Stroke rehabilitation. 2. Co-morbidities and complications

Mechanisms and benefits of cardiac rehabilitation in individuals with stroke: emerging role of its impact on improving cardiovascular and neurovascular health

Human and animal studies have demonstrated the mechanisms and benefits of aerobic exercise for both cardiovascular and neurovascular health. Aerobic exercise induces neuroplasticity and neurophysiologic reorganization of brain networks, improves cerebral blood flow, and increases whole-body VO2peak (peak oxygen consumption). The effectiveness of a structured cardiac rehabilitation (CR) program is well established and a vital part of the continuum of care for people with cardiovascular disease. Individuals post stroke exhibit decreased cardiovascular capacity which impacts their neurologic recovery and extends disability. Stroke survivors share the same risk factors as patients with cardiac disease and can therefore benefit significantly from a comprehensive CR program in addition to neurorehabilitation to address their cardiovascular health. The inclusion of individuals with stroke into a CR program, with appropriate adaptations, can significantly improve their cardiovascular health, promote functional recovery, and reduce future cardiovascular and cerebrovascular events thereby reducing the economic burden of stroke.

Does nutritional treatment in patients with dysphagia affect malnutrition and anxiety?

Introduction

Introduction: dysphagia is common in patients with cerebrovascular disease (CVD), with an incidence reported to be 35 %-50 %. Dysphagia can result in malnutrition, dehydration, and death, and negatively affects anxiety levels. Objectives: this study aimed to evaluate the effects of recommended nutritional treatment (NT) on nutritional status and anxiety levels in patients with dysphagia based on clinical and fiber-optic endoscopic evaluation of swallowing (FEES) tests. Methods: seventy-five patients over the age of 50 who were diagnosed with CVD, hospitalized at the Mersin City Research and Training Hospital, Neurology Clinic, from October 2019 to January 2020 were followed up for the study. The FEES test was performed to diagnose dysphagia in CVD patients. Anthropometric measurements of the patients were taken to calculate their body mass index (BMI) values. To determine a patient's daily energy and food intake, 24-h food recalls were taken, and the Nutritional Risk Screening 2002 (NRS 2002) test was used to identify patients at risk of malnutrition. State (SAI)-Trait Anxiety Inventories (TAI) were used to determine instant and general anxiety levels. After patient evaluations NT was provided. All evaluations were repeated 8 weeks after NT. Our study was carried out based on a longitudinal design since we worked with the same units at two different time points. Results: post-NT SAI scores were significantly lower than pre-NT scores (p < 0.05). A moderate correlation was found between pre- and post-NT SAI scores and daily energy and fluid intake status, and between TAI scores and daily energy, fat, and fluid intake amounts (p < 0.05). Post-NT SAI scores significantly decreased with both NRS 2002 and BMI values (p < 0.05). Conclusions: this study highlights the importance of NT in improving rehabilitation outcomes of patients with dysphagia. Since exercises such as postural techniques or maneuvers, and muscle strengthening to reduce swallowing difficulties are an important part of NT for dysphagia, a multidisciplinary study is required for the management of dysphagia, and further studies are needed on this subject.

Intramuscular innervation of the subscapularis muscle and its clinical implication for the BoNT injection: An anatomical study using the modified Sihler's staining

Shoulder pain is commonly associated with spasticity of the rotator cuff muscles including the subscapularis (SSC). The aim of this study was to elucidate the intramuscular innervation pattern of the SSC using the modified Sihler's staining technique to facilitate the targeting of botulinum neurotoxin (BoNT) injections to alleviate shoulder spasticity. Ten SSC specimens (mean age, 81.5 years) were used in this study. Modified Sihler's staining was used to clarify the muscle and to stain the intramuscular nerves. Their extramuscular and intramuscular innervation patterns were examined. The upper subscapular, lower subscapular, thoracodorsal, and axillary nerves (USN, LSN, TDN, and AXN) innervated the SSC in 100%, 80%, 20%, and 40% of specimens, respectively. There was an anastomosis between the USN and LSN in the central portion of the SSC in more than half of the cases. The USN innervated the overall portion of the muscle. In contrast, the additional branches from the TDN and AXN innervated the inferior SSC portion. The superficial branches of the USN were mostly distributed in the superior SSC portion while the deep branches were distributed in the inferior portion. As a major intramuscular nerve within the SSC, the USN should be targeted by a BoNT injection. Regarding the USN distribution, the aim should be to spread the BoNT injectate within the central SSC portion. For supplementary injection to the AXN, the lateral approach would be more appropriate than alternatives. A physician performing a BoNT injection should consider the intramuscular innervation of the SSC portion. Clin. Anat. 32:110-116, 2019. © 2018 Wiley Periodicals, Inc.

Continuous passive motion improves shoulder joint integrity following stroke

Objective: In a pilot study of patients with a first stroke and hemiparesis, we sought to determine whether treatment of the upper limb with continuous passive motion (CPM) that was device delivered would alter impairment, disability or the associated adverse symptoms of shoulder joint instability, pain and tone.

Design: Patients were randomly assigned to receive daily CPM treatments or participate in self-range of motion groups under the supervision of an occupational therapist. All patients received standard daily poststroke therapy for 3.5 h per day. A blinded evaluator at admission and discharge assessed patients using standardized scales of impairment, disability and adverse symptoms.

Setting: Specialized stroke unit of an acute rehabilitation hospital.

Subjects: Two hundred and eighty consecutive patients were screened and 35 of these with a first unilateral stroke, 139-6 days following the acute event, provided informed consent and were randomly assigned to CPM treatment or supervised group self-range exercise.

Main measures: Thirty-two completed the study and were evaluated using standardized measures for motor impairment (Fugl-Meyer, Motor Status Scale and Medical Research Council Motor Power), adverse symptoms (gleno-humeral stability, pain and tone), and disability (Functional Independence Measure).

Results: CPM-treated patients demonstrated positive trends towards improved shoulder joint stability (p =0.06, confidence interval -0.03, 2.3) when compared with patients performing therapist-supervised self-range of motion. There were no significant differences in motor impairment, disability, pain or tone.

Conclusions: Device-delivered continuous passive range of motion may offer an enhanced benefit for some adverse symptom reduction in the hemiplegic arm after stroke over traditional self-range of motion exercise.

Compensatory recombination phenomena of neurological functions in central dysphagia patients

We speculate that cortical reactions evoked by swallowing activity may be abnormal in patients with central infarction with dysphagia. The present study aimed to detect functional imaging features of cerebral cortex in central dysphagia patients by using blood oxygen level-dependent functional magnetic resonance imaging techniques. The results showed that when normal controls swallowed, primary motor cortex (BA4), insula (BA13), premotor cortex (BA6/8), supramarginal gyrus (BA40), and anterior cingulate cortex (BA24/32) were activated, and that the size of the activated areas were larger in the left hemisphere compared with the right. In recurrent cerebral infarction patients with central dysphagia, BA4, BA13, BA40 and BA6/8 areas were activated, while the degree of activation in BA24/32 was decreased. Additionally, more areas were activated, including posterior cingulate cortex (BA23/31), visual association cortex (BA18/19), primary auditory cortex (BA41) and parahippocampal cortex (BA36). Somatosensory association cortex (BA7) and left cerebellum in patients with recurrent cerebral infarction with central dysphagia were also activated. Experimental findings suggest that the cerebral cortex has obvious hemisphere lateralization in response to swallowing, and patients with recurrent cerebral infarction with central dysphagia show compensatory recombination phenomena of neurological functions. In rehabilitative treatment, using the favorite food of patients can stimulate swallowing through visual, auditory, and other nerve conduction pathways, thus promoting compensatory recombination of the central cortex functions.

Current and future interventions for glenohumeral subluxation in hemiplegia secondary to stroke

Poststroke shoulder pain is a common issue and can be caused by glenohumeral subluxation. This entity hinders function and quality of life and is caused by changes in tone and loss of fi ne control of the shoulder joints' supporting structures after a stroke. Current treatments are limited in number and effectiveness and have significant problems and limitations to their use. Furthermore, prior to percutaneous implantable neuromuscular electrical stimulation, there was no evidence for any treatment to provide relief for chronic hemiplegic shoulder pain from glenohumeral subluxation. This clinical review provides a comprehensive review of the anatomy, pathogenesis, clinical features, management, and clinical efficacy of current treatment modalities.

Three-dimensional shoulder complex kinematics in individuals with upper extremity impairment from chronic stroke

PURPOSE

To evaluate shoulder complex kinematics in persons with chronic upper extremity (UE) impairments due to stroke and determine if kinematics predicts motor function based on the Fugl-Meyer Motor Assessment (FMA).

METHODS

Sixteen stroke survivors with chronic UE impairments (age range = 46-80 years, male = 8, female = 8, mean (SD) 66 (40) months post-stroke) performed the UE portion of the FMA with the shoulder/elbow subscale (FM_se) documented. Three-dimensional kinematics of the shoulder complex was collected with the Motion Monitor™ (Innsport, Chicago, IL, USA). Participants performed three repetitions of arm elevation in the frontal, sagittal and self-selected planes. The third repetition was analyzed. Scapular and humeral kinematics were calculated in the self-selected plane. Scapulohumeral rhythm was analyzed at peak elevation. Backward stepwise regression analysis predicted kinematic contributions to the FM_se.

RESULTS

Mean (SD) FM_se score was 25.3 1(10.9). Peak humeral elevation ranged from 45.6° to 129.2° (median 106.7°). Scapulohumeral rhythm was 4.1:1 when humeral elevation ranged from 45° to 50°, 1.5:1 from 80° to 95° and 2.1:1 from 105° to 130°. Humeral elevation, scapular upward rotation and scapular internal rotation predicted 65.4% of FM_se score variability.

CONCLUSIONS

Persons with chronic UE impairments from stroke demonstrated reduced peak elevation and altered scapulohumeral rhythm. Three predictors of the FM_se were humeral elevation, scapular upward rotation and scapular internal rotation.

Acute medical complications in patients admitted to a stroke unit and safe transfer to rehabilitation

Acute medical complications often prevent patients with stroke from being transferred from stroke units to rehabilitation units, prolonging the occupation of hospital beds and delaying the start of intensive rehabilitation. This study defined incidence, timing, duration and risk factors of these complications during the acute phase of stroke. A retrospective case note review was made of hospital admissions of patients with stroke not associated with other disabling conditions, admitted to a stroke unit over 12 months and requiring rehabilitation for gait impairment. In this cohort, a search was made of hypertension, oxygen de-saturation, fever, and cardiac and pulmonary symptoms requiring medical intervention. Included were 135 patients. Hypertension was the most common complication (16.3%), followed by heart disease (14.8%), oxygen de-saturation (7.4%), fever (6.7%) and pulmonary disease (5.2%). Heart disease was the earliest and shortest complication. Most complications occurred during the first week. Except for hypertension, all complications resolved within 2 weeks.

Can the aspiration detected by videofluoroscopic swallowing studies predict long-term survival in stroke patients with dysphagia?

PURPOSE

This study aimed to evaluate whether the aspiration detected by videofluoroscopic swallowing study (VSS) could predict the long-term survival in stroke patients with dysphagia in the post-acute phase of stroke.

METHODS

A cohort of 182 consecutive patients with stroke-related dysphagia referred for VSS from July 1994 to April 1999 was retrospectively constructed. VSS findings and clinical features in the post-acute phase of stroke were recorded. The records thus obtained were then linked to the National Death Register to track the occurrence of patient deaths until December 31, 2000.

RESULTS

Of the 182 patients, 91 (50%) showed aspiration during VSS performed for a median duration of 8.4 weeks after stroke, and 76 (42%) had silent aspiration. In the post-acute phase of stroke (14.7 +/- 8.7 weeks after stroke, mean + standard deviation), 56 (31%) were tube-fed, and 88 (48%) were wheelchair-confined. A total of 65 patients died in a median follow-up duration of 30.8 months after VSS. Patients were classified into three groups based on the findings of VSS-detected aspiration or penetration, but no difference was noted in their survival curves. In the Cox stepwise regression analysis, only advanced age, recurrent stroke (hazard ratio 1.74, 95% CI 1.06-2.85), the need of tube-feeding (hazard ratio 2.07, 95% CI 1.19-3.59), and being wheelchair-confined (hazard ratio 2.83, 95% CI 1.54-5.19) during follow-up were independent predictors of long-term survival.

CONCLUSIONS

VSS-detected aspiration during the post-acute phase of stroke was not predictive for the long-term survival in stroke patients with dysphagia.

"Holding me back": living with arthritis while recovering from stroke

OBJECTIVE

To describe the experience of living with arthritis while recovering from stroke.

DESIGN

Qualitative, phenomenological study. During the first three months post-stroke, 14 one-on-one semi-structured interviews were conducted. Analysis was guided by the modified van Kaam method.

SETTING

General community.

PARTICIPANTS

Three men and two women with self-reported pre-existing knee arthritis who were recovering from a first stroke.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Not applicable.

RESULTS

"Holding me back" was central to the experience of living with knee arthritis while recovering from stroke, due to pain, mobility limitations, frustration, and additional coping demands. Experiencing arthritic pain occurred during daily physical activity. As a result, arthritis interfered with participants' ability to fully engage in stroke rehabilitation. The resulting mobility limitations due to arthritis were frustrating experiences that required additional coping strategies by all participants.

CONCLUSIONS

From the perspective of the participants, the slowed recovery from stroke due to arthritis illustrated the need to consider the influence of knee arthritis on stroke recovery during inpatient rehabilitation and after discharge. Stroke rehabilitation interventions that emphasize weight-bearing exercise may not be tolerated by those with arthritis. Alternate pharmacological treatments and physical rehabilitation should be considered for people with pre-existing knee arthritis post-stroke.

Proprioception of the shoulder after stroke

OBJECTIVE

To investigate position sense and kinesthesia of the shoulders of stroke patients.

DESIGN

Case-control study.

SETTING

A rehabilitation center.

PARTICIPANTS

A total of 22 inpatients with stroke and 10 healthy control subjects.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Angular displacement (in degrees) for threshold to detection of passive motion (TDPM) tests and absolute error (in degrees) for passive reproduction of joint position tests.

RESULTS

For patients, the TDPM for internal and external rotation was significantly higher for both the contralateral (paretic) side (internal, 7.92 degrees +/-7.19 degrees ; external, 8.46 degrees +/-8.87 degrees ) and the ipsilateral (nonparetic) side (internal, 4.86 degrees +/-5.03 degrees ; external, 6.09 degrees +/-9.15 degrees ) compared with the control group (internal, 1.83 degrees +/-1.09 degrees ; external, 1.71 degrees +/-.85 degrees ). Also, for internal rotation, TDPM was significantly higher for patients on the contralateral side compared with the ipsilateral side. For passive reproduction of joint position tests, no differences were found.

CONCLUSIONS

Both the contralateral and ipsilateral shoulders of stroke patients showed impaired TDPM. Passive reproduction of joint position does not seem to be affected as a result of a stroke. The control of the muscle spindles and central integration or processing problems of the afferent signals provided by muscle spindles might cause these effects.

Intramuscular botulinum toxin-A reduces hemiplegic shoulder pain: a randomized, double-blind, comparative study versus intraarticular triamcinolone acetonide

BACKGROUND AND PURPOSE

Shoulder pain is frequent after stroke and interferes with the rehabilitative process and outcome. However, treatments used for hemiplegic shoulder pain are limited and largely ineffective. This prospective, randomized, double-blind controlled study was conducted to compare the efficacies of botulinum toxin type A (BoNT-A) and triamcinolone acetonide (TA) on hemiplegic shoulder pain and their effects on arm function in patients with stroke.

METHODS

Twenty-nine hemiplegic stroke patients with shoulder pain (duration <or=24 months, pain on numeric rating scale >or=6/10) were randomized into 2 groups. One group received intramuscular injections of BoNT-A (BOTOX 100 U total) during one session to the infraspinatus, pectoralis and subscapularis muscles in conjunction with an intraarticular injection of normal saline to painful shoulder joint, whereas the other group received an intraarticular injection of TA (40 mg) and an intramuscular injection of normal saline to the same muscles. Outcome measures were pain (measured using a numeric rating scale), physician's global rating scale, shoulder range of motion (ROM) in 4 directions, arm function measured using Fugl-Meyer score, and spasticity measured using the modified Ashworth scale. Measurements were made at baseline and 2, 6, and 12 weeks after injection.

RESULTS

At 12 weeks after treatment mean decrease in pain was 4.2 in the BoNT-A-treated group versus 2.5 in the TA-treated group (P=0.051), and improvements in overall ROM were 82.9 degrees versus 51.8 degrees in these groups (P=0.059), showing a strong trend toward there being less pain and better ROM among those treated with BoNT-A than with TA. However, no significant differences were observed between the 2 groups in terms of improvement in physician global rating, Fugl-Meyer score or modified Ashworth scales. No adverse effect was observed in either group.

CONCLUSIONS

Results from this study suggest that injection of BoNT-A into selected muscles of the shoulder girdle might provide more pain relief and ROM improvement than intraarticular steroid in patients with hemiplegic shoulder pain. A larger clinical trial needs to be undertaken to confirm the benefits of this approach.

The influence of different Lokomat walking conditions on the energy expenditure of hemiparetic patients and healthy subjects

To determine the strenuousness and efficacy of therapy, the energy expenditure of 10 healthy and 10 hemiparetic subjects were measured while they walked on a treadmill that was combined with a robot-driven gait orthosis, the Lokomat, which physiologically exercises the legs of a patient on a moving treadmill. Subjects performed different Lokomat conditions after measurement of the baseline, i.e., standing in the Lokomat with 30% body weight support (BWS). Robotic strategies with a position control scheme used fixed gait patterns to produce the following conditions: walking with 100% BWS at a speed of 1 km/h versus 2 km/h and walking with 30% BWS at a speed of 1 km/h versus 2 km/h. Another robotic control option with a force control scheme allowed the force to be reduced on only one leg of the orthosis. In this option a reduction to 60% and to 0% assistance was tested. Oxygen consumption and heart rate were measured by a breath-by-breath respiratory gas analyzing system using standard open circuit methodology. The results for O(2) rate [ml/kg/min] indicate that: (1) walking in the Lokomat is not passive; (2) oxygen uptake is significantly increased due to an effect of loading during active stance phase; (3) speed is not a factor leading to increased oxygen consumption; (4) patients do not significantly increase their oxygen uptake due to the advanced force control scheme.

Predictability of Simple Clinical Tests to Identify Shoulder Pain After Stroke

OBJECTIVE

To identify simple diagnostic musculoskeletal tests that can be performed early after stroke to predict patients' likelihood of reporting early signs of hemiplegic shoulder pain.

DESIGN

Case control.

SETTING

Multicenter acute care hospitals.

PARTICIPANTS

A total of 152 adults after a first episode of stroke, of whom 135 met the inclusion criteria. Thirty patients were assigned to the experimental group because they reported moderate intensity of hemiplegic shoulder pain at rest. The remaining 105 patients made up the control group.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Therapists measured the performance of combined upper-limb movement including the hand-behind-neck (HBN) maneuver, passive pain-free ranges of shoulder motion, 3 musculoskeletal tests, and the strength of deltoid muscles during each patient's hospital stay. The numeric rating scale (NRS) identified those who reported moderate or greater intensities of hemiplegic shoulder pain during rest and during assessment.

RESULTS

In our study, 22.2% (95% confidence interval, 15.5-30.2) of the patients reported hemiplegic shoulder pain, on average 1 week after the onset of stroke. Positive Neer test (NRS score >or=5) during the HBN maneuver and a difference of more than 10 degrees of passive range of external rotation between shoulders had a 98% probability of predicting the presence of hemiplegic shoulder pain (receiver operating characteristic, .994; sensitivity, 96.7%; specificity, 99.0%; positive predictive value, 96.7%; negative predictive value, 99.0%; P<.001).

CONCLUSIONS

Three diagnostic clinical tests that can be performed during a bedside evaluation increase the likelihood of determining those who complain of hemiplegic shoulder pain after an acute episode of stroke.

Predictors of psychological and somatic components of poststroke depression: a longitudinal study

PURPOSE

Depression after stroke is common and increases morbidity and mortality in the first years after stroke onset. Nevertheless, little is known about the role of psychosocial factors on the etiology of depression in early as well as in the late poststroke stages. The aim of our study was to investigate the influence of stroke survivors' mental impairment as well as the quality of their social relationships on the development of poststroke depression (PSD).

METHOD

The study used a longitudinal design. Eighty-one German stroke patients were investigated twice, directly after discharge (on the average of 3 months after stroke onset) and 1 year later. Hierarchical regression analyses and cross-lagged partial correlation analyses tested direct and indirect mediating effects of potential predictors on poststroke depressive symptoms.

RESULTS

Time 1 patients' perceived cognitive and emotional functioning predicted psychological depressive symptoms at Time 2. Quality of patients' social relationships mediated the effect of the stroke-related emotional deficits on depression.

CONCLUSION

In contrast to the previous research, the study provided more evidence for causal influence of different risk factors on PSD. Results support the biopsychosocial model of PSD. Early and late PSD seem to be based on partially different etiological mechanisms.

Pooled analysis of the safety of botulinum toxin type A in the treatment of poststroke spasticity

OBJECTIVE

To examine the safety of botulinum toxin type A (BTX-A).

DESIGN

Analysis of pooled data of 9 double-blind, placebo-controlled studies of patients with spasticity after stroke.

SETTING

University hospitals and specialty rehabilitation centers in the United States.

PARTICIPANTS

A total of 482 patients with upper-limb spasticity and 310 with lower-limb spasticity (overall mean age, 58y; 60% men).

INTERVENTION

Treatment with BTX-A (n=534; 1-3 treatments; mean dose, 231U) or placebo (n=258).

MAIN OUTCOME MEASURE

Adverse events.

RESULTS

Most patients (69%) received only 1 treatment with BTX-A. Patients were followed for a mean of 17.8 weeks (range, 0.1-44.7wk) after each treatment. A total of 352 (65.9%) patients in the BTX-A group and 163 (63.2%) in the placebo group reported at least 1 adverse event (P=.475). The most frequent adverse events reported by patients (>5% but <10% in either group) were respiratory infection, seizures, incoordination, and injection site pain, none of which occurred at a significantly higher rate in the BTX-A group (all P>.05). The majority of adverse events were rated as mild or moderate in severity. Only nausea was reported at a significantly higher rate in the BTX-A group (12/534 [2.2%]) than the placebo group (0/258) (P=.011); in contrast, injection site pain, chest pain, and allergic reaction were reported significantly more frequently in the placebo group.

CONCLUSIONS

BTX-A has an acceptable safety profile for treatment of patients with focal spasticity following stroke, a population in which adverse events and comorbidities are common.

Aerobic exercise training in stroke survivors

Functional aerobic capacity among persons with stroke is severely compromised and may limit their full participation in community living. Even though aerobic conditioning can be potentially valuable to persons with stroke in reducing the risk of recurrent morbid events and improving overall quality of life, there is limited information on the specific dose of aerobic exercise (i.e., frequency, intensity, duration, and modality) that may achieve the most desirable health outcomes under the safest conditions in this population. Because of the many comorbidities associated with stroke (i.e., hypertension, heart disease, obesity, depression), specific recommendations for prescribing aerobic exercise must become more precise and be subsequently added to the treatment regimen for this large and diverse population. Future research must address optimal aerobic training programs necessary for reductions in cardiovascular risk factors and gains in functional status in stroke patients.

Poststroke Neuropsychiatric Illness: An Integrated Approach to Diagnosis and Management

Patients who have had stroke are at significant risk for various neuropsychiatric illnesses. The most common and important of these are poststroke depression and poststroke dementia (attributable to vascular dementia, Alzheimer's dementia, or a combination of mechanisms). Poststroke neuropathology may lead some patients to experience concurrent and "overlapping" mood and cognitive symptoms. Less frequently, poststroke anxiety disorders, psychosis, isolated pathologic expressions of emotions, and apathy or fatigue may be encountered. The authors review the current literature on poststroke neuropsychiatry and offer an integrated approach to pathophysiologic concepts and clinical surveillance, screening, diagnosis, and evidence-based pharmacologic and nonpharmacologic intervention for these clinical problems on the clinical boundary between neurology and psychiatry.

Stroke and neurodegenerative disorders. 2. stroke: comorbidities and complications11No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors(s) or upon any organization with which the author(s) is/are associated

This self-directed learning module highlights diagnosis and treatment of comorbidities and complications encountered by patients with stroke. It is part of the study guide on stroke and neurodegenerative disorders in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article specifically focuses on cardiopulmonary complications and examines neurologic sequelae, risk factors for falls, and prevention strategies. It also discusses upper-limb pain, fatigue, and depression and highlights diagnosis and management of genitourinary complications.

OVERALL ARTICLE OBJECTIVE

To summarize common comorbidities and complications encountered by patients after stroke.

Medical complications experienced by a cohort of stroke survivors during inpatient, tertiary-level stroke rehabilitation

OBJECTIVE

To identify the most common medical complications experienced by stroke survivors during inpatient, tertiary-level stroke rehabilitation.

DESIGN

Prospective, descriptive analysis.

SETTING

A tertiary-level, 23-bed, inpatient stroke rehabilitation unit in Nova Scotia, Canada.

PARTICIPANTS

All stroke survivors (N=133) admitted for tertiary-level stroke rehabilitation during a 1-year period.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The attending physiatrist determined the presence or absence of specific complications during the interdisciplinary team conference held during the week of discharge for each patient.

RESULTS

The 4 most common medical complications were depression (26%), shoulder pain (24%), falls (20%), and urinary tract infection (UTI) (15%). Other less common complications included back and hip pain (5%), gastrointestinal disturbances (4%), and pneumonia (2%). Seizures, pressure ulcers, and shoulder-hand syndrome each occurred in 1.5% of the population.

CONCLUSIONS

Depression, shoulder pain, falls, and UTIs are common complications experienced by stroke survivors during inpatient rehabilitation. Heightened awareness of these potential complications may lead to prevention or to earlier recognition and improved management of these conditions.

Arthrographic and clinical findings in patients with hemiplegic shoulder pain11No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated

OBJECTIVES

To identify the etiology of hemiplegic shoulder pain by arthrographic and clinical examinations and to determine the correlation between arthrographic measurements and clinical findings in patients with hemiplegic shoulder pain.

DESIGN

Case series.

SETTING

Medical center of a 1582-bed teaching institution in Taiwan.

PARTICIPANTS

Thirty-two consecutive patients with hemiplegic shoulder pain within a 1-year period after first stroke were recruited.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Clinical examinations included Brunnstrom stage, muscle spasticity distribution, presence or absence of subluxation and shoulder-hand syndrome, and passive range of motion (PROM) of the shoulder joint. Arthrographic measurements included shoulder joint volume and capsular morphology.

RESULTS

Most patients had onset of hemiplegic shoulder pain less than 2 months after stroke. Adhesive capsulitis was the main cause of shoulder pain, with 50% of patients having adhesive capsulitis, 44% having shoulder subluxation, 22% having rotator cuff tears, and 16% having shoulder-hand syndrome. Patients with adhesive capsulitis showed significant restriction of passive shoulder external rotation and abduction and a higher incidence of shoulder-hand syndrome (P=.017). Those with irregular capsular margins had significantly longer shoulder pain duration and more restricted passive shoulder flexion (P=.017) and abduction (P=.020). Patients with shoulder subluxation had significantly larger PROM (flexion, P=.007; external rotation, P<.001; abduction, P=.001; internal rotation, P=.027), lower muscle tone (P=.001), and lower Brunnstrom stages of the proximal upper extremity (P=.025) and of the distal upper extremity (P=.001). Muscle spasticity of the upper extremity was slightly negatively correlated with shoulder PROM. Shoulder joint volume was moderately positively correlated with shoulder PROM.

CONCLUSIONS

After investigating the hemiplegic shoulder joint through clinical and arthrographic examinations, we found that the causes of hemiplegic shoulder pain are complicated. Adhesive capsulitis was the leading cause of shoulder pain, followed by shoulder subluxation. Greater PROM of the shoulder joint, associated with larger joint volume, decreased the occurrence of adhesive capsulitis. Proper physical therapy and cautious handling of stroke patients to preserve shoulder mobility and function during early rehabilitation are important for a good outcome.

A community-based group exercise program for persons with chronic stroke

PURPOSE

The purpose of this study was to evaluate the physical and psychosocial effects of an 8-wk community-based functional exercise program in a group of individuals with chronic stroke.

METHODS

Twenty-five subjects (mean age 63 yr) participated in a repeated measures design that evaluated the subjects with two baseline assessments 1 month apart, one postintervention assessment, and one retention assessment 1 month postintervention. Physical outcome measures assessed were the Berg Balance Test, 12-Minute Walk Test distance, gait speed, and stair climbing speed. Psychosocial measures assessed were the Reintegration to Normal Living Index (RNL) and Canadian Occupational Performance Measure (COPM). The 8-wk training consisted of a 60-min, 3 x wk-1 group program that focused on balance, mobility, functional strength, and functional capacity. The program was designed to be accessible by reducing the need for costly one-on-one supervision, specialized settings, and expensive equipment.

RESULTS

Improvements from the exercise program were found for all physical measures and these effects were retained 1-month postintervention. Subjects with lower function improved the most relative to their initial physical status. Significant effects were found for the COPM, but not the RNL Index; however, subjects with lower RNL improved the most relative to their initial RNL Score.

CONCLUSION

A short-term community-based exercise program can improve and retain mobility, functional capacity, and balance and result in a demonstrable impact upon the performance of activities and abilities that were considered meaningful to the subjects. Implementation of such community-based programs has potential for improving activity tolerance and reducing the risk for secondary complications common to stroke (e.g., falls resulting in fractures and cardiac events).

Psychosocial risk factors in poststroke depression: a systematic review

OBJECTIVE

To review systematically the psychosocial risk factors for poststroke depression.

METHODS

Medline was searched using the key words "poststroke depression" (PSD) for the period January 1, 1966, to June 30, 2000; using the key words "cerebrovascular disease" and "depression" it was searched from June 1, 1996, to June 30, 2000. Corollary articles were obtained from the bibliographies. Inclusion criteria were as follows: original research in French or English; prospective, case-control or cross-sectional study design; assessment of PSD in the first 6 months following the stroke; an acceptable definition of depression; an acceptable definition of stroke; and at least one psychosocial risk factor. Interrater reliability was tested for the selection and quality of the articles. A qualitative risk factor analysis was conducted.

RESULTS

The risk factors most consistently associated with PSD are a past history of depression, past personal psychiatric history, dysphasia, functional impairments, living alone, and poststroke social isolation. Risk factors not associated with PSD are dementia and cognitive impairment. Controversial risk factors are age, socioeconomic status (SES), prior social distress, dependency in regard to activities of daily living (ADL), and sex.

CONCLUSIONS

Over approximately 30 years, some 25 qualitative studies have addressed psychosocial risk factors for PSD. Further studies should aim for quantitative analysis. The results suggest that identifying psychiatric history and preventing social deterioration and impairment should be part of multidisciplinary efforts to care for poststroke patients.

Management of shoulder pain in patients with stroke

Shoulder pain affects from 16% to 72% of patients after a cerebrovascular accident. Hemiplegic shoulder pain causes considerable distress and reduced activity and can markedly hinder rehabilitation. The aetiology of hemiplegic shoulder pain is probably multifactorial. The ideal management of hemiplegic stroke pain is prevention. For prophylaxis to be effective, it must begin immediately after the stroke. Awareness of potential injuries to the shoulder joint reduces the frequency of shoulder pain after stroke. The multidisciplinary team, patients, and carers should be provided with instructions on how to avoid injuries to the affected limb. Foam supports or shoulder strapping may be used to prevent shoulder pain. Overarm slings should be avoided. Treatment of shoulder pain after stroke should start with simple analgesics. If shoulder pain persists, treatment should include high intensity transcutaneous electrical nerve stimulation or functional electrical stimulation. Intra-articular steroid injections may be used in resistant cases.