.

METHODS

We selected adult patients with stroke onset within 3 hours from a prospectively collected stroke registry. MIS was defined as an admission National Institutes of Health Stroke Scale (NIHSS) score ≤ 5. The primary outcome was a 90-day modified Rankin scale (mRS) score of 0 to 1. Secondary outcomes were a Barthel index (BI) score ≥ 95 at 90 days, symptomatic intracranial hemorrhage (SICH), and death. Multivariable logistic regression was performed to determine the association between outcomes adjusting for age, history of diabetes, and NIHSS score at admission. Reasons for t-PA exclusion were obtained.

RESULTS

We identified 133 patients with MIS; 59 patients received IV t-PA. The NIHSS score (mean ± SD) at admission was higher in the t-PA treated group (3.4 ± 1.4 v 1.9 ± 1.3 in the untreated group; P < .0001). Other baseline characteristics were not significantly different between the 2 groups. At 90 days, 57.6% of patients in the t-PA group and 68.9% of patients in the untreated group had a mRS score of 0 to 1 (odds ratio [OR] 0.93, 95% confidence interval [CI] 0.39-2.2; P = .87). A BI score of 95 to 100 was achieved in 75% of patients in the IV t-PA group versus 78.9% in the untreated group (OR 1.18, 95% CI 0.43-3.23; P = .74). There were 3 deaths (5.1%) in the IV t-PA group and 3 deaths (4.1%) in the control group.

CONCLUSIONS

In our sample, patients with MIS treated with IV t-PA have similar outcomes as patients not receiving thrombolysis. A randomized trial or larger observational study is needed confirm or reject these findings.

Predicting length of stay in patients admitted to stroke rehabilitation with high levels of functional independence

PURPOSE

In Ontario, stroke patients with relatively mild functional deficits are admitted to inpatient rehabilitation programmes. Despite apparently minor impairments, many of these patients remain in rehabilitation for prolonged periods of time. The objective of the present study is to identify variables that predict length of stay (LOS) within this population of high functioning stroke patients.

METHODS

Stroke patients with Functional Independence Measure (FIM™) scores ≥100 admitted to a specialised inpatient rehabilitation programme in Ontario, Canada, from April 2005 to March 2008 were included in this study. Data from the National Rehabilitation Reporting System and chart review were used. Associations with LOS were examined among 25 potential predictor variables using bivariate correlations. Significantly correlated (p <0.002) variables were entered into a multiple linear regression.

RESULTS

Twenty-four percent (n = 134) of patients admitted during the study period were identified as presenting with mild functional deficits. These patients had a mean admission age of 63.5 (SD 14.6) years, a mean admission FIM score of 109.9 (SD 6.6) and a mean LOS of 22.3 (SD 10.5) days. FIM motor and cognitive subscale scores, Mini Mental State Exam scores and five single items assessing orientation, financial independence, and verbal, written and auditory communication ability were significantly correlated with LOS. The regression model, which included all eight variables, explained 60% of the variance associated with LOS (r = 0.80).

CONCLUSIONS

For patients admitted to stroke rehabilitation programmes with mild functional impairment, 60% of the variance in LOS can be explained by a small number of variables indicative of deficits in the areas of motor function, cognition and communication.

Chronometry of mentally versus physically practiced tasks in people with stroke

OBJECTIVE

The purpose of this study was to determine whether chronometry is appropriate for monitoring engagement in mental practice by comparing the time taken for people with chronic stroke to mentally and physically practice five tasks.

METHOD

Eighteen stroke participants mentally and physically rehearsed each task. Time was recorded for each of the three trials per task.

RESULTS

Participants required significantly more time to physically practice than to mentally practice tasks (all p < .05). A significantly greater amount of time for mental practice of the more-affected arm than for the less-affected arm was also observed (p < .01).

CONCLUSION

Because there was no agreement between the time taken to mentally and physically practice the tasks, chronometry does not appear to be valid for monitoring mental practice in this population.

Factors associated with health-related quality of life for adults with stroke sequelae

OBJECTIVE: To assess health-related quality of life (HRQoL) among adults with stroke sequelae and to identify the factors that influenced the domains of HRQoL. METHOD: The subjects were adults with stroke who were admitted to a rehabilitation program between March and August 2008. They were investigated using the following instruments: Medical Outcomes 36-Item Short-Form Health Survey (SF-36), Functional Independence Measure (FIM) and Beck Depression Inventory (BDI). Sixty-four adults of mean age 58.8 years were evaluated. RESULTS: The individuals who had had their injuries for longer times and who were more independent and younger had better HRQoL regarding physical functioning. Social participation was associated with better HRQoL, and there was a difference between groups with and without depressive symptoms. CONCLUSION: HRQoL was compromised primarily with regard to functional characteristics. Moreover, the presence of depressive symptoms contributed towards a decline in HRQoL. Rehabilitation needs to focus on improving functionality and social participation, which may stimulate reductions in depressive symptoms and improvement of HRQoL.

Confirmatory factor analysis of the validity of the SF-12 for persons with and without a history of stroke

PURPOSE

To assess the validity of the Physical and Mental Component Summary scores (PCS and MCS) of the 12-item Short-Form Health Survey (SF-12), a measure of health-related quality of life (HRQoL), among persons with a history of stroke.

METHODS

Persons with (n = 2,581) and without (n = 38,066) a reported history of stroke were enrolled in the REasons for Geographic And Racial Differences in Stroke (REGARDS) study. Confirmatory factor analysis methods were used to evaluate the fit of a 2-factor model that underlies the PCS and MCS and to examine the equivalence of the factors across both study groups.

RESULTS

The 2-factor model provided good fit to the data among individuals with and those without a self-reported history of stroke. Item factor loadings were found to be largely invariant across both groups, and correlational analyses confirmed that the two latent factors were highly related to the PCS and MCS scores, calculated by the standard scoring algorithms. The effect of stroke history on physical health was more than twice its effect on mental health.

CONCLUSIONS

The psychometric measurement model that underlies the PCS and MCS summary scores is comparable between persons with and without a history of stroke. This suggests that the SF-12 has adequate validity for measuring HRQoL not only in the general population but also in cohorts following stroke.

Quality of life declines after first ischemic stroke. The Northern Manhattan Study

OBJECTIVES

Quality of life (QOL) after stroke is poorly characterized. We sought to determine long-term natural history and predictors of QOL among first ischemic stroke survivors without stroke recurrence or myocardial infarction (MI).

METHODS

In the population-based, multiethnic Northern Manhattan Study, QOL was prospectively assessed at 6 months and annually for 5 years using the Spitzer QOL index (QLI), a 10-point scale. Functional status was assessed using the Barthel Index (BI) at regular intervals, and cognition using the Mini-Mental State Examination at 1 year. Generalized estimating equations estimated the association between patient characteristics and repeated QOL measures over 5 years. Follow-up was censored at death, recurrent stroke, or MI.

RESULTS

There were 525 incident ischemic stroke patients >/=40 years (mean age 68.6 +/- 12.4 years). QLI declined after stroke (annual change -0.10, 95% confidence interval -0.17 to -0.04), after adjusting for age, sex, race-ethnicity, education, insurance, depressed mood, stroke severity, bladder continence, and stroke laterality. This decline remained when BI >/=95 was added to the model as a time-dependent covariate, and functional status also predicted QLI. Changes in QLI over time differed by insurance status (p for interaction = 0.0017), with a decline for those with Medicaid/no insurance (p < 0.0001) but not Medicare/private insurance (p = 0.98).

CONCLUSIONS

In this population-based study, QOL declined annually up to 5 years after stroke among survivors free of recurrence or MI and independently of other risk factors. QLI declined more among Medicaid patients and was associated with age, mood, stroke severity, urinary incontinence, functional status, cognition, and stroke laterality.

Symmetrical kinematic changes in highly functioning older patients post-stroke during obstacle-crossing

With the advances in stroke care, the number of high-functioning patients after stroke is increasing. However, existing clinical tools may not be sensitive enough to identify the residual deficits in these patients. The current study aimed to investigate the control of the pelvis, and the joints and end-point of the lower limbs in high-functioning older patients post-stroke during obstacle-crossing using motion analysis techniques. Twenty-four high-functioning older patients following unilateral stroke and fifteen healthy controls walked and crossed obstacles of three different heights. End-point variables (leading toe-clearance and trailing toe-obstacle distance) and crossing pelvic and joint angles were obtained for both limbs during leading limb crossing. Whether leading with the contralesional or ipsilesional limb, the stroke group exhibited significantly different joint kinematics from the controls mainly in the frontal and transverse planes, with greater leading toe-clearance, trailing toe-obstacle distance, and posterior pelvic tilt. None of the end-point and joint variables were significantly different between limbs. High-functioning patients post-stroke appeared to have acquired a specific symmetric kinematic strategy with increased leading toe-clearance during obstacle-crossing, most likely in order to prevent tripping. This symmetric strategy, possibly a consequence of brain reorganization, may help in performing functional activities during which symmetric performance between the contralesional and ipsilesional sides is required. Obstacle-crossing training with both limbs leading alternately may be helpful for the development of this symmetric strategy. It is suggested that computerized motion analysis of obstacle-crossing can be a sensitive assessment tool for distinguishing the motor performance between normal and high-functioning patients post-stroke.

Vision-related quality of life in first stroke patients with homonymous visual field defects

Background

To evaluate vision-related and health-related quality of life (VRQoL, HRQoL) in first stroke patients with homonymous visual field defects (VFD) with respect to the extent of the lesion. Since VFD occur in approximately 10% of stroke patients the main purpose of the study was to investigate the additional impact of VFD in stroke patients hypothesizing that VFD causes diminished VRQoL.

Methods

In 177 first stroke patients with persisting VFD 2.5 years after posterior-parietal lesions VRQoL was assessed by the National-Eye-Institute-Visual-Functioning-Questionnaire (NEI-VFQ) and HRQoL by the Medical-Outcome-Study Short-Form-36 Health-Survey (SF-36). Questionnaire results of VFD-patients were compared with age- and sex-matched healthy controls and with general non-selected stroke samples as published elsewhere. VFD-type and visual acuity were partially correlated with questionnaire results.

Results

Compared to healthy controls VFD-patients had lower NEI-VFQ scores except ocular pain (Z-range -11.34 to -3.35) and lower SF-36 scores except emotional role limitations (Z-range -7.21 to -3.34). VFD-patients were less impaired in SF-36 scores than general stroke patients one month post lesion (6/8 subscales) but had lower SF-36 scores compared to stroke patients six months post lesion (5/8 subscales). Visual acuity significantly correlated with NEI-VFQ scores (r-range 0.27 to 0.48) and VFD-type with SF-36 mental subscales (r-range -0.26 to -0.36).

Conclusions

VFD-patients showed substantial reductions of VRQoL and HRQoL compared to healthy normals, but better HRQoL compared to stroke patients one month post lesion. VFD-patients (although their lesion age was four times higher) had significantly lower HRQoL than a general stroke population at six months post-stroke. This indicates that the stroke-related subjective level of HRQoL impairment is significantly exacerbated by VFD. While VRQoL was primarily influenced by visual acuity, mental components of HRQoL were influenced by VFD-type with larger VFD being associated with more distress.

Study protocol of the YOU CALL--WE CALL TRIAL: impact of a multimodal support intervention after a "mild" stroke

Background

More than 60% of new strokes each year are "mild" in severity and this proportion is expected to rise in the years to come. Within our current health care system those with "mild" stroke are typically discharged home within days, without further referral to health or rehabilitation services other than advice to see their family physician. Those with mild stroke often have limited access to support from health professionals with stroke-specific knowledge who would typically provide critical information on topics such as secondary stroke prevention, community reintegration, medication counselling and problem solving with regard to specific concerns that arise. Isolation and lack of knowledge may lead to a worsening of health problems including stroke recurrence and unnecessary and costly health care utilization.

The purpose of this study is to assess the effectiveness, for individuals who experience a first "mild" stroke, of a sustainable, low cost, multimodal support intervention (comprising information, education and telephone support) - "WE CALL" compared to a passive intervention (providing the name and phone number of a resource person available if they feel the need to) - "YOU CALL", on two primary outcomes: unplanned-use of health services for negative events and quality of life.

Method/Design

We will recruit 384 adults who meet inclusion criteria for a first mild stroke across six Canadian sites. Baseline measures will be taken within the first month after stroke onset. Participants will be stratified according to comorbidity level and randomised to one of two groups: YOU CALL or WE CALL. Both interventions will be offered over a six months period. Primary outcomes include unplanned use of heath services for negative event (frequency calendar) and quality of life (EQ-5D and Quality of Life Index). Secondary outcomes include participation level (LIFE-H), depression (Beck Depression Inventory II) and use of health services for health promotion or prevention (frequency calendar). Blind assessors will gather data at mid-intervention, end of intervention and one year follow up.

Discussion

If effective, this multimodal intervention could be delivered in both urban and rural environments. For example, existing infrastructure such as regional stroke centers and existing secondary stroke prevention clinics, make this intervention, if effective, deliverable and sustainable.

Trial Registration

ISRCTN95662526

Measurement of the functional status of patients with different types of muscular dystrophy

Muscular dystrophy (MD) comprises a group of diseases characterized by progressive muscle weakness that induces functional deterioration. Clinical management requires the use of a well-designed scale to measure patients' functional status. This study aimed to investigate the quality of the functional scales used to assess patients with different types of MD. The Brooke scale and the Vignos scale were used to grade arm and leg function, respectively. The Barthel Index was used to evaluate the function of daily living activity. We performed tests to assess the acceptability of these scales. The characteristics of the different types of MD are discussed. This was a multicenter study and included patients diagnosed with Duchenne muscular dystrophy (DMD) (classified as severely progressive MD), Becker muscular dystrophy (BMD), limb girdle muscular dystrophy (LGMD) and facioscapulohumeral muscular dystrophy (FSHD). BMD, LGMD, and FSHD were classified as slowly progressive MD. The results demonstrated that the Brooke scale was acceptable for grading arm function in DMD, but was unable to discriminate between differing levels of severity in slowly progressive MD. The floor effect was large for all types of slowly progressive MD (range, 20.0-61.9), and was especially high for BMD. The floor effect was also large for BMD (23.8%) and FSHD (50.0%) using the Vignos scale. Grades 6-8 of the Vignos scale were inapplicable because they included items involving the use of long leg braces for walking or standing, and some patients did not use long leg braces. In the Barthel Index, a ceiling effect was prominent for slowly progressive MD (58.9%), while a floor effect existed for DMD (17.9%). Among the slowly progressive MDs, FSHD patients had the best level of functioning; they had better leg function and their daily living activities were less affected than patients with other forms of slowly progressive MD. The results of this study demonstrate the acceptability of the different applications used for measuring functional status in patients with different types of MD. Some of the limitations of these measures as applied to MD should be carefully considered, especially in patients with slowly progressive MD. We suggest that these applications be used in combination with other measures, or that a complicated instrument capable of evaluating the various levels of functional status be used.

A qualitative study of the consequences of 'hidden dysfunctions' one year after a mild stroke in persons <?75 years

BACKGROUND AND PURPOSE

Increased mental fatiguability, concentration and memory difficulties, irritability, emotional instability, impaired stress tolerance, and sound and light sensitivity, in this paper operationalized through the astheno-emotional syndrome (AE syndrome) are known consequences of stroke. The aim of this study was to explore how persons with AE syndrome, one year after a mild stroke, experienced the consequences of the syndrome in everyday life.

METHOD

A qualitative design was used. Fifteen respondents were chosen by strategic sampling and interviewed. The analysis was done using a grounded theory method.

RESULTS

Data analysis yielded harmed/threatened self as the core category with four main categories covering the dimensions of: hidden-apparent dysfunction, predictability-unpredictability, independence-dependence and active life-passive life. The model grounded in data shows the structural properties and the processes that verify the dynamics and interactions of the everyday life consequences of AE syndrome.

CONCLUSIONS

AE syndrome with mental fatiguability as the most common symptom affected many dimensions of everyday life, which in turn affected performance of activities and independence. The symptoms were 'hidden' in many ways, not only indetectable in the appearance of the person, but also on a more symbolic level not apparent to the patient and persons in their environment. The symptoms changed with environmental circumstances and were experienced as unpredictable.

Issues for selection of outcome measures in stroke rehabilitation: ICF activity

PURPOSE

To evaluate the psychometric and administrative properties of outcome measures in the WHO International Classification of Functioning, Disability and Health (ICF) Activity category used in stroke rehabilitation research and reported in the published literature.

METHOD

Critical review and synthesis of measurement properties for nine commonly reported instruments in the stroke rehabilitation literature. Each instrument was rated using the eight evaluation criteria proposed by the UK Health Technology Assessment (HTA) programme. The instruments were also assessed for the rigour with which their reliability, validity and responsiveness were reported in the published literature.

RESULTS

The reporting of specific measurement qualities for outcome instruments was relatively consistent across measures located within the same general ICF category. There was evidence to suggest that the measures were responsive to change as well as being valid and reliable tools. The best available instruments were associated with the assessment of activities of daily living, balance (static and dynamic), functional independence, and functional mobility.

CONCLUSIONS

Given the diversity that exists among available measures, the reader is encouraged to examine carefully the nature and scope of outcome measurement used in reporting the strength of evidence for improved functional activity in stroke rehabilitation. However, there appears to be good consensus regarding the most important indicators of successful rehabilitation outcome, especially in the case of functional mobility.

Experiences of male patients and wife-caregivers in the first year post-discharge following minor stroke: a descriptive qualitative study

BACKGROUND

Most patients with minor stroke are discharged directly home from acute care, under the assumption that little will be required in the way of adaptation and adjustment because informal caregivers will manage the stroke recovery process. We explored male patients with minor stroke and their wife-caregivers' perceptions of factors affecting quality of life and caregiver strain encountered during the first year post-discharge.

METHODS

Data were obtained from responses to two open-ended questions, part of quality of life and caregiver strain scales administered to participants in a larger descriptive study. Conventional content analysis was used to assess narrative accounts of living with minor stroke provided by 26 male patients and their wife-caregivers over a period of 1-year post-discharge.

RESULTS

Two major themes that emerged from these data were 'being vulnerable' and 'realization'. Subthemes that arose within the vulnerability theme included changes to patients' masculine image and wife-caregivers' assumption of a hyper-vigilance role. In terms of 'realization' patients and their wife-caregivers shared 'loss' as well as 'changing self and relationships'. Patients in this study focused primarily on their physical recovery and their perceptions of necessary changes. Wife-caregivers were actively involved in managing the day-to-day demands that stroke placed on individual, family and social roles.

CONCLUSIONS

We conclude that patients and wife-caregivers expend considerable time and energy reestablishing control of their lives following minor stroke in an attempt to incorporate changes to self and their relationship into the fabric of their lives.

Effects of rehabilitation on quality of life in patients with chronic stroke

PRIMARY OBJECTIVE

To evaluate the effects of rehabilitation on disability and quality of life (QoL) in patients with chronic stroke.

RESEARCH DESIGN

This is an observational, prospective and multidimensional study.

METHODS AND PROCEDURES

Sixty-six consecutive inpatients were enrolled. A rehabilitation programme of 2 months consisting of six exercise periods per week was performed. An impairment of cognitive function was the exclusion criteria for patient enrolment.

MAIN OUTCOMES AND RESULTS

European Stroke Scale, Barthel Index, Modified Rankin Scale, Deambulation Index and SF-36 were performed both before and after rehabilitation. A short-term follow-up (2 months after discharge) was performed by phone administration of SF-36. Significant improvement in clinical and disability measurements was observed after rehabilitation. For QoL, a significant improvement was observed both in physical function and in social function immediately after rehabilitation. At follow-up the social function improvement was maintained, while physical function improvement was lost.

CONCLUSIONS

The data show that rehabilitation in patients with chronic stroke lessens disability and improves physical and social function and that repeated cycles of treatment are needed to maintain the level of improvement reached.

Health-related quality of life in elderly patients with familial hypercholesterolemia

Objectives:There are very few descriptions on how familial hypercholesterolemia (FH), a genetic disorder with an increased risk of coronary heart disease (CHD), affects older patients. The aim of this study was to analyze the health-related quality of life (HRQoL) of elderly patients with FH.

Methods:All FH patients with the same FH North Karelia-mutation aged 65 and over living in North Karelia province in Eastern Finland were asked to participate in the study in 2003. They were compared with age-standardized controls from the Finnish general population. A total of forty-three elderly FH patients were identified and thirty-seven of them (aged 65 to 84 years, M/F 10/27) agreed to participate. Most of them (27/37) had been diagnosed with CHD. All but one of these FH patients had been using statins for approximately 15 years. HRQoL was assessed with the RAND-36 (SF-36) and 15D instruments.

Results:Despite the clear cardiovascular morbidity and low socioeconomic status, these FH patients enjoyed a similar HRQoL as the age-standardized controls in the general population.

Conclusions:Lifelong hypercholesterolemia was not associated with poorer HRQoL in elderly survivors of FH. These elderly FH individuals were characterized by their healthy lifestyle and long-term statin treatment.

A four-week, task-specific neuroprosthesis program for a person with no active wrist or finger movement because of chronic stroke

BACKGROUND AND PURPOSE

This case report describes a task-specific training protocol incorporating functional electrical stimulation for a person who had chronic stroke and who initially exhibited no active wrist or finger movement.

CASE DESCRIPTION

A 63-year-old man with hemiparesis caused by an ischemic stroke 7 years before the intervention described here received task-specific training incorporating an electrical stimulation neuroprosthesis 3 hours per day, 5 days per week, for 4 weeks. Testing was conducted before and after the intervention and again 6 weeks later with stroke-specific outcome measures.

OUTCOMES

Increases in function and quality of life were observed after the intervention.

DISCUSSION

An intervention incorporating task-specific training with functional electrical stimulation appears to have increased function and quality of life in a person with chronic stroke. This type of intervention might provide a pathway by which people with similar impairments would become eligible for more advanced treatment regimens, such as modified constraint-induced therapy.

Determinants of change in quality of life from 1 to 6 months following acute stroke

BACKGROUND AND PURPOSE

Little information is available about change in health-related quality of life (HRQoL) during the first few months following acute stroke, and whether baseline variables can predict who will have the largest improvement in HRQoL. This study assessed the change in HRQoL from 1 to 6 months following acute stroke and the determinants of these changes.

METHODS

Patients >60 years of age, who had experienced an acute stroke and were admitted to hospital within 24 h of onset, were followed longitudinally. HRQoL was assessed with the Short Form 36 (SF-36) health status questionnaire.

RESULTS

Of 550 eligible stroke patients, 315 fulfilled the inclusion criteria and were alive after 30 days. At 1 month, 179 patients responded to the questionnaire, of whom also 140 responded at 6 months following acute stroke. From 1 to 6 months following stroke, all dimensions of the SF-36 improved. The magnitude of change was largest on the role-physical and role-emotional scales and lowest on the bodily pain and mental health scales. Higher physical component summary (PCS) score at 1 month was associated with lower odds of being above the 75th percentile of change in PCS score between the assessments, and higher baseline mental component summary (MCS) score was associated with lower odds of being above the 75th percentile of change in MCS. Treatment in a stroke unit was associated with an increase in the MCS score and higher neurological score with an increase in PCS score of the SF-36.

CONCLUSION

This prospective study showed a considerable improvement in HRQoL from 1 to 6 months after stroke; however, no baseline variables except baseline scores were associated with changes in HRQoL during the 5-month period.

Protocol for the Locomotor Experience Applied Post-stroke (LEAPS) trial: a randomized controlled trial

BACKGROUND

Locomotor training using body weight support and a treadmill as a therapeutic modality for rehabilitation of walking post-stroke is being rapidly adopted into clinical practice. There is an urgent need for a well-designed trial to determine the effectiveness of this intervention. The objective of the Locomotor Experience Applied Post-Stroke (LEAPS) trial is to determine if there is a difference in the proportion of participants who recover walking ability at one year post-stroke when randomized to a specialized locomotor training program (LTP), conducted at 2- or 6-months post-stroke, or those randomized to a home based non-specific, low intensity exercise intervention (HEP) provided 2 months post-stroke. We will determine if the timing of LTP delivery affects gait speed at 1 year and whether initial impairment severity interacts with the timing of LTP. The effect of number of treatment sessions will be determined by changes in gait speed taken pre-treatment and post-12, -24, and -36 sessions.

METHODS/DESIGN

We will recruit 400 adults with moderate or severe walking limitations within 30 days of stroke onset. At two months post stroke, participants are stratified by locomotor impairment severity as determined by overground walking speed and randomly assigned to one of three groups: (a) LTP-Early; (b) LTP-Late or (c) Home Exercise Program -Early. The LTP program includes body weight support on a treadmill and overground training. The LTP and HEP interventions are delivered for 36 sessions over 12 weeks. Primary outcome measure include successful walking recovery defined as the achievement of a 0.4 m/s gait speed or greater by persons with initial severe gait impairment or the achievement of a 0.8 m/s gait speed or greater by persons with initial moderate gait impairment.LEAPS is powered to detect a 20% difference in the proportion of participants achieving successful locomotor recovery between the LTP groups and the HEP group, and a 0.1 m/s mean difference in gait speed change between the two LTP groups.

DISCUSSION

The goal of this single-blinded, phase III randomized clinical trial is to provide evidence to guide post-stroke walking recovery programs.

TRIAL REGISTRATION

NCT00243919.