An Exploration of Central Nervous System Medication Use and Outcomes in Stroke Rehabilitation

A systematic-search-and-review of registered pharmacological therapies investigated to improve neuro-recovery after a stroke

Background

Stroke burden is largely due to long-term impairments requiring prolonged care with loss of productivity. We aimed to identify and assess studies of different registered pharmacological therapies as treatments to improve post-stroke impairments and/or disabilities.

Methods

We performed a systematic-search-and-review of treatments that have been investigated as recovery-enhancing or recovery-promoting therapies in adult patients with stroke. The treatment must have received registration or market authorization in any country regardless of primary indication. Outcomes included in the review were neurological impairments and functional/disability assessments. "The best available studies" based on study design, study size, and/or date of publication were selected and graded for level of evidence (LOE) by consensus.

Results

Our systematic search yielded 7,801 citations, and we reviewed 665 full-text papers. Fifty-eight publications were selected as "the best studies" across 25 pharmacological classes: 31 on ischemic stroke, 21 on ischemic or hemorrhagic stroke, 4 on intracerebral hemorrhage, and 2 on subarachnoid hemorrhage (SAH). Twenty-six were systematic reviews/meta-analyses, 29 were randomized clinical trials (RCTs), and three were cohort studies. Only nimodipine for SAH had LOE A of benefit (systematic review and network meta-analysis). Many studies, some of which showed treatment effects, were assessed as LOE C-LD, mainly due to small sample sizes or poor quality. Seven interventions had LOE B-R (systematic review/meta-analysis or RCT) of treatment effects.

Conclusion

Only one commercially available treatment has LOE A for routine use in stroke. Further studies of putative neuroprotective drugs as adjunctive treatment to revascularization procedures and more confirmatory trials on recovery-promoting therapies will enhance the certainty of their benefit. The decision on their use must be guided by the clinical profile, neurological impairments, and target outcomes based on the available evidence.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=376973, PROSPERO, CRD42022376973.

Neuropsychiatric Complications after Stroke

Neuropsychiatric disturbances represent a common and uniquely challenging consequence of stroke. These disorders arise at the intersection of lesion-related brain dysfunction and psychological distress related to the event and its aftermath, making it difficult to identify what symptom is a direct physiological consequence of the stroke. Depression, anxiety, fatigue, apathy, emotionalism, and anger are the most common of these syndromes, and posttraumatic stress disorder related to the stroke event has become increasingly recognized as a relevant entity. Mania, obsessive-compulsive disorder, and psychosis are less commonly encountered but potentially highly debilitating conditions that may be underrecognized. Early identification and treatment may mitigate functional impairment and improve quality of life. Evidence-based guidelines from the general population are often relied upon to guide treatment. Further research is needed to understand and tailor treatment of these disorders in the poststroke population.

A Scoping Review of Clinical Practice Improvement Methodology Use in Rehabilitation

Context

The Clinical Practice Improvement (CPI) approach is a methodological and quality improvement approach that has emerged and is gaining in popularity. However, there is no systematic description of its use or the determinants of its practice in rehabilitation settings.

Method

We performed a scoping review of the use of CPI methodology in rehabilitation settings.

Results

A total of 103 articles were reviewed. We found evidence of 13 initiatives involving CPI with six different populations. A total of 335 citations of determinants were found, with 68.7% related to CPI itself. Little information was found about what type of external and internal environment, individual characteristics and implementation process might facilitate or hinder the use of CPI.

Conclusion

Given the growing popularity of this methodological approach, CPI initiatives would gain from increasing knowledge of the determinants of its success and incorporating them in future implementation.

Chronic Pain Syndromes After Ischemic Stroke

Background and Purpose—

Chronic pain syndromes are reported to be common after stroke, but most previous epidemiological studies have generally included small cohorts of patients with relatively short-term follow-up. In a large cohort with ischemic stroke (Prevention Regimen for Effectively avoiding Second Stroke [PRoFESS] trial), we determined the prevalence, risk factors, and clinical consequence of new poststroke pain syndromes.

Methods—

Within the PRoFESS trial (mean follow-up 2.5 years), a standardized chronic pain questionnaire was administered (at the penultimate follow-up visit) to all participants who reported chronic pain since their stroke and did not have a history of chronic pain before their index stroke. Multivariable logistic regression analyses were used to determine risk factors for poststroke pain (and pain subtypes), and the association between poststroke pain and cognitive (≥3 reduction in Mini-Mental State Examination score) and functional decline (≥1 increase in m-Rankin).

Results—

In total, 15 754 participants were included; of which 1665 participants (10.6%) reported new chronic poststroke pain, and included 431 participants (2.7%) with central poststroke pain, 238 (1.5%) with peripheral neuropathic pain, 208 (1.3%) with pain from spasticity, and 136 participants (0.9%) with pain from shoulder subluxation. More than 1 pain subtype was reported in 86 participants (0.6%). Predictors of poststroke pain included increased stroke severity, female sex, alcohol intake, statin use, depressive symptoms, diabetes mellitus, antithrombotic regimen, and peripheral vascular disease. A new chronic pain syndrome was associated with greater dependence (odds ratio, 2.16; 95% confidence interval, 1.82–2.56). Peripheral neuropathy and pain from spasticity/shoulder subluxation were associated with cognitive decline.

Conclusions—

Chronic pain syndromes are common after ischemic stroke and are associated with increased functional dependence and cognitive decline.

Group physical therapy during inpatient rehabilitation for acute spinal cord injury: findings from the SCIRehab Study

BACKGROUND

Inpatient rehabilitation for spinal cord injury (SCI) includes the use of both individual and group physical therapy sessions. A greater understanding of group physical therapy use will help in the evaluation of the appropriateness of its use and contribute to the development of standards of practice.

OBJECTIVE

This report describes the extent to which group physical therapy is being used in inpatient rehabilitation for SCI, identifies group physical therapy interventions being delivered, and examines patterns in the types of activities being used for people with different levels and completeness of injury (ie, injury groups).

DESIGN

The SCIRehab Study is a 5-year, multicenter investigation that uses practice-based evidence research methodology.

METHODS

Data on characteristics of participants and treatments provided were collected through detailed chart review and customized research documentation completed by clinicians at the point of care. The analyses described here included data from 600 participants enrolled during the first year of the project.

RESULTS

Most of the participants (549/600) spent time in group physical therapy, and 23% of all documented physical therapy time was spent in group sessions. The most common group physical therapy activities were strengthening, manual wheelchair mobility, gait training, endurance activities, and range of motion/stretching. Time spent in group physical therapy and the nature of activities performed varied among the injury groups.

LIMITATIONS

Physical therapy use patterns observed in the 6 participating centers may not represent all facilities providing inpatient rehabilitation for SCI. Research documentation did not include all factors that may affect group physical therapy use, and some sessions were not documented.

CONCLUSIONS

The majority of physical therapy was provided in individual sessions, but group physical therapy contributed significantly to total physical therapy time. Group physical therapy time and activities differed among the injury groups in patterns consistent with clinical goals.

Pharmacotherapy for traumatic brain injury: focus on sympathomimetics

Traumatic brain injury (TBI) is a devastating neurological injury with broad manifestations. Unfortunately, its diagnosis and efficacious treatments remain elusive. Different post injury symptoms are exhibited at different time frames, indicative of a time-related progression of the pathology. Therefore, particular treatments must be tailored to the post injury time frame. This overview is focused on the secondary chronic phase following TBI and the value of sympathomimetic therapy during this phase. The various direct- and indirect-acting drugs are reviewed, and the treatment protocol employed by the author is described.

Practice based evidence: incorporating clinical heterogeneity and patient-reported outcomes for comparative effectiveness research

BACKGROUND

Comparative effectiveness research analyzes groups of patients and looks for associations between medical treatments and patient outcomes. To make meaningful comparisons of medical interventions, one must consider clinical heterogeneity of patient populations, intervention combinations, and outcomes.

OBJECTIVES

To explain how practice-based evidence (PBE) study methodology measures and controls for heterogeneity of patients, treatments, and outcomes seen in real-world clinical settings.

RESEARCH DESIGN

Overview of PBE methodology.

CONCLUSIONS

PBE study designs address comparative effectiveness by creating a comprehensive set of patient, treatment, and outcome variables, and analyzing them to identify treatments associated with better outcomes for specific types of patients. PBE studies are an alternative to randomized controlled trials, well suited to determine what works best for specific patient types, and provide clinicians with a rational basis for treatment recommendations for individual patients. They provide a holistic picture of patients, treatments, and outcomes, with no preset limits to the number of variables that can be included. Such an approach is needed for high quality comparative effectiveness research.

Beyond the evidence-based practice paradigm to achieve best practice in rehabilitation medicine: a clinical review

OBJECTIVE

Best practice is a practice that, on rigorous evaluation, demonstrates success, has had an impact, and can be replicated. It is differentiated from its constituent parts, evidence-based practice and knowledge translation, by its general meaning and global purview. The purpose of this clinical review is to provide transparency to the concept and achievement of best practice in the context of rehabilitation medicine. The authors will review and analyze the roles of evidence-based practice and knowledge translation in rehabilitation medicine as they work to support best practice. Challenge areas will be discussed, including an evidential hierarchy in need of update, a lack of "high-level" research evidence, and delays in translating evidence to practice. Last, the authors will argue that rehabilitation medicine is well-positioned to effect change by promoting inclusion of emerging research methodologies and analytic techniques that better capture context-specific rehabilitation evidence, into the evidential hierarchy. Achieving best practice is dependent on this, as well as alignment of all key stakeholders, ranging from the patient, researchers and clinicians, to policymakers, payers, and others.

New approach to study the contents and outcomes of spinal cord injury rehabilitation: the SCIRehab Project

BACKGROUND/OBJECTIVE

Limited research evidence is available to show the effectiveness of the many specific interventions provided in spinal cord injury (SCI) rehabilitation; what is available typically focuses on effects of the full rehabilitation package but not specific therapy interventions, medical procedures, patient education, or counseling. Given the problems of conducting randomized controlled trials (RCTs) in rehabilitation, practice-based evidence (PBE) research has been suggested as an alternative methodology for identifying which rehabilitation interventions are associated most strongly with positive outcomes, after controlling for patient differences. Using the PBE research methodology, the SCIRehab project attempts to "open the black box" of acute SCI rehabilitation, provide detailed information on treatments delivered by all rehabilitation disciplines, and contribute to outcomes-based guidelines for clinical decision-making.

METHODS

The SCIRehab project includes 1,500 patients with acute SCI, consecutively admitted to 1 of 6 US inpatient rehabilitation facilities. Details of the rehabilitation process are captured by clinicians from multiple disciplines documenting their interventions in handheld personal digital assistants after sessions with their patients. Outcome data are abstracted from medical records (clinical outcomes data) and obtained from patient interviews at 6 and 12 months after injury. Extensive patient, injury, and other treatment characteristics are abstracted from medical records. SCIRehab is the first research project to collect detailed information on individual interventions offered by the full rehabilitation team.

RESULTS

SCIRehab is the first research project to collect detailed information on individual interventions offered by the full rehabilitation team. These findings are presented in a series of 9 articles.

CONCLUSIONS

To date, SCIRehab's major contribution is a system for categorizing specific contributions of each discipline and a technology for documenting that detail. After data collection is complete, future manuscripts will relate those process elements to outcomes. The SCIRehab Project is an important step toward establishing outcomes-based guidelines for SCI rehabilitation.

Repairing the human brain after stroke: I. Mechanisms of spontaneous recovery

Stroke remains a leading cause of adult disability. Some degree of spontaneous behavioral recovery is usually seen in the weeks after stroke onset. Variability in recovery is substantial across human patients. Some principles have emerged; for example, recovery occurs slowest in those destined to have less successful outcomes. Animal studies have extended these observations, providing insight into a broad range of underlying molecular and physiological events. Brain mapping studies in human patients have provided observations at the systems level that often parallel findings in animals. In general, the best outcomes are associated with the greatest return toward the normal state of brain functional organization. Reorganization of surviving central nervous system elements supports behavioral recovery, for example, through changes in interhemispheric lateralization, activity of association cortices linked to injured zones, and organization of cortical representational maps. A number of factors influence events supporting stroke recovery, such as demographics, behavioral experience, and perhaps genetics. Such measures gain importance when viewed as covariates in therapeutic trials of restorative agents that target stroke recovery.

CNS-active drugs in aging population at high risk of cerebrovascular events: evidence from preclinical and clinical studies

The recovery process following cerebral insults such as stroke is affected by aging and pharmacotherapy. The use of medication including CNS-active drugs has increased in the elderly during recent years. However, surprisingly little is known about how safe they are with respect to severity of sensorimotor and cognitive impairments or recovery of function following possible cerebrovascular accidents. This review examines the experimental and clinical literature, primarily from 1995 onwards, concerning medication in relation to cerebrovascular events and functional recovery. Special attention is directed to polypharmacy and to new CNS-active drugs, which the elderly are already taking or are prescribed to treat emerging, stroke-induced psychiatric symptoms. The neurobiological mechanisms affected by these drugs are discussed.

Stroke rehabilitation patients, practice, and outcomes: is earlier and more aggressive therapy better?

Horn SD, DeJong G, Smout RJ, Gassaway J, James R, Conroy B. Stroke rehabilitation patients, practice, and outcomes: is earlier and more aggressive therapy better?

OBJECTIVE

To examine associations of patient characteristics, rehabilitation therapies, neurotropic medications, nutritional support, and timing of initiation of rehabilitation with functional outcomes and discharge destination for inpatient stroke rehabilitation patients.

DESIGN

Prospective observational cohort study.

SETTING

Five U.S. inpatient rehabilitation facilities.

PARTICIPANTS

Post-stroke rehabilitation patients (N=830; age, >18 y) with moderate or severe strokes, from the Post-Stroke Rehabilitation Outcomes Project database.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Discharge total, motor, and cognitive FIM scores and discharge destination.

RESULTS

Controlling for patient differences, various activities and interventions were associated with better outcomes including earlier initiation of rehabilitation, more time spent per day in higher-level rehabilitation activities such as gait, upper-extremity control, and problem solving, use of newer psychiatric medications, and enteral feeding. Several findings part with conventional practice, such as starting gait training in the first 3 hours of physical therapy, even for low-level patients, was associated with better outcomes.

CONCLUSIONS

Specific therapy activities and interventions are associated with better outcomes. Earlier rehabilitation admission, higher-level activities early in the rehabilitation process, tube feeding, and newer medications are associated with better stroke rehabilitation outcomes.

Applying the clinical practice improvement approach to stroke rehabilitation: methods used and baseline results

Gassaway J, Horn SD, DeJong G, Smout RJ, Clark C, James R. Applying the clinical practice improvement approach to stroke rehabilitation: methods used and baseline results.

OBJECTIVES

To describe the methods used and baseline data for the Post-Stroke Rehabilitation Outcomes Project (PSROP).

DESIGN

Prospective observational cohort study.

SETTING

Seven inpatient rehabilitation facilities (IRFs) in the United States and New Zealand.

PARTICIPANTS

Consecutive convenience sample of 1291 poststroke rehabilitation patients, age older than 18, who were treated between 2001 and 2003 in 7 IRFs (1161 patients in 6 U.S. IRFs).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Change in FIM score, change in severity of illness, and discharge destination.

RESULTS

For the U.S. sample, the average age was 66 years, 52% were men, 60% were white, and 23% were black. Medicare was the most frequent payer. Seventy-seven percent of strokes were ischemic, with 43% in the left brain, 44% in the right brain, and 11% bilateral. Mean admission total FIM score was 61, with a mean motor FIM score of 40 and mean cognitive FIM score of 21. Lower FIM scores are associated with higher severity-of-illness scores. Mean rehabilitation length of stay was 18.6 days; 78% of patients were discharged home. At discharge, the average increase in total FIM score was 26, in motor FIM score was 22, and in cognitive FIM score was 4.

CONCLUSIONS

This article outlines methods used in the PSROP, provides an overview of participating IRFs, describes the database, and summarizes key characteristics to enable readers of subsequent articles to better interpret study findings and determine generalizability.