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Yang S, Boudier-Revéret M, Kwon S, Lee MY, Chang MC. Effect of Diabetes on Post-stroke Recovery: A Systematic Narrative Review. Front Neurol 2021; 12:747878. [PMID: 34970205 PMCID: PMC8712454 DOI: 10.3389/fneur.2021.747878] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 11/19/2021] [Indexed: 01/11/2023] Open
Abstract
Background: Patients with stroke often have comorbid diabetes. Considering its detrimental effects on brain function, diabetes may increase the risk of poor recovery.Methods: The aim of this review was to investigate the effect of diabetes on post-stroke recovery by a systematic review. Several specific aspects of post-stroke recovery, including activities of daily living (ADL), motor, cognitive, and quality of life (QOL) recovery, were examined. We searched the PubMed, SCOPUS, Embase, and Cochrane Library databases for relevant studies on the effect of diabetes on post-stroke recovery, published until May 26, 2021. A total of 52,051 potentially relevant articles were identified. After reading the titles and abstracts and assessing their eligibility based on full-text articles, 34 publications were included in this review.Results: Of 29 studies that assessed ADL recovery after stroke, 22 studies suggested that diabetes had a negative effect on recovery of ADL after stroke. Regarding motor recovery, only one out of four studies showed that diabetes had some effect on motor recovery after stroke. Of the two studies on cognitive recovery, one reported that diabetes was an independent predictor of poor cognitive recovery after stroke. Three studies on QOL reported that a poor QOL after stroke was associated with the presence of diabetes.Conclusions: The current review suggests that the post-stroke recovery of ADL seems to be poorer in patients with diabetes than patients without diabetes. Further, there are insufficient data to conclude the effect of diabetes on motor and cognitive recovery, but it may have some influence on the quality of life after stroke.Systematic Review Registration: doi: 10.37766/inplasy2021.11.0032, identifier: INPLASY2021110032.
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Affiliation(s)
- Seoyon Yang
- Department of Rehabilitation Medicine, Ewha Womans University Seoul Hospital, Ewha Womans University School of Medicine, Seoul, South Korea
| | - Mathieu Boudier-Revéret
- Department of Physical Medicine and Rehabilitation, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - SuYeon Kwon
- Department of Rehabilitation Medicine, Ewha Womans University Seoul Hospital, Ewha Womans University School of Medicine, Seoul, South Korea
| | - Min Yong Lee
- Department of Dermatology, Ewha Womans University Seoul Hospital, Ewha Womans University School of Medicine, Seoul, South Korea
| | - Min Cheol Chang
- Department of Rehabilitation Medicine, College of Medicine, Yeungnam University, Gyeongsan, South Korea
- *Correspondence: Min Cheol Chang
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Robbins GT, Goldstein R, Siddiqui S, Huang DS, Zafonte R, Schneider JC. Capture rates of comorbidity measures at inpatient rehabilitation facilities after a stroke or brain injury. PM R 2021; 14:462-471. [PMID: 33728804 DOI: 10.1002/pmrj.12589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 02/04/2021] [Accepted: 03/08/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND Comorbidity indices have been used to represent the overall medical complexity of patient populations in clinical research; however, it is not known how well they capture the comorbidities of patients with a stroke or brain injury admitted to inpatient rehabilitation facilities (IRFs). OBJECTIVE To determine how well commonly used comorbidity indices capture the comorbidities of patients admitted to IRFs after a stroke or brain injury. DESIGN Cross-sectional, retrospective study. SETTING IRFs nationwide. PARTICIPANTS Adults from four impairment groups: (1) hemorrhagic stroke, (2) ischemic stroke, (3) nontraumatic brain injury (NTBI), and (4) traumatic brain injury (TBI). MAIN OUTCOME MEASURES International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes were extracted from the Uniform Data System for Medical Rehabilitation (UDSMR) for IRF discharges from October 1, 2015 to December 31, 2017. The percentage of discharges captured by Deyo-Charlson, Elixhauser, and Centers for Medicare and Medicaid Services (CMS) tiers was determined, as was the percentage of comorbidities captured. These measures were also compared with respect to their ability to capture chronic medical complexity by examining the percentage of codes captured after removal of codes deemed to represent hospital complications or sequela of the admission diagnosis. RESULTS The percentage of discharges without at least one ICD-10-CM code captured by any index ranged from 0.3%-3.8%. The percentage of comorbidities with a prevalence exceeding 1% captured by at least one index ranged from 37.1%-43.6%. Chronic comorbidities were most likely to be captured by Elixhauser (40.7%-44.4%), followed by Deyo-Charlson (7.8%-9.6%), then CMS tiers (4.5%-6.9%). Existing comorbidity measures capture most IRF discharges related to a brain injury or stroke, whereas most medical comorbidities escape representation. Several common, functionally relevant diagnoses were not captured. CONCLUSION The use of comorbidity indices in the IRF neurologic injury population should account for the fact that these measures miss several common, important comorbidities.
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Affiliation(s)
- Gregory T Robbins
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Charlestown, Massachusetts, USA
| | - Richard Goldstein
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Charlestown, Massachusetts, USA
| | - Sameer Siddiqui
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Charlestown, Massachusetts, USA
| | - Donna S Huang
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Charlestown, Massachusetts, USA
| | - Ross Zafonte
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Charlestown, Massachusetts, USA
| | - Jeffrey C Schneider
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Charlestown, Massachusetts, USA
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Roberts P, Wertheimer J, Park E, Nuño M, Riggs R. Identification of Functional Limitations and Discharge Destination in Patients With COVID-19. Arch Phys Med Rehabil 2021; 102:351-358. [PMID: 33278363 PMCID: PMC7709477 DOI: 10.1016/j.apmr.2020.11.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 10/15/2020] [Accepted: 11/02/2020] [Indexed: 01/08/2023]
Abstract
OBJECTIVES The objectives of this study were to identify functional limitations in patients with coronavirus 2019 (COVID-19) admitted to acute care hospitals; to evaluate functional limitations by demographic, medical, and encounter characteristics; and to examine functional limitations in relation to discharge destination. DESIGN and Setting:This is a cross-sectional, retrospective study of adult patients with COVID-19 who were discharged from 2 different types of hospitals (academic medical center and a community hospital) within 1 health care system from January 1 to April 30, 2020. PARTICIPANTS Patients were identified from the Cedars-Sinai COVID-19 data registry who had a new-onset positive test for severe acute respiratory syndrome coronavirus 2. A total of 273 patients were identified, which included 230 patients who were discharged alive and 43 patients who died and were excluded from the study sample. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Functional limitations in patients with COVID-19 in acute care hospitals and the predictors for discharge disposition. RESULTS A total of 230 records were analyzed including demographic, encounter, medical, and functional variables. In a propensity score-matched cohort based on age and comorbidity, 88.2% had functional physical health deficits, 72.5% had functional mental health deficits, and 17.6% experienced sensory deficits. In the matched cohort, individuals discharged to an institution experienced greater physical (62.7% vs 25.5%, P<.001) and mental health (49.0% vs 23.5%, P=.006) deficits than patients discharged home. Marital status (odds ratio, 3.17; P=.011) and physical function deficits (odds ratio, 3.63; P=.025) were associated with an increase odds ratio of discharge to an institution. CONCLUSIONS This research highlights that functional status is a strong predictor for discharge destination to an institution for patients with COVID-19. Patients who were older, in the acute care hospital longer, and with comorbidities were more likely to be discharged to an institution. Rehabilitation is a significant aspect of the health care system for these vulnerable patients. The challenges of adjusting the role of rehabilitation providers and systems during the pandemic needs further exploration. Moreover, additional research is needed to look more closely at the many facets and timing of functional status needs, to shed light in use of interdisciplinary rehabilitation services, and to guide providers and health care systems in facilitating optimal recovery and patient outcomes.
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Affiliation(s)
- Pamela Roberts
- Department of Physical Medicine and Rehabilitation, Cedars-Sinai, Los Angeles, California; Department of Enterprise Information Services, Cedars-Sinai, Los Angeles, California; Department of Medical Affairs, Cedars-Sinai, Los Angeles, California.
| | - Jeffrey Wertheimer
- Department of Physical Medicine and Rehabilitation, Cedars-Sinai, Los Angeles, California
| | - Eunice Park
- Department of Enterprise Information Services, Cedars-Sinai, Los Angeles, California
| | - Miriam Nuño
- University of California, Davis, Department of Public Health Sciences, Davis, California
| | - Richard Riggs
- Department of Physical Medicine and Rehabilitation, Cedars-Sinai, Los Angeles, California; Department of Medical Affairs, Cedars-Sinai, Los Angeles, California
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Buie JNJ, Zhao Y, Burns S, Magwood G, Adams R, Sims-Robinson C, Lackland DT. Racial Disparities in Stroke Recovery Persistence in the Post-Acute Stroke Recovery Phase: Evidence from the Health and Retirement Study. Ethn Dis 2020; 30:339-348. [PMID: 32346280 PMCID: PMC7186057 DOI: 10.18865/ed.30.2.339] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background and Purpose Blacks have a higher burden of post-stroke disability. Factors associated with racial differences in long-term post-stroke disability are not well-understood. Our aim was to assess the long-term racial differences in risk factors associated with stroke recovery. Methods We examined Health and Retirement Study (HRS) longitudinal interview data collected from adults living with stroke who were aged >50 years during 2000-2014. Analysis of 1,002 first-time, non-Hispanic, Black (210) or White (792) stroke survivors with data on activities of daily living (ADL), fine motor skills (FMS) and gross motor skills (GMS) was conducted. Ordinal regression analysis was used to assess the impact of sex, race, household residents, household income, comorbidities, and the time since having a stroke on functional outcomes. Results Black stroke survivors were younger compared with Whites (69 ± 10.4 vs 75 ± 11.9). The majority (~65%) of Black stroke survivors were female compared with about 54% White female stroke survivors (P=.007). Black stroke survivors had more household residents (P<.001) and comorbidities (P<.001). Aging, being female, being Black and a longer time since stroke were associated with a higher odds of having increased difficulty in ADL, FMS and/or GMS. Comorbidities were associated with increased difficulty with GMS. Black race increased the impact of comorbidities on ADL and FMS in comparison with Whites. Conclusion Our data suggest that the effects of aging, sex and unique factors associated with race should be taken into consideration for future studies of post-stroke recovery and therapy.
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Affiliation(s)
- Joy N. J. Buie
- WISSDOM Center, Medical University of South Carolina, Charleston, SC
| | - Yujing Zhao
- Division of Infectious Diseases, Medical University of South Carolina, Charleston, SC
| | - Suzanne Burns
- WISSDOM Center, Medical University of South Carolina, Charleston, SC
- School of Occupational Therapy, Texas Women’s University, Denton, TX
| | - Gayenell Magwood
- WISSDOM Center, Medical University of South Carolina, Charleston, SC
- College of Nursing Medical University of South Carolina, Charleston, SC
| | - Robert Adams
- WISSDOM Center, Medical University of South Carolina, Charleston, SC
| | | | | | - WISSDOM Research Center Study Group
- WISSDOM Center, Medical University of South Carolina, Charleston, SC
- Division of Infectious Diseases, Medical University of South Carolina, Charleston, SC
- School of Occupational Therapy, Texas Women’s University, Denton, TX
- College of Nursing Medical University of South Carolina, Charleston, SC
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DiVita MA, Granger CV, Goldstein R, Niewczyk PM, Freudenheim JL. Mandated Quality of Care Metrics for Medicare Patients: Examining New or Worsened Pressure Ulcers and Rehabilitation Outcomes in United States Inpatient Rehabilitation Facilities. Arch Phys Med Rehabil 2018; 99:1514-1524.e1. [DOI: 10.1016/j.apmr.2018.03.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 01/03/2018] [Accepted: 03/11/2018] [Indexed: 10/17/2022]
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Comparing Comorbidity Indices to Predict Post-Acute Rehabilitation Outcomes in Older Adults. Am J Phys Med Rehabil 2017; 95:889-898. [PMID: 27149597 DOI: 10.1097/phm.0000000000000527] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Compare 5 comorbidity indices to predict community discharge and functional status following post-acute rehabilitation. DESIGN This was a retrospective study of Medicare beneficiaries with stroke, lower-extremity fracture, and joint replacement discharged from inpatient rehabilitation in 2011 (N = 105,275). Community discharge and self-care, mobility, and cognitive function were compared using the Charlson, Elixhauser, Tier, Functional Comorbidity, and Hierarchical Condition Category comorbidity indices. RESULTS Of the patients, 64.4% were female, and 84.6% were non-Hispanic white. Mean age was 79.3 (SD, 7.5) years. Base regression models including sociodemographic and clinical variables explained 56.6%, 42.2%, and 23.0% of the variance (R) for discharge self-care; 47.4%, 30.9%, and 18.6% for mobility; and 62.0%, 55.3%, and 37.3% for cognition across the 3 impairment groups. R values for self-care, mobility, and cognition increased by 0.2% to 3.3% when the comorbidity indices were added to the models. The base model C statistics for community discharge were 0.58 (stroke), 0.61 (fracture), and 0.62 (joint replacement). The C statistics increased more than 25% with the addition of discharge functional status to the base model. Adding the comorbidity indices individually to the base model resulted in C-statistic increases of 1% to 2%. CONCLUSION Comorbidity indices were poor predictors of community discharge and functional status in Medicare beneficiaries receiving inpatient rehabilitation.
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Tam AKH, Bayley MT. A narrative review of the impact of medical comorbidities on stroke rehabilitation outcomes. Disabil Rehabil 2017; 40:1842-1848. [PMID: 28374631 DOI: 10.1080/09638288.2017.1309465] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE Medical comorbidities in stroke patients influence acute mortality, but may also affect participation of survivors in rehabilitation. There is limited research investigating the impact of comorbidities on stroke rehabilitation outcomes. The review will explore the literature on the impact of comorbidities on stroke rehabilitation outcome. MATERIALS AND METHODS The literature was searched systematically, including MEDLINE database, EMBASE and PsychINFO, combining variations of the terms stroke, rehabilitation and comorbidities. Results were limited to English language publications. Included studies had a functional outcome. RESULTS Twenty relevant articles were identified. Fifteen small prospective or large retrospective studies using global comorbidity scales produced conflicting relationships between comorbidities and rehabilitation outcomes. Five publications addressed specific comorbidities, with three studies finding negative correlation between diabetes and rehabilitation outcomes, although effects diminished with age. In general, there were discrepancies in how comorbidities were identified. Few studies specifically focused on comorbidities and/or rehabilitation outcomes. CONCLUSIONS There is conflicting evidence regarding the impact of comorbidities on stroke rehabilitation outcomes. However, the presence of more severe diabetes may be associated with worse outcomes. The role of comorbidities in stroke rehabilitation would be best clarified with a large cohort study, with precise comorbidity identification measured against rehabilitation specific outcomes. Implications for rehabilitation Benefit of rehabilitation after stroke in improving functional outcome is well-established. Many stroke patients have comorbid conditions which can impact rehabilitation participation, leading to less benefit obtained from rehabilitation. The burden of comorbid conditions may slow rehabilitation progress, which may warrant a longer duration of rehabilitation to obtain required functional gain to be discharged into the community.
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Affiliation(s)
- Alan K H Tam
- a Department of Medicine, Division of Physical Medicine & Rehabilitation , University of Toronto , Toronto , Canada
| | - Mark T Bayley
- a Department of Medicine, Division of Physical Medicine & Rehabilitation , University of Toronto , Toronto , Canada
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Nguyen TQ, Simpson PM, Gabbe BJ. The prevalence of pre-existing mental health, drug and alcohol conditions in major trauma patients. AUST HEALTH REV 2017; 41:283-290. [DOI: 10.1071/ah16050] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 05/23/2016] [Indexed: 11/23/2022]
Abstract
Objective
Capturing information about mental health, drug and alcohol conditions in injury datasets is important for improving understanding of injury risk and outcome. This study describes the prevalence of pre-existing mental health, drug and alcohol conditions in major trauma patients based on routine discharge data coding.
Methods
Data were extracted from the population-based Victorian State Trauma Registry (July 2005 to June 2013, n = 16 096).
Results
Seventeen percent of major trauma patients had at least one mental health condition compared with the Australian population prevalence of 21%. The prevalence of mental health conditions was similar to the Australian population prevalence in men (19% v. 18%), but lower in women (14% v. 25%) and across all age groups. Mental health conditions were more prevalent in intentional self-harm cases (56.3%) compared with unintentional (13.8%) or other intentional (31.2%) cases. Substance use disorders were more prevalent in major trauma patients than the general population (15% v. 5%), higher in men than women (17% v. 10%) and was highest in young people aged 25–34 years (24%).
Conclusions
Under-reporting of mental health conditions in hospital discharge data appears likely, reducing the capacity to characterise the injury population. Further validation is needed.
What is known about the topic?
Medical record review, routine hospital discharge data and self-report have been used by studies previously to characterise mental health, drug and alcohol conditions in injured populations, with medical record review considered the most accurate and reliance on self-report measures being considered at risk of recall bias. The use of routinely collected data sources provides an efficient and standardised method of characterising pre-existing conditions, but may underestimate the true prevalence of conditions.
What does this paper add?
No study to date has explored the prevalence of Abbreviated Injury Scale and International Classification of Diseases and Health Related Problems, Tenth Revision, Australian Modification (ICD-10-a.m)-coded mental health, alcohol and drug conditions in seriously injured populations. The results of this study show the incidence of mental health conditions appeared to be under-reported in major trauma patients, suggesting limitations in the use of ICD-10-a.m. to measure mental health comorbidities.
What are the implications for practitioners?
In order to achieve improvements in measuring mental health, drug and alcohol comorbidities, we suggest the use of a series of different diagnostic systems to be used in conjunction with ICD-10-a.m., such as medical record review and self-reporting as well as linkage to other datasets. When applied simultaneously, diagnosis and outcomes of mental health may be compared and validated across diagnostic systems and deviations in diagnoses could be more readily accounted for.
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Reistetter TA, Kuo YF, Karmarkar AM, Eschbach K, Teppala S, Freeman JL, Ottenbacher KJ. Geographic and facility variation in inpatient stroke rehabilitation: multilevel analysis of functional status. Arch Phys Med Rehabil 2015; 96:1248-54. [PMID: 25747551 DOI: 10.1016/j.apmr.2015.02.020] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Revised: 02/18/2015] [Accepted: 02/25/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To examine geographic and facility variation in cognitive and motor functional outcomes after postacute inpatient rehabilitation in patients with stroke. DESIGN Retrospective cohort design using Centers for Medicare and Medicaid Services (CMS) claims files. Records from 1209 rehabilitation facilities in 298 hospital referral regions (HRRs) were examined. Patient records were analyzed using linear mixed models. Multilevel models were used to calculate the variation in outcomes attributable to facilities and geographic regions. SETTING Inpatient rehabilitation units and facilities. PARTICIPANTS Patients (N=145,460) with stroke discharged from inpatient rehabilitation from 2006 through 2009. INTERVENTION Not applicable. MAIN OUTCOME MEASURES Cognitive and motor functional status at discharge measured by items in the CMS Inpatient Rehabilitation Facility-Patient Assessment Instrument. RESULTS Variation profiles indicated that 19.1% of rehabilitation facilities were significantly below the mean functional status rating (mean ± SD, 81.58±22.30), with 221 facilities (18.3%) above the mean. Total discharge functional status ratings varied by 3.57 points across regions. Across facilities, functional status values varied by 29.2 points, with a 9.1-point difference between the top and bottom deciles. Variation in discharge motor function attributable to HRR was reduced by 82% after controlling for cluster effects at the facility level. CONCLUSIONS Our findings suggest that variation in motor and cognitive function at discharge after postacute rehabilitation in patients with stroke is accounted for more by facility than geographic location.
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Affiliation(s)
- Timothy A Reistetter
- Department of Occupational Therapy, University of Texas Medical Branch, Galveston, TX.
| | - Yong-Fang Kuo
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, TX
| | - Amol M Karmarkar
- Division of Rehabilitation Sciences, University of Texas Medical Branch, Galveston, TX
| | - Karl Eschbach
- Internal Medicine-Division of Geriatrics, University of Texas Medical Branch, Galveston, TX
| | - Srinivas Teppala
- Division of Rehabilitation Sciences, University of Texas Medical Branch, Galveston, TX
| | - Jean L Freeman
- Internal Medicine-Division of Geriatrics, University of Texas Medical Branch, Galveston, TX
| | - Kenneth J Ottenbacher
- Division of Rehabilitation Sciences, University of Texas Medical Branch, Galveston, TX
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Quinlan EB, Dodakian L, See J, McKenzie A, Le V, Wojnowicz M, Shahbaba B, Cramer SC. Neural function, injury, and stroke subtype predict treatment gains after stroke. Ann Neurol 2015; 77:132-45. [PMID: 25382315 PMCID: PMC4293339 DOI: 10.1002/ana.24309] [Citation(s) in RCA: 153] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Revised: 10/10/2014] [Accepted: 11/07/2014] [Indexed: 12/11/2022]
Abstract
OBJECTIVE This study was undertaken to better understand the high variability in response seen when treating human subjects with restorative therapies poststroke. Preclinical studies suggest that neural function, neural injury, and clinical status each influence treatment gains; therefore, the current study hypothesized that a multivariate approach incorporating these 3 measures would have the greatest predictive value. METHODS Patients 3 to 6 months poststroke underwent a battery of assessments before receiving 3 weeks of standardized upper extremity robotic therapy. Candidate predictors included measures of brain injury (including to gray and white matter), neural function (cortical function and cortical connectivity), and clinical status (demographics/medical history, cognitive/mood, and impairment). RESULTS Among all 29 patients, predictors of treatment gains identified measures of brain injury (smaller corticospinal tract [CST] injury), cortical function (greater ipsilesional motor cortex [M1] activation), and cortical connectivity (greater interhemispheric M1-M1 connectivity). Multivariate modeling found that best prediction was achieved using both CST injury and M1-M1 connectivity (r(2) = 0.44, p = 0.002), a result confirmed using Lasso regression. A threshold was defined whereby no subject with >63% CST injury achieved clinically significant gains. Results differed according to stroke subtype; gains in patients with lacunar stroke were best predicted by a measure of intrahemispheric connectivity. INTERPRETATION Response to a restorative therapy after stroke is best predicted by a model that includes measures of both neural injury and function. Neuroimaging measures were the best predictors and may have an ascendant role in clinical decision making for poststroke rehabilitation, which remains largely reliant on behavioral assessments. Results differed across stroke subtypes, suggesting the utility of lesion-specific strategies.
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Affiliation(s)
| | - Lucy Dodakian
- Department of Neurology, University of California, Irvine
| | - Jill See
- Department of Neurology, University of California, Irvine
| | - Alison McKenzie
- Department of Physical Therapy, University of California, Irvine
| | - Vu Le
- Department of Neurology, University of California, Irvine
| | - Mike Wojnowicz
- Department of Statistics; Chapman University, University of California, Irvine
| | - Babak Shahbaba
- Department of Statistics; Chapman University, University of California, Irvine
| | - Steven C. Cramer
- Department of Anatomy & Neurobiology, University of California, Irvine
- Department of Neurology, University of California, Irvine
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Meyer MJ, Pereira S, McClure A, Teasell R, Thind A, Koval J, Richardson M, Speechley M. A systematic review of studies reporting multivariable models to predict functional outcomes after post-stroke inpatient rehabilitation. Disabil Rehabil 2014; 37:1316-23. [DOI: 10.3109/09638288.2014.963706] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Matthew J. Meyer
- Graduate Program in Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, London, Ontario, Canada,
- Ontario Stroke Network, Toronto, Ontario, Canada,
- Aging, Rehabilitation and Geriatric Care Program, Lawson Health Research Institute, London, Ontario, Canada,
| | - Shelialah Pereira
- Aging, Rehabilitation and Geriatric Care Program, Lawson Health Research Institute, London, Ontario, Canada,
| | - Andrew McClure
- Heart and Stroke Foundation of Canada, Toronto, Ontario, Canada,
| | - Robert Teasell
- Aging, Rehabilitation and Geriatric Care Program, Lawson Health Research Institute, London, Ontario, Canada,
- Department of Physical Medicine and Rehabilitation, St Joseph's Health Care, London, Ontario, Canada,
- Department of Physical Medicine and Rehabilitation, Schulich School of Medicine and Dentistry, London, Ontario, Canada,
| | - Amardeep Thind
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, London, Ontario, Canada, and
- Centre for Studies in Family Medicine, Western University, London Ontario, Canada
| | - John Koval
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, London, Ontario, Canada, and
| | - Marina Richardson
- Aging, Rehabilitation and Geriatric Care Program, Lawson Health Research Institute, London, Ontario, Canada,
| | - Mark Speechley
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, London, Ontario, Canada, and
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Lucke-Wold BP, Logsdon AF, Turner RC, Rosen CL, Huber JD. Aging, the metabolic syndrome, and ischemic stroke: redefining the approach for studying the blood-brain barrier in a complex neurological disease. ADVANCES IN PHARMACOLOGY 2014; 71:411-49. [PMID: 25307225 DOI: 10.1016/bs.apha.2014.07.001] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The blood-brain barrier (BBB) has many important functions in maintaining the brain's immune-privileged status. Endothelial cells, astrocytes, and pericytes have important roles in preserving vasculature integrity. As we age, cell senescence can contribute to BBB compromise. The compromised BBB allows an influx of inflammatory cytokines to enter the brain. These cytokines lead to neuronal and glial damage. Ultimately, the functional changes within the brain can cause age-related disease. One of the most prominent age-related diseases is ischemic stroke. Stroke is the largest cause of disability and is third largest cause of mortality in the United States. The biggest risk factors for stroke, besides age, are results of the metabolic syndrome. The metabolic syndrome, if unchecked, quickly advances to outcomes that include diabetes, hypertension, cardiovascular disease, and obesity. The contribution from these comorbidities to BBB compromise is great. Some of the common molecular pathways activated include: endoplasmic reticulum stress, reactive oxygen species formation, and glutamate excitotoxicity. In this chapter, we examine how age-related changes to cells within the central nervous system interact with comorbidities. We then look at how comorbidities lead to increased risk for stroke through BBB disruption. Finally, we discuss key molecular pathways of interest with a focus on therapeutic targets that warrant further investigation.
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Affiliation(s)
- Brandon P Lucke-Wold
- Department of Neurosurgery, West Virginia University, School of Medicine, Morgantown, West Virginia, USA; The Center for Neuroscience, West Virginia University, School of Medicine, Morgantown, West Virginia, USA
| | - Aric F Logsdon
- The Center for Neuroscience, West Virginia University, School of Medicine, Morgantown, West Virginia, USA; Department of Basic Pharmaceutical Sciences, West Virginia University, School of Pharmacy, Morgantown, West Virginia, USA
| | - Ryan C Turner
- Department of Neurosurgery, West Virginia University, School of Medicine, Morgantown, West Virginia, USA; The Center for Neuroscience, West Virginia University, School of Medicine, Morgantown, West Virginia, USA
| | - Charles L Rosen
- Department of Neurosurgery, West Virginia University, School of Medicine, Morgantown, West Virginia, USA; The Center for Neuroscience, West Virginia University, School of Medicine, Morgantown, West Virginia, USA
| | - Jason D Huber
- The Center for Neuroscience, West Virginia University, School of Medicine, Morgantown, West Virginia, USA; Department of Basic Pharmaceutical Sciences, West Virginia University, School of Pharmacy, Morgantown, West Virginia, USA.
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Tanovic E, Selimovic S, Tanovic H. Assessment of the effects of rehabilitation after cerebrovascular accident in patients with diabetes mellitus and hypertension as risk factors. Med Arch 2014; 68:124-7. [PMID: 24937938 PMCID: PMC4272494 DOI: 10.5455/medarh.2014.68.124-127] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Aim: The aim of this study is to evaluate the results of rehabilitation, to determine the prevalence of major risk factors in cerebrovascular accident and their consequences, as well as to propose measures and procedures that will affect the better rehabilitation. Methods: The survey analyzed: age, sex, duration of rehabilitation, activities in daily life through the Barthel index at admission and at discharge, presence of risk factors HTA and DM. The study included a total of 116 patients, the majority of patients are older than 61 years. We had 49% of male patients and 51% of female patients and they spent 31-40 days at the rehabilitation. Results: The most common risk factor is HTA (83%) and diabetes (33%). Most of the patients at admission had a BI from 0 to 4 (32.7%), and at discharge BI in the range 17-20 (36.2%). Statistical analysis shows that there is a statistically significant correlation between the BI at admission, BI at discharge and risk factors of HTA and diabetes mellitus. Conclusions: the rehabilitation results in most patients is good results of rehabilitation. The most important risk factors in patients are HTA, DM and directly affect on results of rehabilitation. For the better results we should have energetic fight against risk factors for HTA and DM through primary and secondary prevention and patient education about early detection and treatment of these risk factors.
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Affiliation(s)
- Edina Tanovic
- Clinic of Physiatry and Rehabilitation, Clinical center of Sarajevo University, Sarajevo, Bosnia and Herzegovina
- Corresponding author: Edina Tanovic, ass.prof. Clinic of Physiatry and Rehabilitation, KCUS, Sarajevo, Bosnia and Herzegovina. Phone: +387 33 278 465; :
| | | | - Haris Tanovic
- Clinic of Abdominal Surgery, Clinical canter of Sarajevo University, Sarajevo, Bosnia and Herzegovina
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Reistetter TA, Karmarkar AM, Graham JE, Eschbach K, Kuo YF, Granger CV, Freeman J, Ottenbacher KJ. Regional variation in stroke rehabilitation outcomes. Arch Phys Med Rehabil 2014; 95:29-38. [PMID: 23921200 PMCID: PMC4006274 DOI: 10.1016/j.apmr.2013.07.018] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2013] [Revised: 06/18/2013] [Accepted: 07/09/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To examine and describe regional variation in outcomes for persons with stroke receiving inpatient medical rehabilitation. DESIGN Retrospective cohort design. SETTING Inpatient rehabilitation units and facilities contributing to the Uniform Data System for Medical Rehabilitation from the United States. PARTICIPANTS Patients (N=143,036) with stroke discharged from inpatient rehabilitation during 2006 and 2007. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Community discharge, length of stay (LOS), and discharge functional status ratings (motor, cognitive) across 10 geographic service regions defined by the Centers for Medicare and Medicaid Services (CMS). RESULTS Approximately 71% of the sample was discharged to the community. After adjusting for covariates, the percentage discharged to the community varied from 79.1% in the Southwest (CMS region 9) to 59.4% in the Northeast (CMS region 2). Adjusted LOS varied by 2.1 days, with CMS region 1 having the longest LOS at 18.3 days and CMS regions 5 and 9 having the shortest at 16.2 days. CONCLUSIONS Rehabilitation outcomes for persons with stroke varied across CMS regions. Substantial variation in discharge destination and LOS remained after adjusting for demographic and clinical characteristics.
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Affiliation(s)
- Timothy A Reistetter
- Department of Occupational Therapy, University of Texas Medical Branch, Galveston, TX.
| | - Amol M Karmarkar
- Division of Rehabilitation Sciences, University of Texas Medical Branch, Galveston, TX
| | - James E Graham
- Division of Rehabilitation Sciences, University of Texas Medical Branch, Galveston, TX
| | - Karl Eschbach
- Sealy Center on Aging and Division of Geriatrics, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX
| | - Yong-Fang Kuo
- Sealy Center on Aging and Division of Geriatrics, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX
| | - Carl V Granger
- Uniform Data System for Medical Rehabilitation, Buffalo, NY
| | - Jean Freeman
- Sealy Center on Aging and Division of Geriatrics, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX
| | - Kenneth J Ottenbacher
- Division of Rehabilitation Sciences, University of Texas Medical Branch, Galveston, TX
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Piernik-Yoder B, Ketchum N. Rehabilitation Outcomes of Stroke Patients With and Without Diabetes. Arch Phys Med Rehabil 2013; 94:1508-12. [DOI: 10.1016/j.apmr.2013.04.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2013] [Revised: 03/08/2013] [Accepted: 04/22/2013] [Indexed: 10/26/2022]
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Chang EY, Chang EH, Cragg S, Cramer SC. Predictors of Gains During Inpatient Rehabilitation in Patients with Stroke- A Review. ACTA ACUST UNITED AC 2013; 25:203-221. [PMID: 25541570 DOI: 10.1615/critrevphysrehabilmed.2013008120] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Stroke remains a major cause of disability. The cost of stroke rehabilitation is substantial. Understanding the factors that predict response to inpatient stroke rehabilitation may be useful, for example, to best individualize the content of therapy, or to maximize the efficiency with which resources are directed. This review reviewed the literature and found that numerous variables were associated with outcome after inpatient stroke rehabilitation. The strongest evidence exists for factors such as age, stroke subtype, nutritional status, psychosocial factors such as living with family prior to stroke or presence of a caregiver. Functional status on admission, urinary incontinence, post-stroke infection, and aphasia each can also impact prognosis. Strengths and weaknesses of cited studies are considered in an attempt to inform design of future studies examining the factors that predict response to inpatient rehabilitation after stroke.
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Affiliation(s)
- Eric Y Chang
- Division of Pain Medicine Department of Anesthesiology & Perioperative Care Department of Physical Medicine & Rehabilitation Reeve-Irvine Research Center for Spinal Cord Injury University of California, Irvine
| | - Enoch H Chang
- Department of Physical Medicine & Rehabilitation University of California, Irvine
| | - Samantha Cragg
- Department of Physical Medicine & Rehabilitation University of California, Irvine
| | - Steven C Cramer
- Department of Neurology Department of Anatomy & Neurobiology Department of Physical Medicine & Rehabilitation University of California, Irvine
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