Predictive value of the NIHSS for ADL outcome after ischemic hemispheric stroke: Does timing of early assessment matter?

Association Between Frequency of Rehabilitation Therapy and Long-Term Mortality After Stroke: A Nationwide Cohort Study

BACKGROUND

Previous studies have demonstrated conflicting results regarding the effects of rehabilitation therapy on poststroke mortality. We aimed to investigate the association between rehabilitation therapy, including both inpatient and outpatient treatment, within the first 6 months after stroke and long-term all-cause mortality in patients with stroke using the Korean National Health Insurance System data.

METHODS

A total of 10 974 patients newly diagnosed with stroke using the International Classification of Diseases, Tenth Revision, codes (I60-I64) between 2003 and 2019 were enrolled and followed up for all-cause mortality until 2019. Follow-up for mortality began 6 months after the index event. Poststroke patients were categorized into 3 groups according to the frequency of rehabilitation therapy: no rehabilitation therapy, ≤40 sessions and >40 sessions. Cox proportional hazards models were used to assess the mortality risk according to rehabilitation therapy stratified by disability severity measured based on activities of daily living 6 months after stroke onset.

RESULTS

Within 6 months after stroke, 6738 patients (61.4%) did not receive rehabilitation therapy, whereas 2122 (19.3%) received ≤40 sessions and 2114 (19.3%) received >40 sessions of rehabilitation therapy. Higher frequency of rehabilitation therapy was associated with significantly lower poststroke mortality in comparison to no rehabilitation therapy (hazard ratio [HR], 0.88 [95% CI, 0.79-0.99]), especially among individuals with severe disability after stroke (mild to moderate: HR, 1.02 [95% CI, 0.77-1.35]; severe: HR, 0.74 [95% CI, 0.62-0.87]). In the context of stroke type, higher frequency of rehabilitation therapy was associated with reduced mortality rates compared with no rehabilitation therapy only in patients with hemorrhagic stroke (ischemic: HR, 1.04 [95% CI, 0.91-1.18]; hemorrhagic: HR, 0.60 [95% CI, 0.49-0.74]).

CONCLUSIONS

We found a positive association between rehabilitation therapy within 6 months after stroke onset and long-term mortality in patients with stroke. A higher frequency of rehabilitation therapy would be recommended for poststroke patients, especially those with hemorrhagic stroke and severe disability.

Cutoff values of motor and cognitive measures for predicting and discriminating levels of activities of daily living after stroke: a scoping review

The various assessments performed by rehabilitation professionals not only indicate the patient's current functional status but can also help determine the future status (prediction) or the ability to perform untested tasks (discrimination). In particular, the cutoff values are the simplest predictive and discriminative tool that can be widely used in clinical practice. The purpose of this scoping review was to summarize the current literature on cutoff values of motor and cognitive function for predicting or discriminating levels of activities of daily living after stroke. A literature search was conducted using the PubMed, CINAHL, and Scopus databases. The creation of the search criteria, primary screening of titles and abstract, and secondary screening by full-text review were performed by two rehabilitation professionals. A total of 54 articles were included. The summary of the cutoff values for prediction based on longitudinal studies revealed that an NIHSS score ≤8 and mRMI score ≥19 at acute hospitalization can predict good functional independence and walking independence, respectively, indicating reliable cutoff values. Cutoff values for predicting specific ADLs, such as toilet use or dressing, were not reported, which was a potential research gap identified in this review. Alternatively, the summary of the cutoff values for discrimination based on cross-sectional studies revealed that 288-367.5 m on the 6-min walk test and 25.5-27.6 points on the FMA-LL can discriminate community and noncommunity walkers. Considering the difference between prediction and discrimination, the reliable predicted cutoff values revealed in this review are useful for planning an intervention based on early prediction. Conversely, cutoff values for discrimination can estimate different performances with simpler test, or use as target values during rehabilitation.

Improvement of predictive accuracies of functional outcomes after subacute stroke inpatient rehabilitation by machine learning models

OBJECTIVES

Stepwise linear regression (SLR) is the most common approach to predicting activities of daily living at discharge with the Functional Independence Measure (FIM) in stroke patients, but noisy nonlinear clinical data decrease the predictive accuracies of SLR. Machine learning is gaining attention in the medical field for such nonlinear data. Previous studies reported that machine learning models, regression tree (RT), ensemble learning (EL), artificial neural networks (ANNs), support vector regression (SVR), and Gaussian process regression (GPR), are robust to such data and increase predictive accuracies. This study aimed to compare the predictive accuracies of SLR and these machine learning models for FIM scores in stroke patients.

METHODS

Subacute stroke patients (N = 1,046) who underwent inpatient rehabilitation participated in this study. Only patients' background characteristics and FIM scores at admission were used to build each predictive model of SLR, RT, EL, ANN, SVR, and GPR with 10-fold cross-validation. The coefficient of determination (R2) and root mean square error (RMSE) values were compared between the actual and predicted discharge FIM scores and FIM gain.

RESULTS

Machine learning models (R2 of RT = 0.75, EL = 0.78, ANN = 0.81, SVR = 0.80, GPR = 0.81) outperformed SLR (0.70) to predict discharge FIM motor scores. The predictive accuracies of machine learning methods for FIM total gain (R2 of RT = 0.48, EL = 0.51, ANN = 0.50, SVR = 0.51, GPR = 0.54) were also better than of SLR (0.22).

CONCLUSIONS

This study suggested that the machine learning models outperformed SLR for predicting FIM prognosis. The machine learning models used only patients' background characteristics and FIM scores at admission and more accurately predicted FIM gain than previous studies. ANN, SVR, and GPR outperformed RT and EL. GPR could have the best predictive accuracy for FIM prognosis.

Impact of skeletal muscle mass on functional prognosis in acute stroke: A cohort study

INTRODUCTION

Changes in skeletal muscle mass affect physical performance in chronic stroke survivors. The skeletal muscle mass index is thus an important assessment factor in stroke; however, its value in the acute phase is unclear.

OBJECTIVE

This study investigated the association between skeletal muscle mass and acute stroke outcome.

DESIGN

This was a single-center cohort study design.

PARTICIPANTS

A total of 189 consecutively hospitalized patients with acute stroke were included in the study.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The main outcome of the study was a good modified Rankin Scale (mRS) score at hospital discharge. We divided the participants into good (mRS score 0-2) and poor (mRS score 3-6) function groups. Logistic regression was performed to identify the factors associated with functional prognosis.

RESULTS

Atrial fibrillation (odds ratio [OR], 14.95; 95% confidence interval [CI], 2.45-91.39; P = 0.003), pre-mRS (OR, 2.22; 95% CI, 1.05-4.68; P = 0.036), National Institutes of Health Stroke Scale (OR, 1.32; 95% CI, 01.12-1.56; P = 0.001), skeletal muscle mass index (OR, 0.31; 95% CI, 0.11-0.87; P = 0.027), and Lower Extremity Fugl-Meyer Assessment (OR, 0.68; 95% CI, 0.56-0.82; P = 0.000) were all independently associated with the functional prognosis of the patients included in the study.

CONCLUSION

This study confirmed that skeletal muscle mass is a strong prognostic factor in acute stroke. Thus, prestroke skeletal muscle mass, along with stroke severity and lower limb paralysis, needs to be assessed to more accurately determine the prognosis of patients with stroke.

Non-invasive brain stimulation for limb motor function and daily living activity improvement in acute stroke: A meta-analysis

OBJECTIVE

To evaluate the effect of non-invasive brain stimulation (NIBS) in improving limb motor dysfunction and daily living activity during at the phase of acute stroke.

MATERIALS AND METHODS

Randomized controlled trials about the effect of NIBS on hemiparesis in acute stroke were retrieved from databases of China National Knowledge Infrastructure (CNKI), China Science and Technology Journal Database (VIP), Wanfang Data, CBM, PubMed, Embase, Cochrane Library, and Web of Science from inception until January 3rd 2022. The quality of the trials was assessed, and the data were extracted according to the Cochrane Handbook for Systematic Reviews of Interventions. A statistical analysis was carried out using Review Manager 5.3 and STATA 14. The effect size was evaluated by using the weighed mean difference (WMD) and a 95% confidence interval (CI). The stability and sensitivity of the results and sources of heterogeneity were also analyzed.

RESULTS

12 studies involving 639 patients were included. Our meta-analysis showed that NIBS could improve the Fugl-Meyer Assessment (weighed mean difference = 3.96, 95% confidence interval = 3.45 to 4.48) and Barthel Index (weighed mean difference = 12.29, 95% confidence interval = 4.93 to 19.66), while reducing the National Institutes of Health Stroke Scale (weighed mean difference = -2.37, 95% confidence interval = -3.43 to -1.31).

CONCLUSION

NIBS is effective in improving paretic limb motor function and activities of daily living in patients during at the phase of acute stroke.

Early prediction of upper limb functioning after stroke using clinical bedside assessments: a prospective longitudinal study

Early and accurate prediction of recovery is needed to assist treatment planning and inform patient selection in clinical trials. This study aimed to develop a prediction algorithm using a set of simple early clinical bedside measures to predict upper limb capacity at 3-months post-stroke. A secondary analysis of Stroke Arm Longitudinal Study at Gothenburg University (SALGOT) included 94 adults (mean age 68 years) with upper limb impairment admitted to stroke unit). Cluster analysis was used to define the endpoint outcome strata according to the 3-months Action Research Arm Test (ARAT) scores. Modelling was carried out in a training (70%) and testing set (30%) using traditional logistic regression, random forest models. The final algorithm included 3 simple bedside tests performed 3-days post stroke: ability to grasp, to produce any measurable grip strength and abduct/elevate shoulder. An 86-94% model sensitivity, specificity and accuracy was reached for differentiation between poor, limited and good outcome. Additional measurement of grip strength at 4 weeks post-stroke and haemorrhagic stroke explained the underestimated classifications. External validation of the model is recommended. Simple bedside assessments have advantages over more lengthy and complex assessments and could thereby be integrated into routine clinical practice to aid therapy decisions, guide patient selection in clinical trials and used in data registries.

Ischemic stroke demographics, clinical features and scales and their correlations: an exploratory study from Jordan

Aims:

The authors aimed to assess the ischemic stroke risk factors and scales.

Materials & methods:

A retrospective cohort study was conducted on patients with acute ischemic stroke (from January 2017 to December 2018). The scores of the National Institutes of Health Stroke Scale (NIHSS) at admission and discharge and of the modified Rankin Scale (mRS) and Barthel Index (BI) scale post-month of the stroke were collected.

Results:

Out of 376 patients, 359 were included, with a mean (standard deviation) age of 67.8 (12.2) years and male predominance (56.2%). Hyperlipidemia and hypertension were the most prevalent comorbidities (91.1% and 80.5%, respectively). The NIHSS, BI and mRS scores were worse among women, with no significant effects for comorbidities. The NIHSS scores at admission and discharge were significantly correlated with the post-month BI and mRS scores.

Conclusion:

The study findings suggest a complex interplay of gender, strict control and prevention of the modifiable stroke risk factors, as well as the association of neurological deficits' intensity with the functional outcomes.

This study aimed to explore the demographics, the clinical risk factors and the scores of the National Institutes of Health Stroke Scale (NIHSS), modified Rankin Scale (mRS) and Barthel Index (BI) scale at different points of time among the survivors of acute ischemic stroke at a tertiary hospital in Jordan. Also, the study aimed to investigate the differences in the scales' scores by the patients' characteristics and the correlations between these scales. Out of 376 screened patients, 359 were included. Their mean (standard deviation) age was 67.8 (12.2) years, and 56.2% were men. Compared with male participants, women scored significantly worse on the NIHSS at admission (7.61 [5.51] vs 9.47 [6.64]; p = 0.048), NIHSS at discharge (5.57 [4.72] vs 7.40 [5.88]; p = 0.028) and BI scale 1 month post-event (78.68 [28.33] vs 66.03 [35.86]; p = 0.011). The mean (standard deviation) mRS score post-month of stroke was lower in men (2.4 [1.7]) than in women (2.9 [1.9]), with a lack of statistical significance (p = 0.097). Thus, despite the male predominance in the cohort, women tended to have a more severe stroke, worse neurological impairment and poorer functional outcomes. Hyperlipidemia had the highest prevalence, sensitivity, positive predictive value and negative predictive value rates, followed by hypertension. No statistically significant differences existed in the comorbidities' NIHSS, BI scale and mRS scores. Strong and significant correlations were observed between the scores of NIHSS at admission and discharge and the BI scale and mRS scores at 1 month post-event. Thus, the authors concluded that neurological deficit severity has a potential role in predicting functioning outcomes and vice versa.

The number of risk factors increases the recurrence events in ischemic stroke

PURPOSE

Stroke is a significant cause of disability worldwide and is considered a disease caused by long-term exposure to lifestyle-related risk factors. These risk factors influence the first event of stroke and recurrent stroke events, which carry more significant risks for more severe disabilities. This study specifically compared the risk factors and neurological outcome of patients with recurrent ischemic stroke to those who had just experienced their first stroke among patients admitted to the Hospital.

PATIENTS AND METHODS

We observed and analyzed 300 patients' data who met the inclusion and exclusion criteria. This retrospective observational study was conducted on consecutive acute ischemic stroke patients admitted to the top referral hospital, West Java, Indonesia. The data displayed are epidemiological characteristics, NIHSS score at admission and discharge, and the type and number of risk factors. Data were then analyzed using appropriate statistical tests.

RESULTS

Most patients had more than one risk factor with hypertension as the most frequent (268 subjects or 89.3%). In patients who experienced ischemic stroke for the first time, the average National Institutes of Health Stroke Scale (NIHSS) score was lower (6.52 ± 3.55), and the alteration of NIHSS score was higher (1.22 ± 2.26) than those with recurrent stroke (6.96 ± 3.55) for NIHSS score and 1.21 ± 1.73 for alteration of NIHSS score). We processed the data with statistical analysis and showed a positive correlation between age (P < 0.05) and the number of risk factors (P < 0.001) in the recurrent ischemic stroke group.

CONCLUSIONS

Age and the number of risk factors correlate with recurrent ischemic strokes.

Physical and rehabilitation medicine intervention in stroke in the acute hospital setting: A cross-sectional study

INTRODUCTION

Stroke represents the main cause of death and disability in Portugal. Resulting functional deficits are widely recognized. This work aims to evaluate the variation in functionality of stroke patients in the acute hospital setting under a rehabilitation program.

MATERIAL AND METHODS

Cross-sectional study of patients admitted to the Neurology department, from January to June 2019, with acute stroke. The variation in functionality was assessed using the Barthel index. Statistical analysis used Student's t-test and Spearman's correlation coefficient, with a p-value≤0.05 as significant.

RESULTS

106 patients with mean age of 63.7±14.2 years and a male predominance (60.4%) were included. Patients started rehabilitation program at 1.37±1.19 days after admission. A gain in functionality between admission and discharge was identified (50.18±32.37 versus 68.73±28.94, p<0.001). A significantly greater increase was observed in patients diagnosed under code stroke protocol (CSP) (p=0.021) and undergoing some type of acute phase treatment (p=0.017). From 90.5% of the patients that pursued rehabilitation after discharge, 40.6% were referred to an inpatient unit on average 12.7±7.0 days after admission.

DISCUSSION

In this study, Physical and Rehabilitation Medicine (PRM) provided early rehabilitation care to stroke patients. According to international evidence this is associated with greater functional gains. The variation in functionality verified during hospitalization demonstrates the importance of PRM in the acute hospital, assessing the rehabilitation needs after hospital discharge and maximizing outpatient rehabilitation. Diagnosis under CSP and undergoing acute treatment were determinants of greater functional improvement.

CONCLUSION

PRM plays a central role in the early management of functional impairment resulting from stroke and in the post-discharge guidance of patients.

Dependency in Activities of Daily Living During the First Year After Stroke

Background: Dependency in personal activities of daily living (ADL) is a common short-term and long-term consequence of stroke and requires targeted rehabilitation. As the duration of hospital stay has become shorter in recent decades, early identification of patients who require rehabilitation has become vital. To our knowledge, no study has investigated whether ADL dependency in the very early stages after admission to the stroke unit can explain ADL dependency 3 and 12 months later. This knowledge would facilitate planning for very early discharge and patient-centered rehabilitation.

Objective: This study evaluated whether ADL dependency within 2 days after stroke could explain ADL dependency at 3 and 12 months after stroke.

Methods: This longitudinal cohort study included patients with stroke who were treated at a stroke unit in the Sahlgrenska University Hospital (Gothenburg, Sweden) between May 2011 and March 2016. The primary independent variable was ADL dependency at 36–48 h after admission to the stroke unit, which was assessed using a Barthel Index (BI) score of ≤90. The dependent variables were self-reported personal ADL dependency at 3 and 12 months after stroke. Binary logistic regression analyses were performed.

Results: Of 366 eligible patients (58% male; median age 71 years), a majority (76%) had mild stroke and 60% were ADL dependent 36–48 h after stroke. Univariable and multivariable logistic regression analyses showed that patients who were dependent within the first 2 days after stroke had higher odds for being dependent 3 months as well as 12 months after stroke.

Conclusion: The results indicated that dependency in personal ADL during the first 2 days can explain dependency at 3- and 12-month post-stroke. Therefore, early ADL assessments post-stroke can be used for understanding rehabilitation needs after stroke.

Normobaric Hypoxia Exposure During Treadmill Aerobic Exercise After Stroke: A Safety and Feasibility Study

Objective

To evaluate the safety and feasibility of performing treadmill aerobic exercise in moderate normobaric hypoxia among chronic hemiparetic stroke survivors.

Design

Observational study using convenience sampling.

Setting

Research laboratory in a tertiary rehabilitation hospital.

Participants

Chronic hemiparetic stroke survivors who could walk at least 10-m with or without assistance and had no absolute contraindications to exercise testing.

Intervention

Participants (three male and four female) were asked to complete three normobaric hypoxia exposure protocols within a single session. First, they were passively exposed to normobaric hypoxia through gradual reductions in the fraction of inspired oxygen (F_IO₂ = 20.9, 17.0, and 15.0%) while seated (5-min at each level of F_IO₂). Participants were then exposed to the same reductions in F_IO₂ during constant-load exercise performed on a treadmill at 40% of heart rate reserve. Finally, participants completed 20-min of exercise while intermittently exposed to moderate normobaric hypoxia (5 × 2-min at F_IO₂ = 15.0%) interspaced with 2-min normoxia intervals (F_IO₂ = 20.9%).

Outcome Measures

The primary outcome was occurrence of adverse events, which included standardized criteria for terminating exercise testing, blood oxygen saturation (SpO₂) <80%, or acute mountain sickness score >2. The increased cardiovascular strain imposed by normobaric hypoxia exposure at rest and during exercise was evaluated by changes in SpO₂, heart rate (HR), blood pressure, and rating of perceived exertion (RPE).

Results

One participant reported mild symptoms of nausea during exercise in normobaric hypoxia and discontinued participation. No other adverse events were recorded. Intermittent normobaric hypoxia exposure was associated with reduced SpO₂ (MD = −7.4%, CI: −9.8 to −5.0) and increased HR (MD = 8.2, CI: 4.6 to 11.7) compared to intervals while breathing typical room air throughout the 20-min constant-load exercise period. The increase in HR was associated with a 10% increase in relative effort. However, reducing F_IO₂ had little effect on blood pressure and RPE measurements.

Conclusion

Moderate normobaric hypoxia appeared to be a safe and feasible method to increase the cardiovascular strain of submaximal exercise in chronic hemiparetic stroke survivors. Future studies evaluating the effects of pairing normobaric hypoxia exposure with existing therapies on secondary prevention and functional recovery are warranted.

Factors associated with time to independent walking recovery post-stroke

BACKGROUND

Past studies have inconsistently identified factors associated with independent walking post-stroke. We investigated the relationship between pre-stroke factors and factors collected acutely after stroke and number of days to walking 50 m unassisted using data from A Very Early Rehabilitation Trial (AVERT).

METHODS

The outcome was recovery of 50 m independent walking, tested from 24 hours to 3 months post-stroke. A set of a priori defined factors (participant demographics: age, sex, handedness; pre-stroke: hypertension, ischaemic heart disease, hypercholesterolaemia, diabetes mellitus, atrial fibrillation; stroke-related: stroke severity, stroke type, ischaemic stroke location, stroke hemisphere, thrombolysis) were investigated for association with independent walking using a cause-specific competing risk Cox proportional hazards model. Respective effect sizes are reported as cause-specific adjusted HR (caHR) adjusted for age, stroke severity and AVERT intervention.

RESULTS

A total of 2100 participants (median age 73 years, National Institutes of Health Stroke Scale 7, <1% missing data) with stroke were included. The median time to walking 50 m unassisted was 6 days (IQR 2-63) and 75% achieved independent walking by 3 months. Adjusted Cox regression indicated that slower return to independent walking was associated with older age (caHR 0.651, 95% CI 0.569 to 0.746), diabetes (caHR 0.836, 95% CI 0.740 to 0.945), severe stroke (caHR 0.094, 95% CI 0.072 to 0.122), haemorrhagic stroke (caHR 0.790, 95% CI 0.675 to 0.925) and right hemisphere stroke (caHR 0.796, 95% CI 0.714 to 0.887).

CONCLUSION

Our analysis provides robust evidence for important factors associated with independent walking recovery. These findings highlight the need for tailored mobilisation programmes that target subgroups, in particular people with haemorrhagic and severe stroke.

Outcome Prediction for Patients With Ischemic Stroke in Acute Care: New Three-Level Model by Eating and Bladder Functions

OBJECTIVE

To develop a new prediction model by combining independence in eating and bladder management functions, and to assess its utility in an acute care setting.

METHODS

Patients with ischemic stroke who were admitted in our acute stroke care unit (n=250) were enrolled in this study. Functional Independence Measure (FIM) scores for eating and bladder management on the initial day of rehabilitative treatment (median, 3 days) were collected as predictive variables. These scores were divided into low (<5) and high (≥5) and categorized as values 0 and 1, respectively. From the simple summation of these two-level model values, we derived a three-level model that categorized the scores as values 0, 1, and 2. The FIM-motor scores at discharge (median, 14 days) were collected as outcome measurements. The three-level model was assessed by observing the distribution patterns of the outcome FIM-motor scores and logistic regression analyses.

RESULTS

The median outcome FIM-motor score was 19 (interquartile range [IQR],13.8-45.3) for the value 0 category (n=14), 66.5 (IQR, 59.5-81.8) for the value 1 category (n=16), and 84 (IQR, 77-89) for the value 2 category (n=95) in the three-level model. Data fitting by logistic regression for FIM-motor scores of 41.3 and 61.4 reached 50% probability of values 1 and 2, respectively.

CONCLUSION

Despite the simplicity of the three-level model, it may be useful for predicting outcomes of patients with ischemic stroke in acute care.

Task-Oriented Circuit Training as an Alternative to Ergometer-Type Aerobic Exercise Training after Stroke

Moderate-intensity aerobic exercise training is an important treatment strategy to enhance functional recovery and decrease cardiometabolic risk factors after stroke. However, stroke related impairments limit access to ergometer-type exercise. The aims of the current study were (1) to evaluate whether our task-oriented circuit training protocol (intermittent functional training; IFT) could be used to sustain moderate-intensity aerobic workloads over a 10-week intervention period, and (2) to investigate its preliminary effects on cardiorespiratory fitness and metabolic profiles compared to constant-load ergometer-type exercise (CET). Forty chronic hemiparetic stroke survivors were randomized to receive 30 sessions of IFT or CET over ten weeks. Similar proportions of participants were randomized to IFT (7/19) and CET (9/18) sustained workloads associated with moderate-intensity aerobic exercise over the study period (p = 0.515). However, CET was associated with more substantial changes in maximal oxygen uptake (MD = 2.79 mL min⁻¹ kg⁻¹ CI: 0.84 to 4.74) compared to IFT (MD = 0.62 mL min⁻¹ kg⁻¹ CI: −0.38 to 1.62). Pre to post changes in C-reactive protein (−0.9 mg/L; p =0.017), short-term glycemia (+14.7 µmol/L; p = 0.026), and resting whole-body carbohydrate oxidation (+24.2 mg min⁻¹; p = 0.046) were observed when considering both groups together. Accordingly, IFT can replicate the aerobic intensities sustained during traditional ergometer-type exercise training. More work is needed to evaluate the dose–response effects of such task-oriented circuit training protocols on secondary prevention targets across the continuum of stroke recovery.

The Lymphocyte Depletion in Patients with Acute Ischemic Stroke Associated with Poor Neurologic Outcome

Purpose

Inflammation plays an important role and is involved in all stages of acute ischemic stroke. One of these stages involves the recruitment of leukocytes from the peripheral circulation into the ischemic tissue. Lymphocytes as a subtype of leukocytes are important mediators and can become a predictor of neurological outcome. Several studies have been conducted regarding the correlation between differential lymphocyte counts and acute ischemic stroke. Most of these studies analyzed lymphocyte ratio to other leukocyte subtypes such as neutrophils and monocytes. This study specifically observed the role of lymphocytes as an indicator of the inflammatory response in patients with acute ischemic stroke. This study aimed to observe the correlation among risk factors, infarct location, leukocyte counts, lymphocyte value and neurologic output in acute ischemic stroke patients.

Patients and Methods

We observed and analyzed 193 patients’ data from medical record which met the inclusion and exclusion criteria with a diagnosis of acute ischemic stroke at the Department of Neurology of Dr. Hasan Sadikin General Bandung. Data were then analysed using appropriate statistical tests.

Results

Most patients have more than one risk factor with a leukocyte count of less than 10,000 cell/mm³. Infarct was mostly located in subcortical area (basal ganglia), with moderate average NIHSS values at admission and at discharge. The number of lymphocytes decreased in the subject group with more than 10,000 cell/mm³ leukocytes. Subsequently, data were analyzed using Spearman’s test and there was a correlation between NIHSS on admission and lymphocyte depletion.

Conclusion

The lymphocyte depletion in patients with leukocytosis is a predictor of poor NIHSS.

Incidental Unruptured Intracranial Aneurysms Do Not Impact Outcome in Patients With Acute Cerebral Infarction

Background: This study was to examine the patients with acute cerebral infarction (ACI) treated at a single center over 9 years and who underwent Unruptured intracranial aneurysm (UIA) screening by three-dimensional time-of-flight magnetic resonance angiography (3D-TOF-MRA), and to explore the factors associated with outcomes.

Methods: The outcome was the modified Rankin scale (mRS) score at 90 days after stroke onset. The outcome was classified into a good outcome (mRS score of 0–2 points) and poor outcome (mRS score of 3–6 points).

Results: UIAs were found in 260 (6.5%) of 4,033 patients with ACI; 2,543 (63.1%) had a good outcome, and 1,490 (36.9%) had a poor outcome. There was no difference in outcomes between the two groups (P = 0.785). The multivariable analysis showed that age (OR = 1.009, 95%CI: 1.003–1.014, P = 0.003), diabetes (OR = 1.179, 95%CI: 1.035–1.342, P = 0.013), ischemic stroke history (OR = 1.451, 95%CI: 1.256–1.677, P < 0.001), and baseline NIHSS score (OR = 1.034, 95%CI: 1.018–1.050, P < 0.001) were independently associated with the 90-day outcomes in patients with ACI. The presence of incidental UIA was not associated with outcomes after ACI.

Conclusions: Age, diabetes, ischemic stroke history, and baseline NIHSS score were independently associated with the early outcomes of patients with ACI.

Analysis of Risk Factors for Poor Short-Term Outcomes in Acute Cardioembolic Stroke Patients without Reperfusion Therapy

PURPOSE

Few clinical indicators of a poor outcome have been defined in acute cardioembolic stroke (CES) patients. We would like to explore practical clinical factors that can predict poor outcomes of CES in the early stage.

PATIENTS AND METHODS

In this single-center, retrospective, observational study, 251 consecutive patients with acute CES who did not undergo reperfusion therapy were evaluated. On the basis of the modified Rankin Scale (mRS) score at 3 months, patients were divided into the good functional outcome group (mRS ≤ 2) and the poor functional outcome group (mRS ≥ 3). Risk factors were analyzed and the independent indicators for a poor outcome were identified using a binary logistic regression model.

RESULTS

One hundred (39.8%) patients had a poor outcome. Patients in the poor outcome group were significantly older (P = 0.002) and had significantly higher baseline National Institutes of Health Stroke Scale (NIHSS) score compared with those with a good outcome (P < 0.001). After adjusting for potential confounders, the baseline NIHSS score (P < 0.001), moderate to severe leukoaraiosis (P = 0.011), non-symptomatic intracranial hemorrhage (P = 0.019), stroke-associated pneumonia (P = 0.001), and fasting glucose (P = 0.040) were independent risk factors for a poor outcome.

CONCLUSION

The short-term outcome in acute CES patients without reperfusion therapy can be predicted by using five practical clinical factors. These indicators should attract more attention.

Self-perceived postural balance correlates with postural balance and anxiety during the first year after stroke: a part of the randomized controlled GOTVED study

BACKGROUND

Postural balance is an important rehabilitation outcome, and screening stroke patients for confidence in postural balance during rehabilitation and before hospital discharge is recommended. Early supported discharge could improve postural balance self-confidence. This study aimed to investigate associations between patient self-confidence in postural balance and observer-assessed postural balance and anxiety during the first year after stroke. Whether very early supported discharge (VESD) affects self-confidence in postural balance compared with standard discharge was also evaluated.

METHODS

A longitudinal trial for with data extracted from a randomized controlled study of 140 adults with confirmed stroke was conducted. The experimental group received VESD. The control group was discharged according to the standard routine. Postural balance was assessed with Berg Balance Scale (BBS), Timed Up and Go (TUG) test, and Falls Efficacy Scale. Anxiety was assessed with the Hospital Anxiety and Depression Scale. Spearman's rank correlation coefficient (rho) was used to test associations between independent variables. The Wilcoxon signed-rank test was used to examine differences over time. A single test, according to Eid, Gollwitzer, and Schmidt, was used to test temporal differences in correlation.

RESULTS

The correlation between self-confidence in postural balance and observer-assessed postural balance was 0.62-0.78 in the first year after stroke. The correlation between self-confidence and anxiety was 0.22-0.41 in the first year after stroke. Correlations did not differ by group affiliation at any time point when the postural balance was assessed with BBS. The intervention group had a significantly higher correlation (r = - 0.709) than the control group (r = - 0.416) when postural balance was assessed with the TUG test 1 month after discharge. There were no significant differences in correlations between confidence in postural balance and anxiety between the two groups at any time point.

CONCLUSIONS

Patients with mild stroke can accurately assess their confidence in performing daily activities without falling. VESD does not substantially affect the correlation between self-confidence in postural balance and observer assessed postural balance and is safe to use as an alternative to standard discharge. Assessment of self-confidence can provide important information for rehabilitation planning and supporting the physical activity of patients after discharge.

TRIAL REGISTRATION

Clinical Trials.gov: NCT01622205 . Registered 19 June 2012 (retrospectively registered).

Motor Impairment Three Months Post Stroke Implies A Corresponding Cognitive Deficit

BACKGROUND

While both motor and cognitive impairment are common after stroke, the focus of (early) treatment has always been on motor deficit.

AIMS

The objective of the current study was to explore the link between motor and cognitive performance in stroke patients and to examine whether motor performance is associated with cognitive functioning at three months post stroke.

METHODS

In both stroke patients (n = 142) and controls (n = 135), with the groups matched on age, gender and premorbid IQ, motor functioning was evaluated using both objective (Purdue Pegboard Test) and subjective measures (specific items from the Frenchay Activities Index and Barthel Index). Cognition, specifically information processing speed, working memory and cognitive flexibility, was assessed using objective tasks. The data were analyzed using Pearson product-moment correlation coefficients and logistic regression.

RESULTS

Significant correlations between motor and cognitive functioning were found in stroke patients. The objective motor task was stronger than subjective measures in statistically explaining and predicting cognitive deficit, irrespective of stroke severity.

CONCLUSIONS

We conclude that motor impairment at three months post-stroke should serve as a 'red flag' for professionals: cognitive impairment is likely and should also be evaluated.

Predicting functional outcomes after stroke: an observational study of acute single-channel EEG

Background: Early and objective prediction of functional outcome after stroke is an important issue in rehabilitation. Electroencephalography (EEG) has long been utilized to describe and monitor brain function following neuro-trauma, and technological advances have improved usability in the acute setting. However, skepticism persists whether EEG can provide the same prognostic value as neurological examination.Objective: The current cohort study examined the relationship between acute single-channel EEG and functional outcomes after stroke.Methods: Resting-state EEG recorded at a single left pre-frontal EEG channel (FP1) was obtained from 16 adults within 72 h of first stroke. At 30 and 90 days, measures of disability (modified Rankin Scale; mRS) and involvement in daily activities (modified Barthel Index; mBI) were obtained. Acute EEG measures were correlated with functional outcomes and compared to an early neurological examination of stroke severity using the National Institute of Health Stroke Scale (NIHSS). Classification of good outcomes (mRS ≤1 or mBI ≥95) was also examined using Receiver Operator Curve analyses.Results: One-third to one-half of participants experienced incomplete post-stroke recovery, depending on the time point and measure. Functional outcomes correlated with acute theta values (r_s 0.45-0.60), with the strength of associations equivalent to previously reported values obtained from conventional multi-channel systems. Acute theta values ≥0.25 were associated with good outcomes, with positive (67-83%) and negative predictive values (70-90%) comparable to those obtained using the NIHSS.Conclusions: Acute, single-channel EEG can provide unique, non-overlapping clinical information, which may facilitate objective prediction of functional outcome after stroke.

Gothenburg Very Early Supported Discharge study (GOTVED): a randomised controlled trial investigating anxiety and overall disability in the first year after stroke

Background and purpose

Early supported discharge (ESD) has been shown to be efficient and safe as part of the stroke care pathway. The best results have been seen with a multidisciplinary team and after mild to moderate stroke. However, how very early supported discharge (VESD) works has not been studied.

The aim of this study was to investigate whether VESD for stroke patients in need of ongoing individualized rehabilitation affects the level of anxiety and overall disability for the patient compared with ordinary discharge routine.

Methods

A randomized controlled trial was performed with intention to treat analyses comparing VESD and ordinary discharge from hospital. All patients admitted at the stroke care unit at Sahlgrenska University Hospital of Gothenburg between August 2011 and April 2016 were screened. Inclusion occurred on day 4 using a block randomization of 20 and with a blinded assessor. Assessments were made 5 days post-stroke and 3 and 12 months post-stroke. Patients in the VESD group underwent continued rehabilitation in their homes with a multidisciplinary team from the stroke care unit for a maximum of 1 month. The patients in the control group had support as usual after discharge when needed such as home care service and outpatient rehabilitation.

The primary outcome was anxiety as assessed by the Hospital Anxiety and Depression Scale-Anxiety subscale (HADS-A). The secondary outcome was the patients’ degree of overall disability, measured by the modified Rankin Scale (mRS).

Results

No significant differences were found between the groups regarding anxiety at three or 12 months post-stroke (p = 0.811). The overall disability was significantly lower in the VESD group 3 months post-stroke (p = 0.004), compared to the control group. However, there was no significant difference between the groups 1 year post-stroke.

Conclusions

The VESD does not affects the level of anxiety compared to ordinary rehabilitation. The VESD leads to a faster improvement of overall disability compared to ordinary rehabilitation. We suggest considering coordinated VESD for patients with mild to moderate stroke in addition to ordinary rehabilitation as part of the service from a stroke unit.

Trial registration

Clinical Trials.gov: NCT01622205. Registered 19 June 2012 (retrospectively registered).

Time-dependence of NIHSS in predicting functional outcome of patients with acute ischemic stroke treated with intravenous thrombolysis

OBJECTIVES

The National Institute of Health Stroke Scale (NIHSS) is a predictor for the prognosis of acute ischaemic stroke (AIS) and its prediction is time-dependent. We examined the performance of NIHSS at different timepoints in predicting functional outcome of patients with thrombolysed AIS.

METHODS

This prospective study included 269 patients with AIS treated with recombinant tissue plasminogen activator (rt-PA). Unfavourable functional outcome was defined as modified Rankin Scale score 4-6 at 3 months after rt-PA treatment. Receiver operating characteristic curves were used to examine the predictive power of NIHSS score at admission and 2 hours/24 hours/7 days/10 days after rt-PA treatment. Youden's index was used to select the threshold of NIHSS score. Logistic regression was used to estimate the ORs of unfavourable functional outcome for patients with NIHSS score higher than the selected thresholds.

RESULTS

The threshold of NIHSS score at admission was 12 (sensitivity: 0.51, specificity: 0.84) with an acceptable predictive power (area under curve [AUC] 0.74) for unfavourable functional outcome. The threshold changed to 5 at 24 hours after rt-PA treatment (sensitivity: 0.83, specificity: 0.65) and remained unchanged afterwards. The predictive power and sensitivity sequentially increased over time and peaked at 10 days after rt-PA treatment (AUC 0.92, sensitivity: 0.85, specificity: 0.80). NIHSS scores higher than the thresholds were associated with elevated risk of unfavourable functional outcome at all timepoints (all p<0.001).

CONCLUSIONS

NIHSS is time-dependent in predicting AIS prognosis with increasing predictive power over time. Since patients whose NIHSS score ≥ 12 are likely to have unfavourable functional outcome with rt-PA treatment only, mechanical thrombectomy should be largely taken into consideration for these patients.

Geriatric rehabilitation

Rehabilitation of elderly persons is accompanied by unique challenges, as the physiologic changes with aging may be compounded by a multitude of psychologic, social, and genetic factors. In this chapter we present an overview of the impairments that develop with aging. We discuss factors to consider when evaluating a patient with functional complaints and opportunities for treatment. We provide an overview of common injuries encountered in the elderly, prognostication, and general strategies employed for rehabilitation. New treatment options and areas of ongoing research are also discussed.

Long-Term Outcomes of FIM Motor Items Predicted From Acute Stage NIHSS of Patients With Middle Cerebral Artery Infarct

Objective

To outline the association between the National Institutes of Health Stroke Scale (NIHSS) in the acute stage and the Functional Independence Measure (FIM) of motor items several months later.

Methods

Seventy-nine infarct cases with middle-cerebral-artery region transferred to long-term rehabilitation facilities were analyzed. Patients were allocated to either the model-development group or the confirmatory group at a 2:1 ratio. Independent variables were based on the NIHSS during the acute care and on demographic factors such as age and modified Rankin Scale (mRS) before onset. Multivariate logistic analyses were performed to predict the independence of each FIM motor item. These models were evaluated in the confirmatory group.

Results

Multivariate logistic analyses in the model-development group (n=53) indicated that at least one NIHSS item was statistically significantly associated with the functional independence of a single FIM motor item. Of the NIHSS items, the affected lower extremity item was the most widely associated with 11 of the FIM motor items, except for eating and shower transfer. The affected upper extremity function was the second widely involved factor associated with 7 of the FIM motor items including eating, grooming, bathing, toileting, bed transfer, toilet transfer, and shower transfer. Age and mRS were also statistically significant contributing factors. The obtained predictive models were assessed in the confirmatory group (n=26); these were successful except for the stairs climb item.

Conclusion

In combination with age and pre-stroke status, the NIHSS items (especially the affected extremity items) may be useful for the prediction of long-term outcome in terms of activities in daily living.

Relationship between outcome in acute stroke patients and multiple stroke related scores obtained after onset of stroke

[Purpose] The purpose of this study is to examine the effectiveness of a stroke-related scale with regard to outcome, onset, and timing of stroke patients. [Participants and Methods] The participants included 583 out of 996 patients who were admitted to the stroke care unit.The outcomes and 3 stroke scale (National Institutes of Health Stroke Scale: NIHSS, Functional Independence Measure: FIM, modified Rankin Scale: mRS) scores immediately at hospitalization, on day 7 after onset, and on day 30 after onset were investigated. This study was analyzed using a generalization linear model with a binomial distribution. The comparisons between outcomes were made in terms of home discharge versus convalescence, and convalescence versus hospital transfer. [Results] Comparisons of home discharge versus convalescence hospital transfer showed a significant difference in the NIHSS and mRS scores at the time of hospitalization, and a significant difference in the NIHSS scale score on day 7 after onset. In comparisons between convalescence and hospital transfer, significant differences were observed in NIHSS and FIM scores at hospitalization, and the FIM scale score showed significant differences on day 7 and day 30. [Conclusion] The study suggested the efficacy of using multiple scales for prediction of stroke outcome with higher accuracy.

Predictive values of CSS and NIHSS in the prognosis of patients with acute cerebral infarction: A comparative analysis

This study aims to investigate the predictive values of the Chinese Stroke Scale (CSS) and National Institutes of Health Stroke Scale (NIHSS) in the prognosis of patients with acute cerebral infarction.A total of 399 patients with acute cerebral infarction were assessed using CSS and NIHSS within 1 day after admission. Then, the receiver operating characteristic (ROC) curves were established, and the area under the curves of these 2 scoring systems was compared.The area under the curve of CSS and NIHSS was 0.796 and 0.794, respectively.CSS and NIHSS have good predictive values for the prognosis of patients with acute cerebral infarction.

Feasibility of Cognitive Functions Screened With the Montreal Cognitive Assessment in Determining ADL Dependence Early After Stroke

Objective: To investigate the feasibility of assessing cognitive function using the Montreal Cognitive Assessment (MoCA) given 36-48 h post stroke to explain dependence in activities of daily living (ADL). Methods: This is a cross-sectional, exploratory study. Cognitive function and basic ADL were assessed with the MoCA and the Barthel Index (BI), respectively, within 36-48 h of admission. Neurological functions were assessed with the National Institute of Health Stroke Scale (NIHSS) upon admittance to the hospital. Binary logistic regression analyses were performed to assess the feasibility of the MoCA in explaining ADL dependence. Results: Data were available for 550 patients (42% females, mean age 69 years). Moderate correlations (r_s > +0.30, p < 0.001) were found between the total score on the BI, MoCA, and visuospatial/executive functions. The regression analysis model including only MoCA as an independent variable had a high sensitivity for explaining ADL dependence. However, the model with independent variables of MoCA, NIHSS, and age had the best area under the curve value (0.74). Conclusions: Cognitive functions assessed with the MoCA partly explain ADL dependence 36-48 h post stroke. Stroke-related neurological deficits and age should be additional considerations.

The clinical utility of a 30-minute neuropsychological assessment battery in inpatient stroke rehabilitation

Cognitive assessment is an important component of inpatient stroke rehabilitation. Few studies have empirically evaluated the clinical utility of specific neuropsychological measures in this setting. We investigated the psychometric properties and clinical utility of a 30-minute neuropsychological battery developed by the National Institute of Neurologic Disorders and Stroke (NINDS) and the Canadian Stroke Network (CSN). Clinical data were analyzed from 100 individuals with mild-moderate stroke severity on an acute inpatient rehabilitation unit who completed the NINDS-CSN battery at admission. The battery comprised the Symbol-Digit Modalities Test (SDMT), Trail Making Test, Controlled Oral Word Association Test, Animal Naming, and the Hopkins Verbal Learning Test-Revised. We evaluated the battery's distribution of scores, frequency of impaired performance, internal consistency, and ability to predict rehabilitation gain and independence in cognitively-based instrumental activities of daily living (IADL) at discharge. Results indicated that the NINDS-CSN battery was sensitive to cognitive impairment, demonstrated moderately strong internal consistency, and predicted discharge IADL. The SDMT demonstrated the strongest sensitivity to impairment and predictive validity. The NINDS-CSN battery is a clinically useful assessment battery in acute inpatient stroke rehabilitation. Complex attention and processing speed performance may be most informative in predicting amount of rehabilitation gain and IADL functioning at discharge.

Contribution of Neuro-Imaging for Prediction of Functional Recovery after Ischemic Stroke

Prediction measures of recovery and outcome after stroke perform with only modest levels of accuracy if based only on clinical data. Prediction scores can be improved by including morphologic imaging data, where size, location, and development of the ischemic lesion is best documented by magnetic resonance imaging. In addition to the primary lesion, the involvement of fiber tracts contributes to prognosis, and consequently the use of diffusion tensor imaging (DTI) to assess primary and secondary pathways improves the prediction of outcome and of therapeutic effects. The recovery of ischemic tissue and the progression of damage are dependent on the quality of blood supply. Therefore, the status of the supplying arteries and of the collateral flow is not only crucial for determining eligibility for acute interventions, but also has an impact on the potential to integrate areas surrounding the lesion that are not typically part of a functional network into the recovery process. The changes in these functional networks after a localized lesion are assessed by functional imaging methods, which additionally show altered pathways and activated secondary centers related to residual functions and demonstrate changes in activation patterns within these networks with improved performance. These strategies in some instances record activation in secondary centers of a network, for example, also in homolog contralateral areas, which might be inhibitory to the recovery of primary centers. Such findings might have therapeutic consequences, for example, image-guided inhibitory stimulation of these areas. In the future, a combination of morphological imaging including DTI of fiber tracts and activation studies during specific tasks might yield the best information on residual function, reserve capacity, and prospects for recovery after ischemic stroke.

Life satisfaction in persons with severe stroke - A longitudinal report from the Sunnaas International Network (SIN) stroke study

Introduction

The overall aim of the present study was to explore perceived life satisfaction in persons with stroke, from admission to specialised rehabilitation until follow up 1 year post-discharge. The secondary aim was to evaluate possible external and internal explanatory factors for perceived life satisfaction.

Patients and methods

A prospective, descriptive study of specialised rehabilitation of persons with stroke. Persons with a primary diagnosis of stroke were enrolled in the study.

Results

Overall, total score on LiSat-11 showed that life was perceived as satisfying by 11% on admission, 21% at discharge, 25% at 6 and 31% at 12 months after discharge from rehabilitation, reported by 230 participating persons with stroke. Repeated measurement indicated significant differences of total life satisfaction between clinics, also when controlled for disability and severity. The items "sexual life," "health," and "vocational life"/"financial" were most dissatisfying at the various reported time points. The linear regression analysis revealed an equal amount of internal and external explanatory factors at the different time points, explaining between 16% and 41% of the variations.

Discussion and conclusion

The perceived life satisfaction was reported as low/dissatisfying at the four stated time points in all the participating clinics. Four items were especially vulnerable post-stroke: vocational situation, sexual life, physical health and mental health. Both internal and external factors contributed to life satisfaction, such as gender, severity of stroke, marital status, country, models of rehabilitation, occupational status, length of stay (LOS), number of therapies and hours in therapy. However, there were significant differences between clinics, indicating that unidentified factors may also influence life satisfaction.

Anatomical Parameters of tDCS to Modulate the Motor System after Stroke: A Review

Transcranial direct current stimulation (tDCS) is a non-invasive brain stimulation method to modulate the local field potential in neural tissue and consequently, cortical excitability. As tDCS is relatively portable, affordable, and accessible, the applications of tDCS to probe brain-behavior connections have rapidly increased in the last 10 years. One of the most promising applications is the use of tDCS to modulate excitability in the motor cortex after stroke and promote motor recovery. However, the results of clinical studies implementing tDCS to modulate motor excitability have been highly variable, with some studies demonstrating that as many as 50% or more of patients fail to show a response to stimulation. Much effort has therefore been dedicated to understand the sources of variability affecting tDCS efficacy. Possible suspects include the placement of the electrodes, task parameters during stimulation, dosing (current amplitude, duration of stimulation, frequency of stimulation), individual states (e.g., anxiety, motivation, attention), and more. In this review, we first briefly review potential sources of variability specific to stroke motor recovery following tDCS. We then examine how the anatomical variability in tDCS placement [e.g., neural target(s) and montages employed] may alter the neuromodulatory effects that tDCS exerts on the post-stroke motor system.

Neuropsychological Outcome and its Predictors Across the First Year after Ischaemic Stroke

Background: Neuropsychological deficits occur in over half of the stroke survivors and are associated with the reduced functioning and a decline in quality of life. However, the trajectory of recovery and predictors of neuropsychological outcomes over the first year post stroke are poorly understood.

Method: Neuropsychological performance, assessed using the CNS-Vital signs, was examined at 1 month, 6 months and 12 months after ischaemic stroke (IS) in a sample drawn from a population-based study (N = 198).

Results: While mean scores across neuropsychological domains at each time-point fell in the average range, one in five individuals produced very low-range scores for verbal memory, attention and psychomotor speed. Significant improvements were seen for executive functioning, psychomotor speed and cognitive flexibility within 6 months post stroke, but no gains were noted from 6 to 12 months. Stroke-related neurological deficits and depression at baseline significantly contributed to the prediction of neuropsychological function at 12 month follow-up.

Conclusions: In a significant minority of IS survivors, focal deficits are evident in psychomotor speed, verbal memory, executive functions and attention. Significant improvements in these domains were only evident in the first 6 months post stroke. Initial stroke-related neurological deficits and concurrent depression may be the best predictors of later cognitive functioning.

Selecting relevant and feasible measurement instruments for the revised Dutch clinical practice guideline for physical therapy in patients after stroke

PURPOSE

To select relevant and feasible instruments for the revision of the Dutch clinical practice guideline for physical therapy in patients with stroke.

METHODS

In this implementation study a comprehensive proposal for ICF categories and matching instruments was developed, based on reliability and validity. Relevant instruments were then selected in a consensus round by 11 knowledge brokers who were responsible for the implementation of the selected instruments. The feasibility of the selected instruments was tested by 36 physical therapists at different work settings within stroke services. Finally, instruments that were deemed relevant and feasible were included in the revised guideline.

RESULTS

A total of 28 instruments were recommended for inclusion in the revised guideline. Nineteen instruments were retained from the previous guideline. Ten new instruments were tested in clinical practice, seven of which were found feasible. Two more instruments were added after critical appraisal of the set of the measurement instruments.

CONCLUSIONS

The revised guideline contains 28 relevant and feasible instrument selected and tested in clinical practice by physical therapists. Further education and implementation is needed to integrate instruments in clinical practice. Further research is proposed for developing and implementing a core set of measurement instruments to be used at fixed time points to establish data registries that allow for continuous improvement of rehabilitation for stroke patients. Implications for Rehabilitation The revised Dutch Stroke Physical Therapy Guideline recommends a total of 28 instruments, that are relevant and feasible for clinical practice of physical therapist in the different settings of stroke rehabilitation. The selection of instrument in daily practice should be part of the clinical reasoning process of PTs and be tailored to individual patients' needs and the degree of priority of the affected ICF category. Suggested education strategies for further integration of instruments in of the daily practice of PTs in Stroke Rehabilitation are: 'Training on the job' and 'peer assessment in clinical situations'.

Comprehensive rehabilitation with integrative medicine for subacute stroke: A multicenter randomized controlled trial

To determine whether integrative medicine rehabilitation (IMR) that combines conventional rehabilitation (CR) with acupuncture and Chinese herbal medicine has better effects for subacute stroke than CR alone, we conducted a multicenter randomized controlled trial that involved three hospitals in China. Three hundred sixty patients with subacute stroke were randomized into IMR and CR groups. The primary outcome was the Modified Barthel Index (MBI). The secondary outcomes were the National Institutes of Health Stroke Scale (NIHSS), the Fugl-Meyer Assessment (FMA), the mini-mental state examination (MMSE), the Montreal Cognitive Assessment (MoCA), Hamilton’s Depression Scale (HAMD), and the Self-Rating Depression Scale (SDS). All variables were evaluated at week 0 (baseline), week 4 (half-way of intervention), week 8 (after treatment) and week 20 (follow-up). In comparison with the CR group, the IMR group had significantly better improvements (P < 0.01 or P < 0.05) in all the primary and secondary outcomes. There were also significantly better changes from baseline in theses outcomes in the IMR group than in the CR group (P < 0.01). A low incidence of adverse events with mild symptoms was observed in the IMR group. We conclude that conventional rehabilitation combined with integrative medicine is safe and more effective for subacute stroke rehabilitation.

Computational neurorehabilitation: modeling plasticity and learning to predict recovery

Despite progress in using computational approaches to inform medicine and neuroscience in the last 30 years, there have been few attempts to model the mechanisms underlying sensorimotor rehabilitation. We argue that a fundamental understanding of neurologic recovery, and as a result accurate predictions at the individual level, will be facilitated by developing computational models of the salient neural processes, including plasticity and learning systems of the brain, and integrating them into a context specific to rehabilitation. Here, we therefore discuss Computational Neurorehabilitation, a newly emerging field aimed at modeling plasticity and motor learning to understand and improve movement recovery of individuals with neurologic impairment. We first explain how the emergence of robotics and wearable sensors for rehabilitation is providing data that make development and testing of such models increasingly feasible. We then review key aspects of plasticity and motor learning that such models will incorporate. We proceed by discussing how computational neurorehabilitation models relate to the current benchmark in rehabilitation modeling - regression-based, prognostic modeling. We then critically discuss the first computational neurorehabilitation models, which have primarily focused on modeling rehabilitation of the upper extremity after stroke, and show how even simple models have produced novel ideas for future investigation. Finally, we conclude with key directions for future research, anticipating that soon we will see the emergence of mechanistic models of motor recovery that are informed by clinical imaging results and driven by the actual movement content of rehabilitation therapy as well as wearable sensor-based records of daily activity.

Synergistic effect of moxibustion and rehabilitation training in functional recovery of post-stroke spastic hemiplegia

OBJECTIVE

To evaluate the therapeutic benefit of combining moxibustion and rehabilitation training for functional recovery in post-stroke spastic hemiplegic patients.

METHODS

We randomly divided 84 cases subjecting to inclusion criteria into moxibustion plus rehabilitation training group (MRT group, n=44) and rehabilitation training group (RT group, n=40). Evaluation of therapeutic effect was observed before treatment, 2 weeks during treatment and 6 months after treatment. Spasticity was evaluated using modified Ashworth scale (MAS) and Clinical Spasticity Index (CSI), recovery of motor function was assessed by Brunnstrom recovery stages and Simplified Fugl-Meyer Motor Scale, and performance of activities of daily living (ADL) was measured, and the quality of life was assessed by Patient Reported Outcomes (PRO).

RESULTS

Evaluation of upper limbs, hands and lower limbs based on CSI and MAS revealed significant improvements in patients treated with MRT, compared to RT alone, both during and after therapy. CSI and MAS also showed significant improvement in patients at each time point in the MRT group, compared to RT group. Marked improvement in Fugl-Meyer Motor Scale was also observed in MRT group at each time point. Based on Brunnstrom grades of upper limbs, hands and lower limbs, significant differences between the two groups were recorded at all time points during and after therapy. Barthel index (BI) and PRO also confirmed the dramatic differences between the two therapy groups.

CONCLUSIONS

Our results demonstrate that combination therapy with moxibustion and rehabilitation training offers greater clinical benefits in relieving spasticity, promoting function recovery of motion, improving the performance of ADL, and increasing quality of life in post-stroke spastic hemiplegic patients, compared to RT alone.

Ischemic Stroke: Risk Stratification, Warfarin Teatment and Outcome Measure

Stroke is a focal neurological syndrome of vascular basis, which may be due to ischemic thrombo-embolism or intra-cerebral haemorrhage. This condition has to be treated on emergency basis as it may cause an irreversible neurological damage. Warfarin has been a widely used oral anti-coagulant in treating ischemic stroke patients. This review highlights the benefits and challenges of warfarin treatment in stroke patients and discusses about the importance of risk stratification scores and bleeding scores in estimating the bleeding risk associated with warfarin treatment. This review also highlights the use of stroke outcome measures in identifying the patients with post-stroke disabilities to provide patient specific treatment.

Pre-admission CHADS2, CHA2DS2-VASc, and R2CHADS2 Scores on Severity and Functional Outcome in Acute Ischemic Stroke with Atrial Fibrillation

BACKGROUND

We examined the association between pre-admission risk scores and severity on admission and functional outcome in acute ischemic stroke with atrial fibrillation (AF).

METHODS

Between September 2011 and April 2014, we retrospectively extracted consecutive ischemic stroke patients with AF whose pre-admission modified Rankin Scale (mRS) score was 2 or less from our prospective database. Pre-admission CHADS2, CHA2DS2-VASc, and R2CHADS2 scores were calculated in each patient, and their association with the National Institutes of Health Stroke Scale (NIHSS) score on admission or unfavorable outcome (mRS ≥ 3 at 3 months from the onset) was assessed.

RESULTS

A total of 344 patients (189 were men; age, 77.7 ± 10.0 years) were included in the analysis. The median pre-admission CHADS2, CHA2DS2-VASc, and R2CHADS2 scores were 2, 4, and 4, respectively. NIHSS score on admission was positively correlated with pre-admission CHADS2 (ρ = .116, P = .031), CHA2DS2-VASc (ρ = .166, P = .020), and R2CHADS2 scores (ρ = .106, P = .049). Receiver operating characteristic (ROC) curve analysis revealed that pre-admission CHADS2 score of 2 or more (sensitivity, 80%; specificity, 45%; area under the ROC curve [AUC], .654), CHA2DS2-VASc score of 3 or more (sensitivity, 86%; specificity, 44%; AUC, .683), and R2CHADS2 score of 4 or more (sensitivity, 61%; specificity, 62%; AUC, .657) were associated with unfavorable outcome. The pre-admission CHA2DS2-VASc score was better than the pre-admission CHADS2 score in estimating unfavorable outcome (P = .017). In multivariate analysis, cutoffs of these scores, female sex, higher NIHSS score, and internal carotid artery occlusion were associated with unfavorable outcome.

CONCLUSIONS

Pre-admission CHADS2, CHA2DS2-VASc, and R2CHADS2 scores were associated with onset severity and functional outcome in acute ischemic stroke with AF.

Daily National Institutes of Health Stroke Scale examinations at stroke centers: why not do them?

The National Institutes of Health Stroke Scale was originally designed to stratify patients according to stroke severity for clinical trials, and now it is used to predict disposition and prognosticate functional outcome. Many researchers have also adopted it to trend patient progress over time and detect early neurologic deterioration. However, few investigators have reported its utility in monitoring the daily progress of patients hospitalized for stroke. In the present article, the authors discuss the advantages of daily National Institutes of Health Stroke Scale assessments and our clinical experience with this invaluable tool.

Generalizability of the Proportional Recovery Model for the Upper Extremity After an Ischemic Stroke

BACKGROUND AND OBJECTIVE

Spontaneous neurological recovery after stroke is a poorly understood process. The aim of the present article was to test the proportional recovery model for the upper extremity poststroke and to identify clinical characteristics of patients who do not fit this model.

METHODS

A change in the Fugl-Meyer Assessment Upper Extremity score (FMA-UE) measured within 72 hours and at 6 months poststroke served to define motor recovery. Recovery on FMA-UE was predicted using the proportional recovery model: ΔFMA-UEpredicted = 0.7·(66 - FMA-UEinitial) + 0.4. Hierarchical cluster analysis on 211 patients was used to separate nonfitters (outliers) from fitters, and differences between these groups were studied using clinical determinants measured within 72 hours poststroke. Subsequent logistic regression analysis served to predict patients who may not fit the model.

RESULTS

The majority of patients (~70%; n = 146) showed a fixed proportional upper extremity motor recovery of about 78%; 65 patients had substantially less improvement than predicted. These nonfitters had more severe neurological impairments within 72 hours poststroke (P values <.01). Logistic regression analysis revealed that absence of finger extension, presence of facial palsy, more severe lower extremity paresis, and more severe type of stroke as defined by the Bamford classification were significant predictors of not fitting the proportional recovery model.

CONCLUSIONS

These results confirm in an independent sample that stroke patients with mild to moderate initial impairments show an almost fixed proportional upper extremity motor recovery. Patients who will most likely not achieve the predicted amount of recovery were identified using clinical determinants measured within 72 hours poststroke.

Are the hierarchical properties of the Fugl-Meyer assessment scale the same in acute stroke and chronic stroke?

BACKGROUND

The motor function section of the Fugl-Meyer assessment scale (FM motor scale) is a robust scale of motor ability in people after stroke, with high predictive validity for outcome. However, the FM motor scale is time-consuming. The hierarchical properties of the upper extremity (UE) and lower extremity (LE) sections of the FM motor scale have been established in people with chronic stroke. These data support the use of a more concise method of administration and confirm scores can be legitimately summed.

OBJECTIVE

The aim of this study was to establish that a similar hierarchy exists in people within 72 hours after stroke onset.

DESIGN

A prospective, cross-sectional design was used.

METHODS

Data were obtained from 75 eligible people in a nationwide prospective study (the Early Prediction of Functional Outcome After Stroke). The full version of both sections of the FM motor scale was administered within 72 hours after stroke onset. The hierarchy of item difficulty was investigated by applying Guttman scaling procedures within each stage and each subsection of the UE and LE sections of the scale. The scaling procedures then were applied to item difficulty between stages and subsections and finally across all scale items (stage divisions ignored) of the FM motor scale.

RESULTS

For all analyses, the results exceeded acceptable levels for the coefficient of reproducibility and the coefficient of scalability.

LIMITATIONS

The sample was a population of people with stroke of moderate severity.

CONCLUSIONS

The unidimensional hierarchy of the UE and LE sections of the FM motor scale (already established for chronic stroke) within 72 hours after stroke onset was confirmed. A legitimate total summed score can indicate a person's level of motor ability.

The reliability and predictive ability of a biomarker of oxidative DNA damage on functional outcomes after stroke rehabilitation

We evaluated the reliability of 8-hydroxy-2′-deoxyguanosine (8-OHdG), and determined its ability to predict functional outcomes in stroke survivors. The rehabilitation effect on 8-OHdG and functional outcomes were also assessed. Sixty-one stroke patients received a 4-week rehabilitation. Urinary 8-OHdG levels were determined by liquid chromatography–tandem mass spectrometry. The test-retest reliability of 8-OHdG was good (interclass correlation coefficient = 0.76). Upper-limb motor function and muscle power determined by the Fugl-Meyer Assessment (FMA) and Medical Research Council (MRC) scales before rehabilitation showed significant negative correlation with 8-OHdG (r = −0.38, r = −0.30; p < 0.05). After rehabilitation, we found a fair and significant correlation between 8-OHdG and FMA (r = −0.34) and 8-OHdG and pain (r = 0.26, p < 0.05). Baseline 8-OHdG was significantly correlated with post-treatment FMA, MRC, and pain scores (r = −0.34, −0.31, and 0.25; p < 0.05), indicating its ability to predict functional outcomes. 8-OHdG levels were significantly decreased, and functional outcomes were improved after rehabilitation. The exploratory study findings conclude that 8-OHdG is a reliable and promising biomarker of oxidative stress and could be a valid predictor of functional outcomes in patients. Monitoring of behavioral indicators along with biomarkers may have crucial benefits in translational stroke research.

Physical activity early after stroke and its association to functional outcome 3 months later

BACKGROUND

Early rehabilitation that includes early mobilization and increased amount of motor activity is hypothesized to be one of the most important factors contributing to the beneficial effect of comprehensive stroke unit treatment, whereas too much bed rest is hypothesized to be harmful. The purpose of the present study was to assess the association between early activity/bed rest and functional outcome 3 months later.

METHODS

This was a prospective cohort study including patients with the diagnosis of stroke admitted to Trondheim University Hospital, Norway. Patients were eligible if they were less than 14 days poststroke and did not receive palliative care. Motor activity/bed rest was recorded in the acute phase using a standard method of observation, and the outcome was assessed by the modified Rankin Scale (mRS) score 3 months later. A proportional odds model was used to analyze the association between motor activity/bed rest and outcome. All analyses were adjusted for age, gender, stroke severity, time from stroke to observation, and prestroke function.

RESULTS

A total of 106 patients (mean age 79.0 years, 56.6% men) were included. The odds ratio for a higher mRS score (poor outcome) was 1.04 (95% confidence interval [CI] 1.02-1.07, P = .001) as time in bed increased and .97 (95% CI .93-1.02, P = .283) as time in motor activity increased.

CONCLUSIONS

This study confirms that time in bed in the early phase is associated with poor functional outcome 3 months later, indicating that too much bed rest should be avoided in the early phase after stroke.