Incidence, circonstances et conséquences des chutes chez les patients en rééducation après un premier accident vasculaire cérébral

Ottawa Panel Evidence-Based Clinical Practice Guidelines for Post-Stroke Rehabilitation

BACKGROUND AND PURPOSE

The purpose of this project was to create guidelines for 13 types of physical rehabilitation interventions used in the management of adult patients (>18 years of age) presenting with hemiplegia or hemiparesis following a single clinically identifiable ischemic or hemorrhagic cerebrovascular accident (CVA).

METHOD

Using Cochrane Collaboration methods, the Ottawa Methods Group identified and synthesized evidence from comparative controlled trials. The group then formed an expert panel, which developed a set of criteria for grading the strength of the evidence and the recommendation. Patient-important outcomes were determined through consensus, provided that these outcomes were assessed with a validated and reliable scale.

RESULTS

The Ottawa Panel developed 147 positive recommendations of clinical benefit concerning the use of different types of physical rehabilitation interventions involved in post-stroke rehabilitation.

DISCUSSION AND CONCLUSION

The Ottawa Panel recommends the use of therapeutic exercise, task-oriented training, biofeedback, gait training, balance training, constraint-induced movement therapy, treatment of shoulder subluxation, electrical stimulation, transcutaneous electrical nerve stimulation, therapeutic ultrasound, acupuncture, and intensity and organization of rehabilitation in the management of post stroke.

Risk factors for falls in stroke patients during inpatient rehabilitation

Objectives: To assess the incidence and circumstances of falls among stroke patients in a rehabilitation ward, the frequency of fall-related fractures, the relationship between falls and rehabilitation outcomes, and risk factors for falls.

Design: Prospective observational study.

Setting: Neurological rehabilitation ward.

Patients: In total 1155 patients (56% men; mean age 61.5 ± 14.3 years) admitted to the neurological rehabilitation ward after a stroke. Median (interquartile range) time since stroke onset was 36.5 (68) days.

Main measures: Patients' falls were registered during hospitalization (1—74 days) and variables relating to the type and symptoms of stroke, current medications, neurological deficit (Scandinavian Stroke Scale) and disability (Barthel Index) were collected from medical records.

Results: A total of 252 falls were recorded for 189 (16.3%) patients and 45 patients experienced 108 repeated falls. The incidence rate for falls was 7.6/1000 patient-days (95% confidence interval (CI) 6.6—8.5). Most patients fell while being transferred (33.9%) and while seated (21.5%), and 1.2% of falls resulted in fractures (n = 3). Increased risk of both first and multiple falls was strongly associated with initial Barthel score below 15 (hazard ratio (HR) 5.2 and 4.5, respectively) and time since stroke onset ≥12 weeks (HR 2.3 and 2.3, respectively). First falls were significantly associated with visuo-spatial neglect (HR 1.5). Repeated falls were related to age greater than 65 years (HR 1.4).

Conclusions: Patients with severe stroke-related disability in the early period after stroke are prone to falls during rehabilitation. Multiple falls are most frequent in patients over 65 years of age.

The Prevalence of Joint Contractures, Pressure Sores, Painful Shoulder, Other Pain, Falls, and Depression in the Year After a Severely Disabling Stroke

Background and Purpose— Complications after stroke have been shown to impede rehabilitation, lead to poor functional outcome, and increase cost of care. This inception cohort study sought to investigate the prevalence of immobility-related complications during the first year after severely disabling stroke in relation to functional independence and place of residence.

Methods— Over a 7-month period, 600 stroke survivors were identified in the hospital through the Nottingham Stroke Register. Those who had a Barthel Index score ≤10 3 months poststroke and did not have a primary diagnosis of dementia were eligible to participate in the study. Assessments of complications were carried out at 3, 6, and 12 months poststroke.

Results— Complications were recorded for 122 stroke survivors (mean age, 76 years; 57% male). Sixty-three (52%) had significant language impairment and of the remaining 59 who were able to complete an assessment of cognitive function, 10 (8%) were cognitively impaired. The numbers of reported complications over 12 months, in rank order, were falls, 89 (73%); contracture, 73 (60%); pain, 67 (55%); shoulder pain, 64 (52%); depression, 61 (50%); and pressure sores, 26 (22%). A negative correlation was found between Barthel Index score and the number of complications experienced (low scores on the Barthel Index correlate with a high number of complications). The highest relative percentages of complications were experienced by patients who were living in a nursing home at the time of their last completed assessment.

Conclusions— Immobility-related complications are very common in the first year after a severely disabling stroke. Patients who are more functionally dependent in self-care are likely to experience a greater number of complications than those who are less dependent. Trials of techniques to limit and prevent complication are required.

Rehabilitation of Balance After Stroke With Multisensorial Training: A Single-Blind Randomized Controlled Study

Objective. To compare 2 rehabilitation strategies to improve balance after stroke: (1) a multisensorial approach based on higher intensity of balance tasks and exercise during visual deprivation and (2) a conventional neurodevelopmentaltheory-based treatment (NDT) that used a general approach for sensorimotor rehabilitation. Methods . This prospective, multicenter, randomized, parallel-group study measured outcomes with blinded assessors. Sixty-eight patients able to walk without human assistance were entered from 3 to 15 months (mean, 7 months) after a first hemispheric stroke. They received 20 sessions in 4 weeks of NDT or multisensorial rehabilitation. On day 0, day 30, and day 90, assessment included the Berg Balance Scale (BBS), posturography, gait (velocity, double stance phase, climbing 10 steps, amount of walking per day), the Functional Independence Measure, and the Nottingham Health Profile. Results. All subjects improved significantly in balance and walking parameters. Regarding the main dependent variable (BBS on day 30), no difference between groups was found. Analysis of secondary outcomes suggested small differences in favor of the experimental group, but the differences are not likely to be clinically relevant. Conclusion. No evidence was found for the superiority of a multisensorial rehabilitation program in ambulatory patients with impairments beyond the time of inpatient therapy. Additional studies are recommended.

[Evaluation of balance in neurologic and geriatric disorders]

OBJECTIVE

To analyse the clinical usefulness and metrological properties of the main techniques and indices used to assess balance disorders.

METHODS

More than 4000 abstracts referenced in MEDLINE and dealing with postural control and postural disorders (wide screening) were reviewed to determine the main postural techniques and indices used in a clinical context. We retained abstracts with a high citation frequency and those with interesting findings. Corresponding key words were identified for a specific search of articles that we analysed.

RESULTS

Postural assessment tools can be classified as scales of ordinal items, tests based on metric or chronometric measurement, posturography, and verticality perception. These techniques are complementary, and their association is recommended in a clinical context. Regarding generic tools, the Falls-related Efficacy Scale (FES) and the Activities-specific Balance Confidence scale (ABC scale) would be enhanced if comparatively analysed and reworked to allow for a feasible and reliable assessment of the fear of falling. Despite a wide diffusion in numerous postural fields worldwide, the Berg Balance Scale (BBS) and the Functional Reach Test (FRT) do not have the required criteria to remain the gold standards they were in the 1990s. Static posturography should be normalised and yield more reliable indices. The clinical relevance of the subjective assessment of visual, haptic, and postural verticals are questionable, especially to explain postural disability. Regarding specific tools, the Tinetti test (TT) and the Time Up and Go test (TUG) are the most suited to assess postural capacities in very elderly people, in whom the predictive validity of the postural assessment of falls is still modest. In stroke patients, the Postural Assessment Scale for Stroke (PASS), posturography, lateropulsion assessment, and vertically perception are interesting and complementary techniques. Postural assessment relies mainly upon the 5 postural items of the Unified Parkinson Disease Rating Scale (UPDRS) in people with Parkinson disease and upon the Romberg test and posturography in patients with cerebellar or proprioceptive ataxia. Some novel postural scales for patients with multiple sclerosis or spinal cord injury are also emerging.

CONCLUSION

Among numerous tools that contribute to the assessment of postural disorders, only the most recent ones (developed in the last 10 years) have undergone complete validation. It is now crucial to compare these tools, not only in terms of reproducibility and internal consistency, but also overall, in terms of feasibility, responsiveness, and predictive validity for a given population.

Vers une meilleure compréhension et une évaluation quantifiée du « pushing », un comportement postural dû à certains AVC

INTRODUCTION

Postural control aims to build up and align the body orientation (posture) and stabilize body segments. The existence of two separate mechanisms, one for the control of body orientation with respect to gravity and one for its stabilisation, is an emerging concept that allows a better understanding of postural disorders, including pushing, after stroke. Objectives. - Literature review concerning pushing, one of the most puzzling postural behaviours after stroke.

METHODS

Critical review of papers indexed in Medline and book chapters dealing with pushing.

RESULTS

There is no agreement about the definition of pushing: some authors consider that pushers push himself toward the paretic side using the healthy arm or leg; others consider that pushers lean (list) toward the side opposite the lesion and resist any attempt to become more upright. Surprisingly, the push itself has never been measured. Some ordinal scales have been recently proposed, but their psychometric properties have not been analysed. These methodological insufficiencies explain in part the disagreements about frequency (from 5% to 50% of patients with stroke) and cause(s) of pushing.

CONCLUSION

Pushing may be the most dramatic clinical manifestations of an extreme bias in the construction of the biological vertical. We argue for a better assessment of vertical perception/representation after stroke involving the three modalities of the biological (subjective) vertical: the visual vertical, the haptic or tactile vertical, and especially the postural vertical.