2. Comorbidities and complications

Safety and Stability of Pulmonary Function in Patients with Decreased Respiratory Function Treated for Spasticity with OnabotulinumtoxinA

Two randomized, placebo-controlled studies evaluated the pulmonary function safety of onabotulinumtoxinA (onabotA) for treatment of upper and/or lower limb spasticity. Patients with stable baseline respiratory status received one or two treatments with placebo, 240 U, or 360 U of onabotA. Pulmonary function tests, adverse events, and efficacy were measured at least every 6 weeks for 18 weeks (Study 1) or 30 weeks (Study 2). Study 1 enrolled 109 patients (n = 36–37/group) and Study 2 enrolled 155 patients (n = 48–54/group). Mean baseline forced vital capacity (FVC) was 76–78% of predicted per group in Study 1 and 71% of predicted per group in Study 2. In Study 1, change from baseline FVC values were significantly (p < 0.05) decreased vs. placebo at weeks 3 (240 U −57 mL vs. placebo +110 mL) and 12 (360 U −6 mL vs. +167 mL placebo). In Study 2, change from baseline FVC values were significantly decreased in the 360 U group vs. placebo at weeks 6 (−78 mL vs. +49 mL placebo), 13 (−60 mL vs. +119 mL placebo), 18 (−128 mL vs. +80 mL placebo), and 24 (−82 mL vs. +149 mL placebo). Individual pulmonary function-related adverse events were not correlated with PFT decreases. The most frequent pulmonary-related adverse events were nasopharyngitis (Study 1) and upper respiratory tract infection (Study 2). Ashworth scores were significantly improved at multiple time points in both studies. Injection of onabotA for spasticity in patients with decreased pulmonary function, at single and repeated doses of up to 360 U, was associated with small but statistically significant decreases in FVC or forced expiratory volume 1 s (FEV1) (>12% and 200 mL) that were subclinical and not correlated with any adverse clinical pulmonary events.

Comparative lung function performance of stroke survivors and age-matched and sex-matched controls

BACKGROUND AND PURPOSE

Reduced endurance and excessive fatigue in stroke survivors (SS) during exercise may be linked to impairment of lung function and breathing mechanics, but little is known about lung function of SS. The purpose of this study is to determine lung function (forced expiratory volume in 1 second [FEV1], forced vital capacity [FVC], FEV1 /FVC ratio and peak expiratory flow [PEF]) and influence of anthropometrics on lung function in SS compared with healthy controls (CG).

METHODS

In this case-control, cross-sectional study, we recruited 70 participants (42 males, 28 females), comprising 35 SS and 35 CG (range 34-73 years). Anthropometrics were measured using standard instruments and procedure. Chest excursion was measured at the axilla, xiphoid and lower costal levels. Lung function indices were measured using a micro-computerized spirometer. Ethical approval was obtained from the Ethics and Research Committee of Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria.

RESULTS/FINDINGS

Compared with the CG, the SS had significantly lower values for FEV1 (1.99 ± 0.66 vs. 2.36 ± 0.45 L, p = 0.004), FVC (2.55 ± 0.70 vs. 2.90 ± 0.54 L, p = 0.014), PEF (3.88 ± 1.38 vs. 5.24 ± 1.30 L second(-1) , p = 0.001) and chest excursion (3.0 ± 0.71 vs. 3.5 ± 0.91 cm, p = 0.018). Correlations between chest excursion, FEV1 , FVC and PEF were not significant (p > 0.05).

DISCUSSION

The weakness of respiratory muscles associated with stroke may have contributed to decreases in lung function observed. There was a significant reduction in chest excursion of SS compared with CG. Chest excursion has been used as an indicator of respiratory muscle function because the range of motion of the thorax serves the respiration. Movements of the thorax influence the content of the thorax cavity, leading to alterations in lung volumes.

IMPLICATIONS FOR PHYSIOTHERAPY PRACTICE

Stroke survivors have lower lung function when compared with CG; this has implications for clinicians in stroke rehabilitation, underscoring the importance for inclusion of interventions to improve lung function.

Inspiratory muscle training for the recovery of function after stroke

BACKGROUND

Inspiratory muscle weakness has been observed in patients with stroke. Inspiratory muscle training is an intervention that has shown possible effects for functional recovery of patients with stroke.

OBJECTIVES

To investigate the effect and safety of inspiratory muscle training for improving activities of daily living, respiratory muscle function, quality of life and cardiorespiratory fitness after stroke.

SEARCH METHODS

We searched the Cochrane Stroke Group's Trials Register (August 2011), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, October Issue 4), MEDLINE (1948 to October 2011), EMBASE (1974 to October 2011), CINAHL (1982 to October 2011), AMED (1985 to October 2011), PEDro (October 2011) and four Chinese databases. In an effort to identify further published, unpublished and ongoing trials, we searched ongoing trials registers and conference proceedings, checked reference lists, and contacted authors of relevant studies and training devices manufactures. There were no language restrictions.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing inspiratory muscle training with no intervention, sham inspiratory muscle training or other cardiorespiratory training for patients with stroke were eligible.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. The primary outcomes were activities of daily living and respiratory muscle strength; the secondary outcomes were quality of life, cardiorespiratory fitness and adverse effects.

MAIN RESULTS

We included two trials involving a total of 66 patients in this review. Pooling analyses of data was not possible due to considerable heterogeneity between the trials and a lack of data in both trials. One study found a significant increase in respiratory muscle strength favouring inspiratory muscle training over sham inspiratory muscle training, but there was no significant difference between groups on quality of life. The other study showed that patients receiving inspiratory muscle training were more likely to improve their activities of daily living, quality of life and cardiorespiratory fitness than those patients who received no intervention. However, the main results were not compared directly with breathing retraining. Furthermore, neither of the trials assessed the safety and tolerance of inspiratory muscle training.

AUTHORS' CONCLUSIONS

There is insufficient evidence to support inspiratory muscle training as an effective treatment to improve function after stroke, and no evidence relating to the safety of inspiratory muscle training. Further well-designed RCTs are required.

Respiratory muscle training improves cardiopulmonary function and exercise tolerance in subjects with subacute stroke: a randomized controlled trial

OBJECTIVE

To determine whether two types of exercise--breathing retraining (BRT) and inspiratory muscle training (IMT)--improve on cardiopulmonary functions and exercise tolerance in patients with stroke.

DESIGN

A randomized controlled trial.

SETTING

Education and research hospital.

SUBJECTS

Forty-five inpatients with stroke (24 men, 21 women) were recruited for the study. The subjects were randomized into three groups: 15 assigned to receive inspiratory muscle training (IMT); 15 assigned to received breathing retraining, diaphragmatic breathing and pursed-lips breathing (BRT); 15 assigned to a control group.

INTERVENTIONS

All study groups participated in a conventional stroke rehabilitation programme. For the same period, the IMT and BRT groups trained daily, six times a week, with each session consisting of one half-hour of training for six weeks.

MAIN MEASURES

Each subject underwent pulmonary function and cardiopulmonary exercise tests. Subjects were also assessed for exertional dyspnoea, stages of motor recovery, ambulation status, activity of daily living and quality of life.

RESULTS

After the training programme, the IMT group had significantly improved forced expiratory volume at 1 second (FEV(1)), forced vital capacity (FVC), vital capacity (VC), forced expiratory flow rate 25-75% (FEF 25-75%) and maximum voluntary ventilation (MVV) values compared with the BRT and control groups, although there were no significant differences between the BRT and control groups (P<0.01). Peak expiratory flow rate (PEF) value was increased significantly in the BTR group compared with the IMT and control groups. The IMT group also had significantly higher peak oxygen consumption (Vo(2peak)) than the BRT and control groups, although there were no significant differences between the BRT and control groups (P<0.001). There was a statistically significant increase in maximum inspiratory pressure (PI(max)) and maximum inspiratory and expiratory pressure (PE(max)) in the BRT group and, PI(max) in the IMT group compared with baseline and the control group. In the IMT group, this was associated with improvements in exercise capacity, sensation of dyspnoea and quality of life.

CONCLUSIONS

Significant short-term effects of the respiratory muscle training programme on respiratory muscle function, exercise capacity and quality of life were recorded in this study.

Stroke rehabilitation: indwelling urinary catheters, enteral feeding tubes, and tracheostomies are associated with resource use and functional outcomes

BACKGROUND AND PURPOSE

The aim of this study was to investigate the associations between tracheostomies, enteral feeding tubes, and indwelling urinary catheters and functional outcome measures, incidence of medical complications, and resource use in an inpatient stroke rehabilitation program.

METHODS

A cohort of 1553 patients consecutively admitted for inpatient stroke rehabilitation was studied. Demographic and stroke characteristics, impairment (National Institutes of Health Stroke Scale) and disability level (Functional Independence Measure [FIM]), preexisting medical conditions, and the presence of tracheostomies, enteral feeding tubes, and indwelling urinary catheters were recorded at admission. The occurrence of medical complications during rehabilitation, discharge disability level, length of rehabilitation stay, and rehabilitation hospital charges were recorded at discharge.

RESULTS

Compared with patients with no medical tubes, patients with 3 medical tubes had significantly higher National Institutes of Health Stroke Scale scores, lower admission and discharge FIM scores, reduced FIM efficiency scores (average FIM score change per day), and twice the number of medical complications. Patients with 3 medical tubes stayed 28 days longer in acute hospitalization and 20 days longer in rehabilitation compared with patients with no medical tubes. The presence of even a single medical tube was associated with longer length of stay, more medical complications during rehabilitation, and greater disability level at discharge.

CONCLUSIONS

The presence of > or =1 medical tubes is associated with more severe and disabling strokes, an increased number of medical complications, longer acute and rehabilitation hospitalizations, and greater resource use.

Incidence of and risk factors for medical complications during stroke rehabilitation

BACKGROUND AND PURPOSE

The aims of this study were to examine the frequency, types, and clinical factors associated with medical complications that occur during inpatient rehabilitation and to identify risk factors for complications that require a transfer to an acute care facility.

METHODS

A cohort of 1029 patients consecutively admitted for inpatient stroke rehabilitation was studied. Demographic and stroke information, impairment, preexisting medical conditions, and admission laboratory abnormalities were recorded. Medical complications, defined as new or exacerbated medical problems, were documented for each patient. Complications that required transfer off rehabilitation were noted. Univariate and multiple logistic regression analyses were used to determine factors that were associated with risk of medical complications and risk of transfer off rehabilitation.

RESULTS

Seventy-five percent of patients experienced >/=1 medical complication during rehabilitation. Significant factors for the development of any medical complication included greater neurological deficit (odds ratio [OR], 4.10; confidence interval [CI], 1.88 to 8.91), hypoalbuminemia (OR, 1.71; 95% CI, 1.15 to 2.52), and history of hypertension (OR, 1.81; 95% CI, 1.27 to 2.59). Nineteen percent of patients had a medical complication that required transfer to an acute care facility. Significant factors for transfers were elevated admission white blood cell counts (OR, 1.92; 95% CI, 1.32 to 2.79), low admission hemoglobin levels (OR, 1.89; 95% CI, 1.32 to 2.68), greater neurological deficit (OR, 2.46; 95% CI, 1.37 to 4.39), and a history of cardiac arrhythmia (OR, 1.79; 95% CI, 1.18 to 2.67).

CONCLUSIONS

Medical complications are common among patients undergoing stroke rehabilitation. A significant number of these medical complications may require a transfer to an acute facility.

Comorbidities in stroke patients as assessed with a newly developed comorbidity scale

We previously reported reliability and validity of our newly developed comorbidity scale (CS) for stroke outcome research based on a retrospective sample. The objectives of this study were to cross-validate the comorbidity scale in a new prospective sample and to investigate longitudinal changes of the comorbidity scale during hospitalization. In a prospective sample of 175 stroke patients admitted to five nonacute rehabilitation hospitals in Japan, we analyzed the frequency and grading of comorbidities and compared the comorbidity scale with demographic data, impairment as assessed with the Stroke Impairment Assessment Set (SIAS), and disability as measured with the Functional Independence Measure (FIM(SM)). The results were compared with our previous retrospective study. We also studied longitudinal changes by measuring the comorbidity scale on admission, 2 wk later, and at discharge of 67 patients. As a result, the comorbidity scaling was significantly lower in the prospective sample, and it increased at the second measurement and then plateaued. Among the comorbidities, hypertension ranked first, followed by shoulder pain, and diabetes mellitus. Similar to our previous retrospective study, the comorbidity scale correlated positively with age and length of stay and correlated negatively with the SIAS motor item scores and the FIM scores. In conclusion, the present study suggested concurrent and predictive validity of the comorbidity scale in a prospective sample as well and clarified the comorbidity characteristics of stroke inpatients.

State self-esteem following stroke

BACKGROUND AND PURPOSE

Physical rehabilitation after stroke is often highlighted in the absence of consideration of psychosocial factors. This study sought to determine the relationship between state self-esteem and functional independence in patients recovering from stroke.

METHODS

In a longitudinal study, data were collected from 152 stroke patients within 48 hours of admission to a rehabilitation hospital and at 2 weeks and 3 months after admission. The Modified Barthel Index was used to assess functional ability. Patients' current feelings of self-worth were assessed with use of the State Self-Esteem Scale. Additional variables included perceived social support, trait self-esteem, age, previous stroke, side of stroke, comorbidity, marital status, and gender.

RESULTS

State self-esteem was significantly correlated to functional independence. The results of linear stepwise regression analysis indicated that functional ability and state self-esteem at 2 weeks, as well as the presence of heart disease, were significant predictors (55%) of functional ability at 3 months. For those with a functional ability score of >/=81 on admission to the rehabilitation unit, state self-esteem and functional ability at 2 weeks as well as previous stroke explained 53% of the variance in functional ability at 3 months. When functional ability was </=80, baseline and 2-week functional ability, state self-esteem at 2 weeks, and age predicted 53% of the variance in functional ability at 3 months.

CONCLUSIONS

Functional ability at 2 weeks was a stronger predictor than baseline functional ability in this study. The level of state self-esteem was also a consistent factor in the prediction of functional outcome of patients after stroke.