Factors predicting stroke disability at discharge: a study of 793 Chinese

Development of a core outcome set for hypertensive intracerebral hemorrhage in clinical trials of traditional Chinese medicine: a study protocol

Background

Intracerebral hemorrhage (ICH) is a devastating disease, its mortality and disability rate are high. In China, hypertensive intracerebral hemorrhage (HICH) is responsible for 75% of all the cases of primary ICH. A lot of randomized controlled trials (RCTs) of traditional Chinese medicine (TCM) for treating HICH have been carried out. However, these RCTs have a lot of problems, such as heterogeneous outcomes, non-uniform point of measurement. These lead to systematic review/meta-analysis only can include a small number of studies. And outcome measures did not take the wishes of patients and other stakeholders into account. The aim of this study is to establish the core outcome set (COS) for future TCM clinical trials of HICH.

Methods and analysis

First, we will develop a long list of general outcomes by making systematic literature review and semi-structured interviews. Then healthcare professionals and patients with HICH will be invited to participate in two rounds of the Delphi survey to determine the importance of the outcome. Finally, a face-to-face consensus meeting will be conducted to determine the final COS of HICH, including what outcomes should be measured and when and how to measure the outcomes.

Results

We aim to develop a COS that includes TCM core syndrome for HICH to determine what outcomes should be reported and when and how to measure them.

Conclusion

By doing this, we can increase the reporting consistency and reduce the reporting bias in the outcome, which leads to the reuse of research data in meta-analysis and the making of informed healthcare decisions.

Ethics and dissemination

The entire project has received approval from the Ethics Committee of Xiyuan Hospital, China Academy of Chinese Medical Sciences. The final COS will be published and reported at the national and international conferences.

Trial registration

This study is registered with the Core Outcome Measures in Effectiveness Trials database as study 1475. Registered on December 2019.

Young individuals with stroke in rehabilitation: a cohort study

Stroke in younger populations is a public health crisis and the prevalence is rising. Little is known about the progress of younger individuals with stroke in rehabilitation. Characterization of the course and speed of recovery is needed so that rehabilitation professionals can set goals and make decisions. This was a cohort study with data extracted from electronic medical records. Participants were 408 individuals diagnosed with stroke who participated in inpatient rehabilitation in an urban, academic medical center in the USA. The main predictor was age which was categorized as (18-44, 45-64, 65-74 and 75+). Outcomes included baseline-adjusted discharge functional independence measure (FIM) scores and FIM efficiency. In linear regression models for FIM scores, the reference category was the youngest age group. The oldest group was discharged with significantly lower FIM total (B = -8.84), mobility (B = -4.13), self-care (B = -4.07) and cognitive (B = -1.57) scores than the youngest group after controlling for covariates. The 45-64 group also finished with significantly lower FIM total (B = -6.17), mobility (B = -2.61) and self-care (B = -3.01) scores than youngest group. FIM efficiencies were similar for all ages in each of the FIM scales. Younger individuals with stroke make slightly greater functional gains compared to older individuals with stroke, but other factors, such as admission scores, are more important and the rates of recovery may be similar.

Functional decline in hospitalized older patients with coronavirus disease 2019: a retrospective cohort study

Background

This study aimed to determine the frequency of functional decline and to identify the factors related to a greater risk of functional decline among hospitalized older patients with coronavirus disease 2019 (COVID-19).

Methods

We reviewed the medical records of patients aged over 65 years who were admitted to a tertiary care hospital for COVID-19 over 1 year from February 2020. We evaluated the proportion of functional decline, which was defined as a decrease in the Barthel Index score from before the onset of COVID-19 to discharge. Multivariable logistic regression analyses were performed to evaluate the associations between the demographic and clinical characteristics of patients at admission and a greater risk of functional decline. Two sensitivity analyses with different inclusion criteria were performed: one in patients without very severe functional decline before the onset of COVID-19 (i.e., limited to those with Barthel Index score ≥ 25), and the other with a composite outcome of functional decline and death at discharge.

Results

The study included 132 patients with COVID-19; of these, 72 (54.5%) developed functional decline. The severity of COVID-19 did not differ between patients with functional decline and those without (P = 0.698). Factors associated with a greater risk of functional decline included female sex (adjusted odds ratio [aOR], 3.14; 95% confidence interval [CI], 1.25 to 7.94), Barthel Index score < 100 before the onset of COVID-19 (aOR, 13.73; 95% CI, 3.29 to 57.25), and elevation of plasma D-dimer level on admission (aOR, 3.19; 95% CI, 1.12 to 9.07). The sensitivity analyses yielded similar results to those of the main analysis.

Conclusions

Over half of the older patients who recovered from COVID-19 developed functional decline at discharge from a tertiary care hospital in Japan. Baseline activities of daily living impairment, female sex, and elevated plasma D-dimer levels at admission were associated with a greater risk of functional decline.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02597-w.

Proteomic Analysis Reveals that Di Dang Decoction Protects Against Acute Intracerebral Hemorrhage Stroke in Rats by Regulating S100a8, S100a9 Col1a1, and Col1a2

OBJECTIVE

The present study aimed to explore the neuroprotective mechanism of Di Dang decoction (DDD) during acute intracerebral hemorrhage (AICH) stroke in Sprague Dawley rats through proteomic analysis.

METHODS

A total of 135 healthy Sprague Dawley rats were randomly divided into five groups: control (n = 27), model (n = 27), DDD low-dose (n = 27), DDD medium-dose (n = 27), and DDD high-dose (n = 27). AICH stroke in rats was induced by injecting autologous blood into the caudate nucleus. The modified Neurological Severity Score (mNSS) was used to evaluate the cerebral nerve function deficit. Hematoxylin and eosin (HE) staining was performed to observe the brain tissue at the lesion site. Albumin concentration was assessed on obvious blood-brain barrier damaged and brain water content was used to evaluate the brain injury. For quantitative proteomics, proteins were extracted from the cerebral cortices. Target proteins were identified using mass spectrometer-based targeted proteomic quantification.

RESULTS

mNSS score, HE staining results, albumin concentration, and brain water content showed the most significant improvements in the neuroprotective in the high-dose group 7 days after DDD exposure. Furthermore, quantitative proteomics analysis showed that, relative to the control group, S100a8 and S100a9 were downregulated by 0.614 (p = 0.033702) and 0.506 times (p = 0.000024) in the high-dose group. Compared with the control group, Col1a1 and Col1a2 were upregulated by 1.319 (p = 0.000184) and 1.348 (p = 0.014097) times in the high-dose group. These results were confirmed using mass spectrometer-based targeted proteomic quantification.

CONCLUSION

Application of a high-dose DDD for 7 days in AICH stroke rats showed the most significant improvements in neuroprotective. Mechanistically, this effect was mediated by S100a8 and S100a9 protein downregulation and Col1a1 and Col1a2 upregulation.

Prevalence and risk factors of disability and anxiety in a retrospective cohort of 432 survivors of Coronavirus Disease-2019 (Covid-19) from China

OBJECTIVE

To estimate the prevalence of disability and anxiety in Covid-19 survivors at discharge from hospital and analyze relative risk by exposures.

DESIGN

Multi-center retrospective cohort study.

SETTING

Twenty-eight hospitals located in eight provinces of China.

METHODS

A total of 432 survivors with laboratory-confirmed SARS CoV-2 infection participated in this study. At discharge, we assessed instrumental activities of daily living (IADL) with Lawton's IADL scale, dependence in activities of daily living (ADL) with the Barthel Index, and anxiety with Zung's self-reported anxiety scale. Exposures included comorbidity, smoking, setting (Hubei vs. others), disease severity, symptoms, and length of hospital stay. Other risk factors considered were age, gender, and ethnicity (Han vs. Tibetan).

RESULTS

Prevalence of at least one IADL problem was 36.81% (95% CI: 32.39-41.46). ADL dependence was present in 16.44% (95% CI: 13.23-20.23) and 28.70% (95% CI: 24.63-33.15) were screened positive for clinical anxiety. Adjusted risk ratio (RR) of IADL limitations (RR 2.48, 95% CI: 1.80-3.40), ADL dependence (RR 2.07, 95% CI 1.15-3.76), and probable clinical anxiety (RR 2.53, 95% CI 1.69-3.79) were consistently elevated in survivors with severe Covid-19. Age was an additional independent risk factor for IADL limitations and ADL dependence; and setting (Hubei) for IADL limitations and anxiety. Tibetan ethnicity was a protective factor for anxiety but a risk factor for IADL limitations.

CONCLUSION

A significant proportion of Covid-19 survivors had disability and anxiety at discharge from hospital. Health systems need to be prepared for an additional burden resulting from rehabilitation needs of Covid-19 survivors.

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.

Use of Selective Serotonin Reuptake Inhibitors and Outcomes in Stroke Rehabilitation: A Prospective Observational Pilot Cohort Study

Purpose

The aim of this study was to examine the association between selective serotonin reuptake inhibitor (SSRI) therapy and rehabilitation outcomes, specifically disability and quality of life (QOL), in a real-world setting of multi-ethnic Asian patients with first-ever stroke.

Methods

In this prospective observational pilot cohort study, we included patients with first-ever stroke admitted to two inpatient rehabilitation centres in Singapore between January and July 2018. Outcomes were measured using Functional Independence Measure (FIM)-motor scale, modified Barthel Index (MBI) and the Stroke and Aphasia Quality of Life Scale-39 generic (SAQOL-39g) questionnaire. Linear regression was used to assess the association between SSRI therapy and outcomes. Regression coefficients and 95% confidence intervals (CIs) were reported.

Results

Among 57 patients included for analyses, 38.6% received SSRIs. Although SSRI therapy was significantly associated with gains in MBI (coefficient 11.35; 95% CI 0.21–22.50) and SAQOL-39g overall score (coefficient 0.45; 95% CI 0.05–0.85) based on simple linear regression, no significant association between SSRI therapy and any of the investigated outcomes was found after adjustment for confounders. However, an increase in the mean number of physiotherapy and occupational therapy (PT/OT) sessions per day significantly improved FIM-motor (coefficient 16.86; 95% CI 2.64–31.07) and MBI (coefficient 22.79; 95% CI 2.35–43.23) scores.

Conclusion

SSRI therapy did not improve disability and QOL in multi-ethnic Asian patients with first-ever stroke undergoing rehabilitation.

Electronic supplementary material

The online version of this article (10.1007/s40268-019-00287-y) contains supplementary material, which is available to authorized users.

Disabled life expectancy with and without stroke: a 10-year Japanese prospective cohort study

PURPOSE

A stroke is a debilitating condition that can cause lifelong disability, severely limiting the ability of individuals to perform daily activities. In Japan, strokes are the fourth leading cause of death; however, no previous studies have examined the influence of strokes on a disabled or disability-free life for older Japanese residents. This study aims to address this gap.

METHODS

The study used data from the Nihon University Japanese Longitudinal Study of Aging (NUJLSOA) and incidence-based multistate life tables to estimate disabled and disability-free life expectancy based on the stroke status of Japanese residents aged 65 and older.

RESULTS

Japanese stroke survivors aged 65 who experienced an initial disability-free state could expect to live approximately 3 fewer total years of life, 4-5 fewer years in a disability-free state, and 1-2 more years in a disabled state compared to those without history of a stroke (p < 0.05). For those disabled at the beginning of the survey interval, the differences between individuals with and without stroke history were also similar to those disability-free at the beginning of the survey interval (2-4 and 5-6 fewer total and disability-free years, respectively) (p < 0.05). The same pattern was observed for older age groups.

CONCLUSION

Older adults who have experienced a stroke could experience a shorter total life expectancy, shorter disability-free life expectancy, and longer disabled life expectancy than those who have not experienced a stroke. These results can inform policymakers and rehabilitation practitioners on stroke survivor long-term care needs and their post-stroke health status.

Add-On Effects of Chinese Herbal Medicine for Post-Stroke Spasticity: A Systematic Review and Meta-Analysis

Background: Treatment for post-stroke spasticity (PSS) remains a major challenge in clinical practice. Chinese herbal medicine (CHM) is often administered to assist in routine care (RC) in the treatment of PSS, with increasing numbers of clinical research and preclinical studies suggesting that it has potential benefits. Therefore, we conducted a systematic review and meta-analysis to evaluate the add-on effects and safety of CHM for PSS. Methods: Five English and four Chinese databases were searched from their respective inception to 28 February 2018. We included randomized controlled trials that evaluated the add-on effects of CHM for PSS, based on changes in the scores of the (Modified) Ashworth Scale (AS or MAS), Fugl-Meyer Assessment of Sensorimotor Recovery (FMA), and Barthel Index (BI). Results: Thirty-five trials involving 2,457 patients were included. For upper-limb AS or MAS, the estimated add-on effects of CHM to RC were significantly better when using oral (SMD -1.79, 95% CI: -3.00 to -0.57) or topical CHM (SMD -1.06, 95% CI: -1.40 to -0.72). For lower-limb AS or MAS, significant add-on benefits to RC were also detected (SMD -1.01, 95% CI: -1.43 to -0.59 and SMD -1.16, 95% CI: -1.83 to -0.49) using oral and topical CHM, respectively. For FMA and BI, better results were detected when adding CHM to RC, except for the subgroup of oral CHM for upper-limb FMA. Ten of the 35 included studies reported safety information, with two of them mentioning two mild adverse events. Conclusions: Noting the quality concerns of the included trials, this review suggests that CHM appears to be a well-tolerated therapy for patients with PSS, and the potential add-on effects of CHM in reducing spasticity and improving the daily activities of patients with PSS require further rigorous assessment.

How to Prevent Loss of Muscle Mass and Strength among Older People in Neuro-Rehabilitation?

Stroke is the second leading cause of death worldwide but also of disability. Stroke induces certain alterations of muscle metabolism associated with gross muscle atrophy and a decrease in muscle function, leading to sarcopenia. The vast majority of stroke cases occur in adults over 65 years of age, and the prevalence is expected to massively increase in the coming years in this population. Sarcopenia is associated with higher mortality and functional decline. Therefore, the identification of interventions that prevent muscle alterations after stroke is of great interest. The purpose of this review is to carry out a systematic literature review to identify evidence for nutritional and pharmacological interventions, which may prevent loss of muscle mass in the elderly after stroke. The search was performed on Medline in December 2018. Randomized controlled studies, observational studies and case reports conducted in the last 20 years on post-stroke patients aged 65 or older were included. In total, 684 studies were screened, and eight randomized control trials and two cohort studies were finally included and examined. This review reveals that interventions such as amino acid supplementation or anabolic steroid administration are efficient to prevent muscle mass. Little evidence is reported on nutritional aspects specifically in sarcopenia prevention after stroke. It pinpoints the need for future studies in this particular population.

Rehabilitation in oldest-old stroke patients: a comparison within over 65 population

BACKGROUND

Considering the demographic trend, characterized by a marked aging due to the increase in life expectancy and the improvement in medical care, in the next future elderly patients will represent the majority of stroke victims with a strong impact on rehabilitative services.

AIM

To investigate and characterize differences in functional outcome in elderly patients after stroke.

DESIGN

Observational study.

SETTING

Post-acute inpatient rehabilitation.

POPULATION

Subjects aged ≥65 years with acute (i.e. within 30 days from onset) ischemic or hemorrhagic stroke.

METHODS

At admission, all patients underwent neurological and clinical examination, functional evaluation and laboratory assessment. Comorbidities and clinical complications during hospital stay were recorded. Functional status was evaluated by means of the Functional Independence Measure (FIM) administered at admission and discharge. All patients underwent neuromotor rehabilitation, and speech therapy in case of aphasia, once a day, six days per week.

RESULTS

The study enrolled 402 patients, who were stratified in three groups according to age: 145 patients in Group 1, the young-old (65-74.9 years, G1), 206 in Group 2, the middle-old (75-84.9 years, G2) and 51 in Group 3, the oldest-old (≥85 years, G3). At discharge, FIM total scores increased significantly for all the groups (P<0.001); however FIM gains, as well as the efficiency parameters derived from FIM were significantly lower in G3 when compared with G1 and G2. G3 showed a significantly higher rate of comorbidities and a higher presence of pressure sores; infections occurred mainly in G2 and G3. Hospitalization was significantly longer for G1 and G2 with respect to G3, while mortality rates were significantly higher in G2 and G3 with respect to G1. The variables that predicted functional outcome were age, previous stroke, stroke severity and functional status at admission.

CONCLUSIONS

Despite advancing age seems to be associated with a reduced effectiveness of the rehabilitation process and a greater number of complications, intensive rehabilitation can produce significant functional gains for all stroke survivors, regardless of age.

CLINICAL REHABILITATION IMPACT

Understanding the specificity of this population will offer older subjects targeted interventions and, for health systems, better allocation of resources and the development of more effective approaches.

Electroacupuncture for poststroke spasticity (EAPSS): protocol for a randomised controlled trial

INTRODUCTION

Spasticity is a common complication of stroke. Current therapies for poststroke spasticity (PSS) have been reported to be associated with high costs, lack of long-term benefit and unwanted adverse events (AEs). Electroacupuncture (EA) has been used for PSS, however, its efficacy and safety is yet to be confirmed by high-quality clinical studies. This study is designed to evaluate the add-on effects and safety profile of EA when used in combination with usual care (UC).

METHODS AND ANALYSIS

This study is a parallel group randomised controlled trial. A total of 136 participants will be included and randomly assigned to either the treatment group (EA plus UC) or the control group (UC alone). Prior to the main trial, a pilot study involving 30 participants will be conducted to assess the feasibility of the trial protocol. EA will be administered by registered acupuncturists for 20min to 30 min, three times per week for 4 weeks. The primary outcome measure (Modified Ashworth Scale) and secondary outcome measures (Fugl-Meyer Assessment and Barthel Index) will be evaluated at baseline, the end of treatment (week 4) and the end of follow-up (week 8). AEs will be monitored, recorded and reported, and their causality will be explored.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the ethics committees of Guangdong Provincial Hospital of Chinese Medicine and RMIT University in December 2016. The results will be disseminated in a peer-reviewed journal, and PhD theses and might be presented at international conferences.

TRIAL REGISTRATION NUMBER

ChiCTR-IOR-16010283; Pre-results.

PG2 for patients with acute spontaneous intracerebral hemorrhage: a double-blind, randomized, placebo-controlled study

PG2 is an infusible polysaccharide extracted from Astragalus membranaceus, which is a Chinese herb traditionally used for stroke treatment. We investigated the effect of PG2 on patients with spontaneous acute intracerebral hemorrhage (ICH). A total of 61 patients with acute spontaneous ICH were randomized to either the treatment group (TG, 30 patients), which received 3 doses of PG2 (500 mg, IV) per week for 2 weeks, or the control group (CG, 31 patients), which received PG2 placebo. At 84 days after PG2 administration, the percentage of patients with a good Glasgow outcome scale (GOS 4–5) score in the TG was similar to that in the CG (69.0% vs. 48.4%; p = 0.2). The percentage of good mRS scores (0–2) in the TG was similar to that in the CG (62.1% vs. 45.2%; p = 0.3). In addition, no significant differences were seen when comparing differences in the C-reactive protein, erythrocyte sedimentation rate, interleukin-6 (IL-6), IL-1β, tumor necrosis factor-α, and S100B levels between baseline and days 4, 7, and 14 after PG2 administration (all p > 0.05). The results are preliminary, necessitating a more thorough assessment.

Effectiveness and safety of Chinese massage therapy (Tui Na) on post-stroke spasticity: a prospective multicenter randomized controlled trial

OBJECTIVE

To evaluate the effectiveness and safety of Chinese massage therapy (Tui Na) for patients with post-stroke spasticity.

DESIGN

A prospective, multicenter, blinded, randomized, placebo-controlled intervention trial.

SUBJECT

A total of 90 patients with post-stroke spasticity were randomly assigned to the experimental (Tui Na therapy) group ( n = 45) or control (placebo Tui Na therapy) group ( n = 45).

INTERVENTION

Participants in the experimental group received Tui Na therapy, while those in the control group received placebo-Tai Na (gentle rubbing) for 20-25 minutes per limb, once per day, five days per week for a total of four weeks. All participants in both groups received conventional rehabilitation.

MAIN MEASURE

The Modified Ashworth Scale, the Fugl-Meyer Assessment and the Modified Barthel Index were used to assess the severity of spasticity, motor function of limbs and activities of daily living, respectively. Assessments were performed at baseline, at four weeks and at three months.

RESULTS

Tui Na group had a significantly greater reduction in Modified Ashworth Scale in only four muscle groups than the control did (elbow flexors, P = 0.026; wrist flexors, P = 0.005; knee flexors, P = 0.023; knee extensors, P = 0.017). Improvements were sustained at three months follow-up. There was no significant difference between the two groups in Fugl-Meyer Assessment ( P = 0.503) and Modified Barthel Index ( P = 0.544). No adverse reaction was recorded in any of the cases mentioned at all study sites.

CONCLUSIONS

Tui Na might be a safe and effective treatment to reduce post-stroke spasticity of several muscle groups.

Old benefit as much as young patients with stroke from high-intensity neurorehabilitation: cohort analysis

BACKGROUND AND OBJECTIVE

In current clinical practice, old patients with stroke are less frequently admitted to neurorehabilitation units following acute care than younger patients based on an assumption that old age negatively impacts the benefit obtained from high-intensity neurorehabilitation. Our objective was to test this assumption empirically in a large sample of patients with stroke.

METHODS

Functional recovery during 4 weeks of inpatient neurorehabilitation was assessed with the Barthel Index (BI) in 422 middle-aged (<65 years), 1399 old (65-80 years) and 473 very old (>80 years) patients with stroke. Overall functional recovery, recovery patterns and the relationship between therapy intensity and recovery were statistically compared between the three age groups.

RESULTS

Overall functional recovery was statistically equivalent in middle-aged, old and very old patients (average improvement in BI total score: middle-aged: 15 points; old: 15 points; very old: 14 points). A novel item-wise logistic regression analysis (see Pedersen, Severinsen & Nielsen, 2014, Neurorehabil Neural Repair) revealed that this was true for 9 of the 10 everyday functions assessed by the BI. Furthermore, functional recovery was predicted by the amount of therapy (R=0.14; p=0.0001), and age did not moderate this relationship between therapy intensity and recovery (p=0.70).

CONCLUSIONS

Old and even very old patients with stroke benefit from specialised inpatient neurorehabilitation and high amounts of therapy in the same degree as younger patients. Contrary to current clinical practice, old age should not be a criterion against admission to a neurorehabilitation unit following acute stroke treatment.

Medical complications experienced by first-time ischemic stroke patients during inpatient, tertiary level stroke rehabilitation

[Purpose] The aim of this study was to assess the medical complications in first-time ischemic stroke patients, to identify the factors related to occurrence of complications. [Subjects and Methods] First-time ischemic stroke patients (n=81) admitted to a tertiary level inpatient rehabilitation center during a 5 year period were included in the study. The attending physiatrist noted the presence of specific medical complications and complications that required transfer to the acute care facility from patient records. The Oxfordshire Community Stroke Project classification was used to define the clinical subtypes of the ischemic stroke patients. The Charlson comorbidity index was used to evaluate co-morbid conditions. Functional disability was assessed using the Functional Independence Measure at admission and discharge. [Results] We found that 88.9% of the patients had at least one complication. The five most common complications were urinary tract infection (48.1%), shoulder pain (37.0%), insomnia (37.0%), depression (32.1%), and musculoskeletal pain other than shoulder pain (32.1%) and 11.1% of patients were transferred to acute care facility during rehabilitation period. Functional Independence Measure scores both at admission and discharge were significantly lower in patients with at least one complication than in patients with no complications. [Conclusion] Medical complications are common among patients undergoing stroke rehabilitation. Close interdisciplinary collaboration between physiatrists and other medical specialities is necessary for optimal management.

Change of the Corticospinal Tract in the Unaffected Hemisphere by Change of the Dominant Hand Following Stroke: A Cohort Study

We investigated the change of the corticospinal tract (CST) in the unaffected hemisphere by the change of the dominant hand in stroke patients, using diffusion tensor tractography (DTT).Forty-eight stroke patients with right-hand dominance were recruited. The patients were assigned to 3 groups: group A (12 patients)-right-hand dominance was maintained after the right-hand weakness, group B (17 patients)-right-hand dominance changed to the left-hand dominance after the right-hand weakness, and group C (19 patients)-right-hand dominance was maintained after the left-hand weakness had developed. The function of the unaffected upper extremity was evaluated using the grip strength (GS), Manual Function Test (MFT), Purdue Pegboard Test (PPT), and modified Barthel Index (MBI). DTT was performed twice (1st DTT, 2nd DTT), and the fractional anisotropy (FA), apparent diffusion coefficient (ADC), and voxel number (VN) of the CST in the unaffected hemisphere were measured.In group B, the VN on 2nd DTT was significantly increased compared with the 1st DTT, and all other clinical data (GS, MFT, PPT, and MBI) showed a significant increase between 1st and 2nd DTT (P < 0.05). The change of the VN showed moderate correlation with the change of the GS (r = 0.499, P < 0.05), PPT (r = 0.531, P < 0.05), and MBI (r = 0.551, P < 0.05).We found that the fiber number of the CST in the unaffected hemisphere was increased by the change of the dominant hand in stroke patients. We believe that our results have important implications in terms of neurorehabilitation.

Acupuncture Efficacy on Ischemic Stroke Recovery

Background and Purpose—

Acupuncture is a frequently used complementary treatment for ischemic stroke in China but the evidence available from previous randomized trials is inconclusive. The objective of this study was to assess the efficacy and safety of acupuncture in a more robustly designed larger scale trial.

Methods—

This is a multicenter, single-blinded, randomized controlled trial. Eight hundred sixty-two hospitalized patients with limb paralysis between 3 to 10 days after ischemic stroke onset were allocated acupuncture plus standard care or standard care alone. The acupuncture was applied 5 times per week for 3 to 4 weeks. The primary outcomes were defined as follows: (1) death/disability according to Barthel index and (2) death/institutional care at 6 months.

Results—

There was a tendency of fewer patients being dead or dependent in acupuncture group (80/385, 20.7%) than in control group (102/396, 25.8%) at 6 months (odds ratio, 0.75; 95% confidence interval, 0.54–1.05). The benefit was noted in subgroup receiving ≥10 sessions of acupuncture (odds ratio, 0.68; 95% confidence interval, 0.47–0.98). There was no statistical difference in death or institutional care between the 2 groups (odds ratio, 1.06; 95% confidence interval, 0.63–1.79). Severe adverse events occurred in 7.6% and 8.3% of patients in the 2 groups, respectively.

Conclusions—

Acupuncture seemed to be safe in the subacute phase of ischemic stroke. If the potential benefits observed are confirmed in future larger study, the health gain from wider use of the treatment could be substantial.

Clinical Trial Registration—

URL: http://www.chictr.org/en/ . Unique identifier: ChiCTR-TRC-11001353.

Age and Functional Outcome After Stroke

The effect of age on functional outcome after stroke remains uncertain. Many studies have found that younger patients do better than older patients, whereas others have found minimal or no effect of age on rehabilitation outcomes. We examined the effect of advancing age on FIM trade mark gain, length of stay, length of stay efficiency, and home discharge in 979 stroke rehabilitation patients at a long-term acute care rehabilitation hospital. We found a strong relationship of increasing age to poorer outcome in all measures for patients with admission FIM (AFIM) score <40, a variable relationship in those with AFIM 40-80, and no relationship of age to the outcome measures in patients with AFIM >80.

Acupuncture for spasticity after stroke: a systematic review and meta-analysis of randomized controlled trials

The aim of this systematic review was to determine how effective acupuncture or electroacupuncture (acupuncture with electrical stimulation) is in treating poststroke patients with spasticity. We searched publications in Medline, EMBASE, and the Cochrane Library in English, 19 accredited journals in Korean, and the China Integrated Knowledge Resources Database in Chinese through to July 30, 2013. We included randomized controlled trials (RCTs) with no language restrictions that compared the effects of acupuncture or electroacupuncture with usual care or placebo acupuncture. The two investigators assessed the risk of bias and statistical analyses were performed. Three RCTs in English, 1 in Korean, and 1 in Chinese were included. Assessments were performed primarily with the Modified Ashworth Scale (MAS). Meta-analysis showed that acupuncture or electroacupuncture significantly decreased spasticity after stroke. A subgroup analysis showed that acupuncture significantly decreased wrist, knee, and elbow spasticity in poststroke patients. Heterogeneity could be explained by the differences in control, acupoints, and the duration after stroke occurrence. In conclusion, acupuncture could be effective in decreasing spasticity after stroke, but long-term studies are needed to determine the longevity of treatment effects.

The effectiveness of functional electrical stimulation based on a normal gait pattern on subjects with early stroke: a randomized controlled trial

Objective. To investigate the effectiveness of four-channel FES based on a normal gait pattern on improving functional ability in subjects early after ischemic stroke. Methods. Forty-five subjects were randomly assigned into a four-channel FES group (n = 16), a placebo group (n = 15), or a dual-channel group (n = 14). Stimulation lasted for 30 min in each session with 1 session/day, 5 days a week for 3 weeks. All subjects were assessed at baseline, at 3 weeks of treatment, and at 3 months after the treatment had finished. The assessments included Fugl-Meyer Assessment (FMA), the Postural Assessment Scale for Stroke Patients (PASS), Berg Balance Scale (BBS), Functional Ambulation Category (FAC), and the Modified Barthel Index (MBI). Results. All 3 groups demonstrated significant improvements in all outcome measurements from pre- to posttreatment and further gains at followup. The score of FMA and MBI improved significantly in the four-channel group at the end of the 3 weeks of training. And the scores of PASS, BBS, MBI, and FAC in the four-channel group were significantly higher than those of the placebo group. Conclusions. This study indicated that four-channel FES can improve motor function, balance, walking ability, and performance of activities of daily living in subjects with early ischemic stroke.

Predictors of functional recovery in patients admitted to geriatric postacute rehabilitation

OBJECTIVE

To examine characteristics associated with functional recovery in older patients undergoing postacute rehabilitation.

DESIGN

Observational study.

SETTING

Postacute rehabilitation facility.

PARTICIPANTS

Patients (N=2754) aged ≥65 years admitted over a 4-year period.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Functional status was assessed at admission and again at discharge. Functional recovery was defined as achieving at least 30% improvement on the Barthel Index score from admission compared with the maximum possible room for improvement.

RESULTS

Patients who achieved functional recovery (70.3%) were younger and were more likely to be women, live alone, and be without any formal home care before admission, and they had fewer chronic diseases (all P<.01). They also had better cognitive status and a higher Barthel Index score both at admission (mean ± SD, 63.3±18.0 vs 59.6±24.7) and at discharge (mean ± SD, 86.8±10.4 vs 62.2±22.9) (all P<.001). In multivariate analysis, patients <75 years of age (adjusted odds ratio [OR]=1.51; 95% confidence interval [CI], 1.16-1.98; P=.003), women (adjusted OR=1.24; 95% CI, 1.01-1.52; P=.045), patients living alone (adjusted OR=1.61; 95% CI, 1.31-1.98; P<.001), and patients without in-home help prior to admission (adjusted OR=1.39; 95% CI, 1.15-1.69; P=.001) remained at increased odds of functional recovery. In addition, compared with those with moderate-to-severe cognitive impairment (Mini-Mental State Examination score <18), patients with mild-to-moderate impairment (Mini-Mental State Examination score 19-23) and those cognitively intact also had increased odds of functional recovery (adjusted OR=1.56; 95% CI, 1.13-2.15; P=.007; adjusted OR=2.21; 95% CI, 1.67-2.93; P<.001, respectively).

CONCLUSIONS

Apart from sociodemographic characteristics, cognition is the strongest factor that identifies older patients more likely to improve during postacute rehabilitation. Further study needs to determine how to best adapt rehabilitation processes to better meet the specific needs of this population and optimize their outcome.

Significance of urinary incontinence, age, and consciousness level on arrival among patients with stroke

Purpose:

We retrospectively investigated prognostic factors including urinary incontinence on arrival among the patients with stroke.

Materials and Methods:

A medical chart review was retrospectively performed for patients with stoke admitted between January 2010 and December 2010 in Ken-o Tokorozawa Hospital which had stroke care unit. The subjects were divided into a control group (functional outcome with modified Rankin scale (mRS) 0-3 at 3 months) and a poor group (severe disability or death, mRS 4-6).

Results:

There were 160 cases that had favorable outcome (the Control group) and 77 cases that had poor outcome (the Poor group). There were no significant differences between the two groups concerning the sex ratio, systolic blood pressure, heart rate, temperature, ratio of diabetes mellitus. However, the average age, ratio of hemorrhagic stroke, ratio of patients with a previous stroke, ratio of urinary incontinence upon admission, and duration of hospitalization in the Poor group was significantly higher than in the Control group. The Glasgow Coma Scale upon admission and ratio of hypertension in the Poor group were significantly lower than that in the Control group. Using a multiple logistic regression analysis, urinary incontinence (odds ratio, 3.17; 95% confidence interval, 1.45-6.93; P = 0.002), age (odds ratio, 1.04; 95% confidence interval, 1.01-1.07; P = 0.003) and Glasgow Coma Scale (odds ratio, 0.87; 95% confidence interval, 0.78-0.97; P = 0.01) were found to be factors independently associated with a poor outcome.

Conclusion:

Among the patients with strokes, the presence of urinary incontinence on arrival, the old age, and the level of consciousness are important prognostic factors. Physicians should therefore check for these factors when evaluating a patient who has experienced a stroke or suspected stroke.

Chinese Herb Astragalus membranaceus Enhances Recovery of Hemorrhagic Stroke: Double-Blind, Placebo-Controlled, Randomized Study

We tested the effect of Astragalus membranaceus (AM) on acute hemorrhagic stroke. Seventy-eight patients were randomly assigned to Group A (3 g of AM three times/day for 14 days); or Group B (3 g of placebo herb). A total of 68 patients (Group A 36, Group B 32) completed the trial. The increase of functional independence measure scale score between baseline and week 4 was 24.53 ± 23.40, and between baseline and week 12 was 34.69 ± 28.89, in the Group A was greater than 11.97 ± 11.48 and 23.94 ± 14.8 in the Group B (both P≦0.05). The increase of Glasgow outcome scale score between baseline and week 12 was 0.75 ± 0.77 in the Group A was greater than 0.41 ± 0.50 in the Group B (P < 0.05). The results are preliminary and need a larger study to assess the efficacy of AM after stroke.

How can we improve targeting of frail elderly patients to a geriatric day-hospital rehabilitation program?

Background

The optimal patient selection of frail elderly persons undergoing rehabilitation in Geriatric Day Hospital (GDH) programs remains uncertain. This study was done to identify potential predictors of rehabilitation outcomes for these patients.

Methods

This study is a retrospective cohort analysis of patients admitted to the rehabilitation program of our GDH, in Montreal, Canada, over a five year period. The measures considered were: Barthel Index, Older Americans Resources and Services, Folstein Mini Mental Status Exam, Timed Up & Go (TUG), 6-minute walk test (6 MWT), Gait speed, Berg Balance, grip strength and the European Quality of life - 5 Dimensions. Successful improvement with rehabilitation was defined as improvement in three or more tests of physical function. Logistic regression analysis using the Bayesian Information Criterion (BIC) was employed to select the optimal model for making predictions of rehabilitation success.

Results

A total of 335 patients were studied, but only 233 patients had a complete data set suitable for the predictive model. Average age was 81 years and patients attended the GDH an average of 24 visits. Significant changes were found in several measures of physical performance for many patients ranging from improved gait speed in 21.3% to improved TUG in 62.7% of the cohort. Fifty-eight percent of patients attained successful improvement with rehabilitation by our criteria. This group was characterized by lower test scores on admission. Using BIC, the best predictor model was the 6 MWT [OR: 0.994 per meter walked (95% CI: 0.990-0.997)].

Conclusions

The GDH rehabilitation program is effective in improving patients' physical performance. Although no single measure was found to be sufficiently predictive to help target candidates appropriately, the 6 MWT showed a trend to significance. Further research will be done to elucidate the utility of a composite 'rehab appropriateness index' and the role of International Classification of Function concepts for targeting frail elderly to GDH rehabilitation services.

Comparison of Recovery Patterns and Prognostic Indicators for Ischemic and Hemorrhagic Stroke in China

Background and Purpose— Limited data exist on the comparative recovery patterns and outcomes of patients with ischemic stroke and intracerebral hemorrhage in China.

Methods— Data on baseline characteristics and outcomes of 6354 patients at 3 and 12 months poststroke are from ChinaQUEST (QUality Evaluation of Stroke Care and Treatment), a multicenter, prospective, 62-hospital registry study in China. Logistic regression was used to determine factors associated with a poor outcome defined by death/dependency (modified Rankin Scale score of 3 to 5) on follow-up. Generalized estimating equations were used to assess variations in recovery pattern by stroke type.

Results— Baseline severity and rate of functional recovery in the early phase were significantly greater for intracerebral hemorrhage. However, patients with ischemic stroke were on average twice as likely to experience a good outcome (modified Rankin Scale score <3) by 12 months poststroke (OR: 1.98, CI: 1.76 to 2.24). In patients with ischemic stroke, diabetes and atrial fibrillation were strongly associated with a poor outcome at 12 months poststroke even after adjustment for confounding factors such as age, prior stroke/dependency, time to presentation, and stroke severity, whereas use of antiplatelets and lipid-lowering therapy after stroke were associated with improved outcome. For patients with intracerebral hemorrhage, low education and atrial fibrillation were associated with a poor outcome after adjustment for potential confounders and antihypertensive use was strongly associated with improved outcome.

Conclusions— Patients with intracerebral hemorrhage and ischemic stroke have different recovery patterns in China. However, they share similar prognostic factors and in the use of evidence-based secondary prevention therapies to maximize chances of a good outcome.

Bladder management and the functional outcome of elderly ischemic stroke patients

The purpose of this study was to investigate how bladder management, rather than urinary incontinence, may affect the functional outcome of ischemic stroke patients. We studied 919 consecutive patients admitted for ischemic stroke rehabilitation. Level of bladder management was determined by Functional Independence Measurement (FIM TM) sub-scale scores relevant to bladder control. FIM scores less than 5 points was determined as low-bladder management score (Low-BMS) while FIM scores greater than 5 was determined as high-bladder management score (High-BMS). Data were analyzed by t-test, Pearson correlation, and chi-square test as well as by multiple linear regression analysis. There were 594 low-bladder score patients (Low-BMS) and 325 high-bladder score patients (High-BMS), at admission. Compared with High-BMS, Low-BMS patients were slightly older (p = 0.002), had longer rehabilitation stays (p < 0.001) and lower mini-mental state examination (MMSE) scores (p < 0.001). Total FIM at admission and discharge were lower in Low-BMS, yet their total FIM gain upon discharge was higher, compared with High-BMS (19.5 ± 16.46 vs. 17.59 ± 12.55, p = 0.07). Multiple linear regression analyses showed that total FIM at discharge was inversely associated with Low-BMS at admission (beta = -0.407; p<0.001) and age (beta = -0.127; p < 0.001). A high MMSE score (beta = 0.334; p < 0.001) emerged as predicting higher total FIM scores upon discharge. Low-BMS was independently predictive for total FIM gain at discharge (beta = 0.166; p < 0.001). The findings suggest that Low-BMS should be held as adversely affecting the rehabilitation outcomes of elderly stroke patients. However, Low-BMS patients do obtain significant gains and should not be deprived of rehabilitation.

Predictors of functional recovery (FR) for elderly hospitalized patients in a geriatric evaluation and management unit (GEMU) in Taiwan

Elderly patients who are hospitalized with acute illnesses frequently have adverse outcomes. To maintain functional independence, the geriatric evaluation and management unit (GEMU) was established to provide the opportunity for functional recovery (FR). This study's aim was to investigate potential prognostic factors for functional improvement in a GEMU of Taichung Veterans General Hospital, Taiwan. A total of 117 elderly patients (age, 80.0+/-6.3 years, 84.6% males) were enrolled. A comprehensive geriatric assessment and functional status evaluation, including the functional reach test (FRT) and the timed up-and-go (TUG) test, were performed. FR was defined by a greater than 10% improvement in the Barthel Index (BI) before GEMU discharge. Lower BI (44.7+/-25.2 vs. 68.7+/-34.5, p < 0.001), lower instrumental activities of daily living (IADL) scores (1.8+/-1.5 vs. 3.5+/-2.6, p < 0.001), impaired FRT (83.3% vs. 63.5%, p = 0.028), and impaired TUG test (94.4% vs. 74.6%, p = 0.008) were predictive factors for functional improvement. On multivariate logistic regression, an impaired TUG test (Odds ratio = OR = 6.18, 95% confidence interval = 95% C.I. = 1.69-22.6, p = 0.006) was an independent variable associated with FR. The results indicate that elderly hospitalized patients, even with poor physical function, could benefit from geriatric integrated care delivered by a GEMU.

Effectiveness of Supportive Educative Learning programme on the level of strain experienced by caregivers of stroke patients in Thailand

In Thailand, the crude death rate from stroke is 10.9/100,000 population and increasing. Unlike Western countries where community rehabilitation programmes have been established to provide services following the acute stage of stroke recovery, there is no stroke rehabilitation team in the community in Thailand. Therefore, family caregivers are the primary source for ongoing care and support. While family members accompany patients during their hospitalisation, they receive little information about how to assist their relatives, and as a result feel inadequately trained, poorly informed and dissatisfied with the support that is available after discharge. Family caregivers report that they suffer both physically and psychologically and find themselves overwhelmed with strain, experiencing burden and exhaustion. This study aimed to develop and implement a nurse-led Supportive Educative Learning programme for family caregivers (SELF) of stroke survivors in Thailand and to evaluate the effect of the SELF programme on family caregiver's strain and quality of life. This was a non-randomised comparative study with concurrent controls, using a two-group pre-test and post-test design. A total of 140 stroke survivors and 140 family caregivers were recruited; 70 patients/caregiver pair in each group. Caregivers of patients admitted to the intervention hospital following an acute stroke received the intervention, while caregivers of patients admitted to the comparison hospital received the usual care provided at the hospital. The data were collected prior to discharge of the patients and after 3 months. The family caregivers in the intervention group had a significantly better quality of life than the comparison group (GHQ-28 at discharge t = 2.82, d.f. = 138, P = 0.006; and at 3 months t = 6.80, d.f. = 135, P < 0.001) and they also reported less strain (Caregiver Strain Index at discharge t = 6.73, d.f. = 138, P < 0.001; and at 3 months t = 7.67, d.f. = 135, P < 0.001). This research demonstrated that providing education and support to the family caregiver of stroke survivors can reduce caregiver strain and enhance their quality of life.

In patient stroke rehabilitation efficiency: influence of organization of service delivery and staff numbers

Background

Outcomes of inpatient stroke rehabilitation need to be reviewed in terms of optimal resource utilization (staff time, service organization, and duration of stay). We compared FIM efficiency scores between three hospitals, and also variation in FIM scores over a ten year period in one hospital undergoing reduction in staff numbers, to examine the relationship between outcome and service characteristics.

Method

This is a retrospective study comparing the mean FIM efficiency for stroke patients (FIM score – FIM admission score) divided by duration of stay for 2005 among three rehabilitation hospitals adjusting for age and baseline FIM score, and a longitudinal study of changes in mean FIM efficiency during a ten year period in one hospital, to examine the effects of different service organization and staff numbers.

Results

FIM efficiency (FIMEG) was inversely associated with age, and positively associated with admission FIM score. FIMEG was higher in the hospital with a coordinated care plan involving medical, nursing, occupational, physiotherapy staff and other healthcare providers working as a team, with a seamless interface with community rehabilitation services. Over a ten year period, reduction in staff numbers was associated with reduction in FIMEG, which may be offset to some extent by service re-engineering.

Conclusion

Within hospital organization of stroke rehabilitation services may influence outcome. A critical number of staff may be identified for the provision of services, below which rehabilitation efficiency may be affected.

Changing needs of Chinese family caregivers of stroke survivors

AIM

To examine the changing needs of Chinese family caregivers before and after stroke survivors' discharge from hospital.

BACKGROUND

Stroke ranks third as the most common cause of death in Hong Kong and is the leading cause of adult disability. Community care has been adopted as the major source of care for older people in Hong Kong and this has impacted on family caregivers.

DESIGN AND METHODS

This is a descriptive-correlational design using a within-subjects design. The needs of 40 Chinese family caregivers who met the inclusion criteria were assessed before discharge and two weeks later using the Carer Assessment Scale, Cost of Care Index and one open-ended question. Modified Barthel Index measured the functional ability of stroke survivors.

RESULTS

Family caregivers are able to anticipate most of their needs and to make provision to meet the basic practical needs before discharge. Although needs changed after discharge the four most important needs persisted. These were associated with emotional and psychological problems and financial difficulties. Discharge destinations made no difference to the total scores obtained using the above scales.

CONCLUSIONS

This study provides information about need at a time of transition in an under-researched population of Chinese caregivers. Assessment of need is important with Chinese family carers in order to identify focused interventions in a population, i.e. reluctant to make their needs known to professional services. More research about caregiving problems for Chinese family caregivers at the transition from hospital to community is required.

RELEVANCE TO CLINICAL PRACTICE

Ongoing need assessment by nurses who are in regular contact with caregivers in hospital and community will enable appropriate interventions such as providing education and emotional support both before and after discharge to be offered to Chinese communities.

Individuals with the dominant hand affected following stroke demonstrate less impairment than those with the nondominant hand affected

OBJECTIVE

The purpose was to determine if upper extremity impairment and function in individuals with chronic stroke is dependent upon whether the dominant or non-dominant hand is affected.

METHODS

Ninety-three community-dwelling individuals with stroke. The Modified Ashworth Scale (tone), handheld dynamometry (isometric strength), monofilaments (sensation), Brief Pain Inventory (pain), Chedoke Arm and Hand Activity Inventory Motor Activity Log (paretic arm use), and Reintegration to Normal Living Index (participation) were used to form impairment and function models.

RESULTS

Multivariate analysis models (Dominance x Severity) were created for impairment and function variables. There was a significant interaction and main effect of Dominance for the impairment model (P = 0.01) but not the function model (P = 0.75). The dependent variables of tone, grip strength, and pain were all significantly affected by Dominance, indicating less impairment if the dominant hand was affected. All dependent variables except pain were affected by Severity.

CONCLUSION

This study looked at the effect of the dominant hand being affected versus the nondominant in individuals with chronic stroke. Individuals with the dominant hand affected demonstrated less impairment than those with the nondominant hand affected. However, there was no effect of dominance on paretic arm use or performance in activities of daily living. Prospective studies to further explore the issue of hand dominance and poststroke function are suggested.

Stroke rehabilitation outcome: the Turkish experience

The objectives of this study were to examine the demographic and clinical characteristics of stroke patients admitted for inpatient rehabilitation, to study the occurrence of medical problems/complications, and to document functional outcome and possible factors influencing outcome. The mean age of this cohort (30 females, 53 males) was 58+/-12 years and the mean length of hospital stay was 45.7+/-23 days. The most common medical comorbidity was hypertension (65%), followed by heart disease (42%) and diabetes mellitus (22%). The length of hospital stay was related to the number of medical comorbidities (r=0.24, P<0.05). Almost all patients experienced several medical problems during rehabilitation stay (average 7.1 events/patient). Shoulder dysfunction (80.7%), symptomatic blood pressure fluctuations (72.3%) and psychosocial problems (57.8%) were among the most common problems. There was a statistically significant improvement in total Functional Independence Measure scores from admission to discharge (56.5 vs. 74.6), with a mean gain of 18.1. Functional Independence Measure gain was significantly correlated with onset to admission time (r=-0.21, P<0.05), length of hospital stay (r=0.50, P<0.001) and the number of previous strokes (r=-0.23, P<0.05), but not with age, onset to admission interval, comorbidities and the presence of medical problems. Discharge total Functional Independence Measure scores were significantly correlated only with the admission total Functional Independence Measure scores (r=0.72, P<0.001) and onset-admission interval (r=-0.23, P<0.05). Significant functional improvements were documented in this cohort of stroke patients after an interdisciplinary rehabilitation approach. Discharge functional status was best correlated with admission functional status. Medical problems/complications were common among patients undergoing stroke rehabilitation. In our patients, functional outcomes were not significantly influenced by the occurrence of medical problems.

Frequency and clinical determinants of poststroke cognitive impairment in nondemented stroke patients

The objective of this study was to examine the prevalence and clinical correlates of poststroke cognitive impairment in Chinese stroke patients in Hong Kong. One hundred seventy-nine stroke patients were interviewed by a psychiatrist 3 months after their stroke. Cognitive impairment was determined according to the Mini-Mental State Examination score. Thirty-nine participants (21.8%) had cognitive impairment. Univariate analysis found that cognitive impairment was associated with age, female sex, level of education, previous stroke, prestroke Rankin score, National Institutes of Health Stroke Scale dysarthria and total scores, urinary incontinence, and cerebral atrophy index. Multivariate logistic regression suggested that female sex, education, National Institutes of Health Stroke Scale dysarthria score, urinary incontinence, and atrial fibrillation were independent risk factors of poststroke cognitive impairment. After removal of 54 patients with previous stroke from the sample, the frequency of cognitive impairment decreased to 18.4%. It was concluded that cognitive impairment is common among nondemented Chinese stroke patients in Hong Kong.

Functional decline in frail community-dwelling stroke patients

Patients who suffer a stroke event are at high risk of functional decline after the post-acute rehabilitation period. The aim of the present study was the evaluation of factors associated with functional decline in a large sample of older patients with stroke living in the community. The study population consisted of all patients admitted to home care programs after a post-acute rehabilitation program--with at least 1 year of follow-up--in twenty-two Italian Home Health Agencies from 2000 to 2002 (n=1338). For the present study we selected 355 (26%) patients with diagnosis of stroke. After 1 year of in-home care program, 149 out of 355 stroke survivors (42%) had presented a worsening in the activities of daily living (ADL) scale score. In the final adjusted model, patients with cognitive impairment (OR 2.59, 95% CI, 1.45-4.64), pressure ulcer (OR 2.74, 95% CI, 1.45-5.18), urinary incontinence (OR 1.64, 95% CI, 1.01-3.29), or hearing impairment (OR 1.83, 95% CI, 1.02-3.29) were more likely to significantly decline in physical functioning after a period of 1 year in-home care program. Our study documents that functional decline of stroke patients was largely dependent on specific subjects' clinical characteristics. Three of four concomitant disabling conditions associated in our sample with functional decline--pressure ulcer, urinary incontinence, hearing--can be prevented and eventually treated or modified. Appropriate post-acute rehabilitation programs and adequate home care interventions focused on the prevention and treatment of these conditions might be correlated to better outcomes in older post-stroke patients.

Does Age Predict Outcome in Stroke Rehabilitation? A Study of 878 Chinese Subjects

BACKGROUND

The predicting value of age on stroke rehabilitation has been controversial. There is a lack of large-scale studies in the Chinese population to examine the effect of age on stroke rehabilitation outcomes. This study examines the predictors of a good outcome after rehabilitation in Chinese stroke patients with special attention to age as a factor.

PATIENTS AND METHODS

This retrospective cohort study includes stroke patients receiving a standard inpatient multidisciplinary rehabilitation program in a neuro-rehabilitation ward of a convalescence hospital in Hong Kong from January 2000 to December 2003. Functional independence measure (FIM) >or=90 was used to define a good outcome. Multivariate regression analysis was used to assess the independent predictors of a good outcome.

RESULTS

There were important differences in clinical characteristics and complications of stroke among patients of three age groups: <65, >or=65 and <80, and >or=80 years. The total FIM scores both upon admission and at discharge were lower in the older age groups. No significant difference was observed in the changes in FIM scores across these age groups. Age was not an independent predictor for a good outcome. FIM upon admission was an independent predictor for a good outcome (discharge FIM >or=90) in all patients and in individual age groups. Having employment before stroke was a predictor for good outcome in all patients. Living at home prior to stroke was a predictor for the total population and the >or=65 and <80 years group. The length of stay predicted a good outcome in the group >or=80 years.

CONCLUSIONS

Admission functional status, employment and living at home before stroke but not age per se are predictors of a good outcome following stroke rehabilitation. As older patients show comparable improvement during rehabilitation, intensive rehabilitation should not be withheld in stroke patients simply because of advanced age.

L'âge très élevé constitue-t-il un facteur pronostique du devenir après un premier accident vasculaire cérébral ?

AIM

To determine whether very old age, older than 80 years, after a stroke is a significant predictor of mortality, orientation to a specific care pathway after the acute phase and functional status at 6 months after the stroke.

PATIENTS

A sample of 112 consecutive patients admitted to the emergency department because of a first stroke, with hemiplegia and/or aphasia over 6 months, who satisfied strict inclusion/exclusion criteria. Forty-seven patients were older than 80.

METHOD

After initial diagnosis and enrolment in the study, follow-up assessments were conducted at 48 hours, 15 days and 6 months. Demographic, medical, and radiographic data were collected, and patients were evaluated on the NIHSS, MMSE, Barthel Index, FIM(TM) and FAM scales. Descriptive statistics were generated, as were uni- and multivariate between group comparisons.

RESULTS

Our study shows that after a first stroke, old age is significantly associated with a high rate of death, a low rate of orientation to a physical medicine and rehabilitation unit and return to home but not poorer functional outcome.

CONCLUSION

Old age is therefore a determinant of post stroke management. Further studies are needed to evaluate whether in patient rehabilitation would result in significant functional benefit, considering the high cost of care, high risk of recurrent stroke, and high rate of death.

Predicting the Grade of Disability 1 Year After Stroke Following Rehabilitation

The purpose of this study was to identify predictors of grades of disability at least 1 year after stroke rehabilitation therapy. We recruited stroke patients from the inpatient rehabilitation department of a university hospital. The degree of disability was graded using the disability evaluation at least 1 year after stroke onset. Functional ability was evaluated using the Functional Independence Measure instrument on admission, on discharge from the inpatient rehabilitation program, and at the 6-month follow-up visit after discharge. Major sociodemographic, medical, and rehabilitative factors were also collected during the hospitalization period. Of the 109 patients surveyed, 64 (58.7%) had severe or very severe grades of disability. The correlates of severe or very severe disability in logistic regression analyses were bilaterally affected (odds ratio, OR, 10.8), impaired orientation (OR, 3.6), and poorer functional ability at discharge (OR, 7.6). Based on the significant predictors identified, the logistic regression model correctly classified severe or very severe disability in 68.0% of subjects. The higher frequency of severe or very severe disability in this study may have been due to the relatively more severely affected stroke patient population in the inpatient rehabilitation service and the use of unique disability evaluation criteria. These results may provide information useful in planning continuous rehabilitation care and setting relevant socio-welfare policies for stroke victims.

Broad-Perspective Perceptual Disorder of the Right Hemisphere

Traditional accounts of right-posterior brain injury describe a syndrome of low-level perceptual sequelae producing marked acute dependency and transient safety concerns. The syndrome is also held to spare cognition and to carry a generally favorable long-term prognosis. The present paper reviews publications and anecdotal data that challenge this picture. Recent theoretical expositions and empirical studies stipulate three major cognitive functions of the right posterior association cortex: processing novel input, guiding reactions to emergencies, and anticipating consequences. Appearing benign after acute recovery, the impairment of these processes produces vocational, social and marital dysfunctions that increase as a function of chronicity, ultimately becoming more broadly disabling than focal injuries in other cortical loci. The unique symptom picture and serious implications suggest that the long-term syndrome should be labeled (Broad-Perspective Perceptual Disorder) and incorporated in future clinical taxonomies, underscoring the need for extraordinary long-term assistance and specialized therapeutics. Procedures for assessment and differential diagnosis are outlined.

Detecting depression in Chinese stroke patients: a pilot study comparing four screening instruments

OBJECTIVE

To determine which screening instrument is most suitable for detecting depression in Chinese stroke patients.

METHOD

A random sample of 60 Chinese subjects recruited from consecutively admitted patients with first-ever stroke to a rehabilitation facility were assessed using the Visual Analogue Mood Scale (VAMS), the Hospital Anxiety and Depression Scale (HADS), and the Geriatric Depression Scale (GDS). Psychiatric diagnoses, which served as a benchmark for the comparison of screening instruments, were made using the SCID-DSM-III-R. Rating instruments were compared with respect to response rate, sensitivity, specificity, positive and negative predictive values, and receiver operating characteristic (ROC) curves.

RESULTS

The VAMS was not useful in screening for depression in Chinese stroke patients while both the HADS and the GDS demonstrated satisfactory accuracy in detecting depression in Chinese stroke patients.

CONCLUSIONS

Screening instruments for poststroke depression are culture-specific and even scales well established in other cultures should be tested before being used in clinical practice and research.

Functional Electrical Stimulation Improves Motor Recovery of the Lower Extremity and Walking Ability of Subjects With First Acute Stroke

Background and Purpose— The effectiveness of functional electrical stimulation (FES) has been investigated in chronic hemiplegia. The present study examines whether FES, given during acute stroke, was more effective in promoting motor recovery of the lower extremity and walking ability than standard rehabilitation alone.

Methods— Forty-six subjects, 70.9±8.0 years old and 9.2±4.1 days after stroke, were assigned randomly to 1 of 3 groups receiving standard rehabilitation with FES or placebo stimulation or alone (control). FES was applied 30 minutes and placebo stimulation 60 minutes, 5 days per week for 3 weeks. Outcome measurements included composite spasticity score, maximum isometric voluntary contraction of ankle dorsi-flexors and planter-flexors, and walking ability. They were recorded before treatment, weekly during the 3-week treatment, and at week 8 after stroke.

Results— No significant differences were found in the baseline measurements. After 3 weeks of treatment, there was a significant reduction in the percentage of composite spasticity score, and a significant improvement in the ankle dorsiflexion torque, accompanied by an increase in agonist electromyogram and a reduction in electromyogram cocontraction ratio in the FES group, when compared with the other 2 groups ( P <0.05). All subjects in the FES group were able to walk after treatment, and 84.6% of them returned home, in comparison with the placebo (53.3%) and control (46.2%, P <0.05) groups.

Conclusions— Fifteen sessions of FES, applied to subjects with acute stroke plus standard rehabilitation, improved their motor and walking ability to the degree that more subjects were able to return to home.