Functional outcome of hemorrhagic and nonhemorrhagic stroke patients after in-patient rehabilitation

Undetected language deficits in left or right hemisphere post-stroke patients

Previous studies have reported that widely used tests for aphasia identification are unable to detect the subtle language deficits of left hemisphere brain damaged (LHBD) individuals. Similarly, the language disorders of individuals with right hemisphere brain damage (RHBD) usually remain undetected, due to the lack of any specialized test for the evaluation of their language processing skills. The aim of the present study was to evaluate the language deficits of 80 individuals suffering from the effects of either a LHBD or RHBD stroke, who were diagnosed as having no aphasia or language deficits based on the application of Boston Diagnostic Aphasia Examination. Their language abilities were examined with the use of the Adults' Language Abilities Test, which explores morpho-syntactic and semantic phenomena of the Greek language in both the comprehension and production modalities. Results revealed that both groups of stroke survivors performed significantly worse compared to the group of healthy participants. Thus, it appears that the latent aphasia of LHBD and the language deficits of RHBD patients are likely to remain undetected and that patients are at risk of not receiving appropriate treatment if their language abilities are not evaluated by an effective and efficient battery of language tests.

Longitudinal outcomes of ischemic versus hemorrhagic stroke: Differences may impact future trial design

OBJECTIVES

Patients with intracerebral hemorrhage (ICH) are more likely to present with severe symptoms than those with ischemic stroke (IS); however, the way in which long-term outcomes differ between groups is less clear. Given that the tissue surrounding ICH is not always irreversibly infarcted, it may have the potential to recover more fully over time. Understanding the differences in expected outcome severity is critical in order to prognosticate and to determine appropriate outcome measures when designing clinical trials.

MATERIALS AND METHODS

We used our prospectively collected stroke registry to identify and follow a cohort of 300 patients with ICH and 300 patients with IS, matched by age, sex, lesion size, location, and admission date. Paired t-tests were used to compare modified Rankin Scores (mRS) between groups at hospital discharge, 90-day, and >12-month follow-up time points.

RESULTS

Not surprisingly, patients with ICH had worse discharge mRS scores compared to individuals with IS (4.20 (SD 0.09) versus 3.42 (SD 0.08)). However, rather than improving, the long-term outcomes remained significantly worse for ICH patients compared to their IS matches (4.02 (SD 0.15) versus 2.89 (SD 0.14) at 90 days, and 4.32 (SD 0.20) versus 3.16 (SD 0.22) at >12 months (p < 0.001 for all analyses)).

CONCLUSIONS

This study longitudinally followed matched cohorts of patients with ICH and IS, confirming that outcomes for those with ICH remain significantly worse over time. Results allow for better long-term prognostication, illustrate the need for further intervention trials to improve outcomes, and inform the development of evidence-based endpoints.

Clinical and demographic predictors of unilateral spatial neglect recovery after prism therapy among stroke survivors in the sub-acute phase of recovery

BACKGROUND AND AIMS: Unilateral Spatial Neglect (USN) affects the rehabilitation process and leads to poor outcomes after stroke. Factors that influence USN recovery following prism adaptation therapy have not been investigated. This study investigated predictors of USN recovery after prism therapy at the sub-acute phase of recovery. METHODS: This study was a randomized controlled trial. USN was assessed with the Behavioural Inattention Test and Catherine Bergego scale. Seventy-four patients with USN were divided into control and intervention group (prism). The prism group used 20 dioptre prism lenses for repeated aiming for 12 sessions while the control group used neutral lenses for aiming training. Regression analysis was conducted to establish clinical and sociodemographic factors that influence USN recovery. RESULTS: Gender, age, years of education, race, employment status, handedness, type of stroke, time since stroke and site of stroke (p > 0.005) showed no significant influence on USN recovery following PA treatment. Higher Cognitive function (OR  = 1.52, CI = 1.08-2.14, p =  0.016) and group allocationng (being in the prism group) (OR = 63.10, CI =  9.70-410.59, P < 0.001) were found to significantly influence USN recovery following PA treatment session. CONCLUSIONS: A significant modulating effect on general cognitive ability was found in this study. This suggests that prism adaptation therapy's effect on neural activity and spatial neglect depends on the cognitive function of stroke survivors.Trial registration: Pan African Clinical Trial Registry identifier: PACTR201903732473573.

Ischemic and hemorrhagic strokes in young adults: Comparison of functional outcomes and return to work after stroke

BACKGROUND

Functional recovery and return to work (RTW) after stroke are important rehabilitation goals that have significant impact on quality of life. Comparisons of functional outcomes and RTW between ischemic stroke (IS) and hemorrhagic stroke (HS), especially among young adults with stroke, have either been limited or yielded inconsistent results. We aimed to assess functional outcomes and ability to RTW in young adults with IS and HS, specifically primary spontaneous intracranial hemorrhage (SICH).

METHODS

Young adults with IS or SICH aged 18-50-years-old were included. Outcome measures were modified Rankins score (mRS) on discharge and 3-months and RTW at 3-months after stroke. Good functional outcome was defined as an mRS of 0-2.

RESULTS

We included 459 patients (71.5% male) with a mean age of 43.3 ± 5.7 years, comprising 49.2% IS and 50.8% SICH. Patients with SICH were more likely to have unfavourable shifts in ordinal mRS on discharge (OR 7.52, CI 5.18-10.87, p < 0.001) and at 3-months (OR 6.41, CI 4.17-9.80, p < 0.001). Patients with IS more likely achieved good functional outcomes (80.2% vs. 51.8%, p < 0.001) and were able to RTW at 3-months (54.4% vs. 36.3%, p = 0.004). Among all stroke patients with good functional outcomes, one-third did not RTW at 3-months. Patients with longer length of hospitalisation and higher National Institutes of Health Stroke Scale (NIHSS) score on admission, especially in the domain categories of level of consciousness, vision, motor function, language and neglect, were less likely to RTW at 3-months.

CONCLUSION

Patients with IS were more likely to RTW when compared to SICH patients. Many young stroke patients did not RTW despite good functional outcomes. Further research should therefore address differences in prognosis and identify predictors that influence ability to RTW after stroke in the young adult population.

The Use of the ICF Classification Sheet to Assess Cognitive-Behavioral Disorders and Verbal Communication in Patients after Ischemic and Hemorrhagic Stroke during Rehabilitation

Background: In patients after experiencing stroke, the cognitive-behavioral deficits and disorders of verbal communication limit the effectiveness of rehabilitation. The key is to diagnose them at an early stage of rehabilitation and to implement appropriate psychological and speech therapy. Objective: Identify differences in the frequency and effectiveness of cognitive-behavioral disorder therapy depending on the clinical type of stroke, assessed before and after rehabilitation treatment, and their presentation using the ICF (International Classification of Functioning, Disability, and Health) classification. Materials and Methods: The study was prospective and included the analysis of cognitive-behavioral and verbal communication disorders. The study consisted of 47 patients after intracerebral hemorrhage (ICH) and 47 patients after an ischemic stroke (IS) before the implementation of rehabilitation and after completing a 4-week rehabilitation. Results: In the group after ICH, psychological therapy significantly reduced the disturbances of consciousness and orientation (p < 0.001) and improved the speed of performing tasks in tests (p < 0.001). In patients after IS and ICH, memory and attention function improved significantly (p < 0.001). Moreover, in patients after ICH, language function deficits decreased significantly (p = 0.018). Mood disturbances were maintained in 17% of patients after ICH and 40% of patients after IS (p = 0.007). Speech therapy reduced speech articulation disorders and aphasia in 85% of patients after ICH (p = 0.001) and in 68% of patients after IS (p = 0.033). Conclusions: The frequency and type of cognitive-behavioral and verbal communication disorders vary depending on the history of ICH or IS. The ICF classification may be useful in assessing and analyzing cognitive-behavioral and verbal communication disorders, which may lead to the implementation of appropriate psychological and speech therapy at an early stage of rehabilitation and increase the effectiveness of the therapy.

The Impact of Stroke Subtype on Recovery and Functional Outcome after Inpatient Rehabilitation: A Retrospective Analysis of Factors

The aims of this study were to compare inpatient rehabilitation outcomes between acute stroke subtypes of Cerebral Infarction (CI) and Intracerebral Hemorrhage (ICH), and to determine the predictors of discharge outcomes. A retrospective study of stroke inpatients was carried out using the discharge Functional Independence Measure (FIM) as the primary outcome measure. Relationships between stroke subtype, rehabilitation impairments, and medical complications on FIM -gain were analyzed. Altogether, 280 datasets including 211 (75.4%) CI and 69 (24.6%) ICH were analyzed. ICH patients were significantly younger than CI patients (55 years ICH vs. 64.0 years CI years, p < 0.001), had a 10-fold higher proportion needing ICU admission (ICH 82.6% vs. CI 7.6%, p < 0.001), and had significantly lower total admission FIM scores (67 points ICH vs. 74 CI points, p = 0.006), with lower motor-FIM scores in particular (38 points ICH vs. 48 points CI, p = 0.003). Significant functional improvements after inpatient rehabilitation, i.e., FIM gain, occurred regardless of stroke subtype (FIM-ICH Δ 27 vs. FIM-CI Δ 21, p = 0.05). Despite significantly worse initial stroke severity, ICH patients achieved similar functional gains, independence levels, and return-home rates compared with their CI counterparts after inpatient rehabilitation.

Functional Recovery Patterns of Hemorrhagic and Ischemic Stroke Patients Under Post-Acute Care Rehabilitation Program

BACKGROUND

Tailored rehabilitation programs for stroke patients cannot be made without knowledge of their recovery potential. The aim of this study is to characterize the functional recovery patterns of ischemic stroke (IS) and intracerebral hemorrhage (ICH) patients under post-acute care stroke rehabilitation.

METHODS

This retrospective study analyzed the data of patients enrolled in the Post-Acute Care-Cerebrovascular Disease (PAC-CVD) rehabilitation program, which provides an individualized 1- to 3-hour intensive physical, occupational, and speech and language therapy for post-acute stroke patients in Taoyuan Chang Gung Memorial hospital in Taiwan. Our primary endpoint measure was Barthel Index (BI), and secondary endpoint measures included other 12 functional measures.

RESULTS

A total of 489 patients were included for analysis. Patients with stroke history had less BI improvement than those who suffered their first-ever stroke. In first-ever stroke patients who had completed 6 to 12 weeks of PAC-CVD program, subcortical ICH patients had greater BI, quality of life, sensation, and balance improvements, and had greater late-phase recovery than their IS counterparts. In IS patients, those with age >75 had less BI improvement; those with National Institute of Health Stroke Scale (NIHSS) score 1-5 had greater Motor Activity Log quality of use (MAL-quality) improvement than those with NIHSS score >5; those with Mini-Mental State Examination (MMSE) score ≥24 had greater BI and instrumental activities of daily living (IADL) improvement. Using the general linear model, previous stroke (ß: -6.148, p=0.01) and subcortical ICH (ß: 5.04, p=0.03) were factors associated with BI improvement.

CONCLUSION

Subcortical ICH patients have greater functional improvement and greater late-phase recovery than their IS counterparts following PAC rehabilitation. More studies are needed to validate our findings and unravel the underlying mechanisms of stroke recovery to optimize the treatment strategy following a stroke.

Functional Improvement Among Intracerebral Hemorrhage (ICH) Survivors up to 12 Months Post-injury

BACKGROUND AND PURPOSE

As survival rates have increased for intracerebral hemorrhage (ICH) patients, there is limited information regarding recovery beyond 3-6 months. This study was conducted to examine recovery curves using the modified Rankin Scale (mRS) and Barthel Index (BI) up to 12 months post-injury.

METHODS

We prospectively enrolled 173 patients admitted with ICH who were subsequently evaluated using the mRS and BI at discharge as well as 3, 6, and 12 months. Repeated measures nonparametric testing was conducted to assess functional trajectories across time.

RESULTS

The mRS scores showed significant improvement between discharge (median 4) and 3 (median 4), 6 (median 4), and 12 months (median 3) (p values <0.001). However, the mRS scores did not differ between follow-up time-points (i.e., 3-6, 6-12 months). There was significant improvement in scores using the BI (p values <0.001), showing improvement between discharge (mean 43.0) and 3 (mean 73.0), 6 (mean 78.2), and 12 months (mean 83.4). Additionally, there were differences in the BI between 3 and 12 months (p = 0.013), as well as between 6 and 12 months (p = 0.025).

CONCLUSIONS

The BI may be a more sensitive measure of long-term recovery post-injury than the mRS, which shows minimal improvement for some survivors after 3 months. BI scores indicate survivors continually improve till 12 months post-injury. These results may have implications for the prognostication of ICH and design of clinical trial outcome measures.

Impact of spontaneous intracerebral hemorrhage on cognitive functioning: An update

Intracerebral hemorrhage (ICH) accounts for 15% of all strokes and approximately 50% of stroke-related mortality and disability worldwide. Patients who have experienced ICH are at high risk of negative outcome, including stroke and cognitive disorders. Vascular cognitive impairment are frequently seen after brain hemorrhage, yet little is known about them, as most studies have focused on neuropsychological outcome in ischemic stroke survivors, using well-documented acute and chronic cognitive scores. However, recent evidence supports the notion that ICH and dementia are closely related and each increases the risk of the other. The location of the lesion also plays a significant role as regards the neuropsychological profile, while the pathophysiology of ICH can indicate a specific pattern of dysfunction. Several cognitive domains may be affected, such as language, memory, executive function, processing speed and gnosis.

Hemorrhagic versus ischemic stroke: Who can best benefit from blended conventional physiotherapy with robotic-assisted gait therapy?

BACKGROUND

Contrary to common belief of clinicians that hemorrhagic stroke survivors have better functional prognoses than ischemic, recent studies show that ischemic survivors could experience similar or even better functional improvements. However, the influence of stroke subtype on gait and posture outcomes following an intervention blending conventional physiotherapy with robotic-assisted gait therapy is missing.

OBJECTIVE

This study compared gait and posture outcome measures between ambulatory hemorrhagic patients and ischemic patients, who received a similar 4 weeks' intervention blending a conventional bottom-up physiotherapy approach and an exoskeleton top-down robotic-assisted gait training (RAGT) approach with Lokomat.

METHODS

Forty adult hemiparetic stroke inpatient subjects were recruited: 20 hemorrhagic and 20 ischemic, matched by age, gender, side of hemisphere lesion, stroke severity, and locomotor impairments. Functional Ambulation Category, Postural Assessment Scale for Stroke, Tinetti Performance Oriented Mobility Assessment, 6 Minutes Walk Test, Timed Up and Go and 10-Meter Walk Test were performed before and after a 4-week long intervention. Functional gains were calculated for all tests.

RESULTS

Hemorrhagic and ischemic subjects showed significant improvements in Functional Ambulation Category (P<0.001 and P = 0.008, respectively), Postural Assessment Scale for Stroke (P<0.001 and P = 0.003), 6 Minutes Walk Test (P = 0.003 and P = 0.015) and 10-Meter Walk Test (P = 0.001 and P = 0.024). Ischemic patients also showed significant improvements in Timed Up and Go. Significantly greater mean Functional Ambulation Category and Tinetti Performance Oriented Mobility Assessment gains were observed for hemorrhagic compared to ischemic, with large (dz = 0.81) and medium (dz = 0.66) effect sizes, respectively.

CONCLUSION

Overall, both groups exhibited quasi similar functional improvements and benefits from the same type, length and frequency of blended conventional physiotherapy and RAGT protocol. The use of intensive treatment plans blending top-down physiotherapy and bottom-up robotic approaches is promising for post-stroke rehabilitation.

Management of intracerebral hemorrhage

Intracerebral hemorrhage (ICH) is a potentially devastating neurologic injury representing 10-15% of stroke cases in the USA each year. Numerous risk factors, including age, hypertension, male gender, coagulopathy, genetic susceptibility, and ethnic descent, have been identified. Timely identification, workup, and management of this condition remain a challenge for clinicians as numerous factors can present obstacles to achieving good functional outcomes. Several large clinical trials have been conducted over the prior decade regarding medical and surgical interventions. However, no specific treatment has shown a major impact on clinical outcome. Current management guidelines do exist based on medical evidence and consensus and these provide a framework for care. While management of hypertension and coagulopathy are generally considered basic tenets of ICH management, a variety of measures for surgical hematoma evacuation, intracranial pressure control, and intraventricular hemorrhage can be further pursued in the emergent setting for selected patients. The complexity of management in parenchymal cerebral hemorrhage remains challenging and offers many areas for further investigation. A systematic approach to the background, pathology, and early management of spontaneous parenchymal hemorrhage is provided.

Hybrid Assistive Limb (HAL) Rehabilitation in Patients with Acute Hemorrhagic Stroke

The efficacy of hybrid assistive limb (HAL) rehabilitation in the acute phase of stroke remains unclear. The purpose of this study was to evaluate the outcomes of patients with acute intracranial hemorrhage (ICH) who were treated with or without HAL rehabilitation. Among 270 patients with acute ICH from 2009 to 2014, 91 patients with supratentorial ICH were included in this retrospective study. Of these, 14 patients (HAL group) received HAL rehabilitation at approximately 1 week after ICH occurrence, while the remaining 77 patients received usual rehabilitation without HAL (N-HAL group). We obtained various patient data from the hospitals where the patients were moved to for further rehabilitation. Statistical comparisons were performed for the characteristics of the ICH patients, and outcomes between the HAL and N-HAL groups. There were no differences in outcomes between the HAL and N-HAL groups. However, patients with right ICH in the HAL group exhibited a significant association with a functional independence measure (FIM) score of ≥ 110 compared with patients in the N-HAL group (HAL group: 81.8%, N-HAL group: 43.9%, P = 0.04). In patients with right ICH, HAL rehabilitation was associated with improved outcomes as evaluated by the FIM score. Thus, HAL rehabilitation may improve outcomes of acute ICH in appropriately selected patients.

Rehabilitation Outcomes: Ischemic versus Hemorrhagic Strokes

Background. Ischemic and hemorrhagic strokes have different pathophysiologies and possibly different long-term cerebral and functional implications. Hemorrhagic strokes expose the brain to irritating effects of blood and ischemic strokes reflect localized or diffuse cerebral vascular pathology. Methods. Participants were individuals who suffered either an ischemic (n = 172) or hemorrhagic stroke (n = 112) within the past six months and were involved in a postacute neurorehabilitation program. Participants completed three months of postacute neurorehabilitation and the Mayo Portland Adaptability Inventory-4 (MPAI-4) at admission and discharge. Admission MPAI-4 scores and level of functioning were comparable. Results. Group ANOVA comparisons show no significant group differences at admission or discharge or difference in change scores. Both groups showed considerably reduced levels of productivity/employment after discharge as compared to preinjury levels. Conclusions. Though the pathophysiology of these types of strokes is different, both ultimately result in ischemic injuries, possibly accounting for lack of findings of differences between groups. In the present study, participants in both groups experienced similar functional levels across all three MPAI-4 domains both at admission and discharge. Limitations of this study include a highly educated sample and few outcome measures.

Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

PURPOSE

The aim of this guideline is to present current and comprehensive recommendations for the diagnosis and treatment of spontaneous intracerebral hemorrhage.

METHODS

A formal literature search of PubMed was performed through the end of August 2013. The writing committee met by teleconference to discuss narrative text and recommendations. Recommendations follow the American Heart Association/American Stroke Association methods of classifying the level of certainty of the treatment effect and the class of evidence. Prerelease review of the draft guideline was performed by 6 expert peer reviewers and by the members of the Stroke Council Scientific Oversight Committee and Stroke Council Leadership Committee.

RESULTS

Evidence-based guidelines are presented for the care of patients with acute intracerebral hemorrhage. Topics focused on diagnosis, management of coagulopathy and blood pressure, prevention and control of secondary brain injury and intracranial pressure, the role of surgery, outcome prediction, rehabilitation, secondary prevention, and future considerations. Results of new phase 3 trials were incorporated.

CONCLUSIONS

Intracerebral hemorrhage remains a serious condition for which early aggressive care is warranted. These guidelines provide a framework for goal-directed treatment of the patient with intracerebral hemorrhage.

Risks and benefits of CT angiography in spontaneous intracerebral hemorrhage

BACKGROUND

Few studies have examined the risk of computed tomography angiography (CTA) during the acute phase of spontaneous intracerebral hemorrhage (ICH), while the benefits of CTA in ICH have been well-documented. The present study investigated both the benefits of identifying spot signs, which are supposed to indicate hematoma enlargement after admission, and risks of CTA performed during the acute phase of ICH.

METHODS

We retrospectively assessed 323 consecutive patients with spontaneous ICHs admitted to our hospital between April 2009 and March 2012 and who underwent CTA on admission.

RESULTS

In 80 patients (24.7 %), spot signs were demonstrated on CTA source images. Multivariate analysis revealed two independent factors correlated with presence of the spot sign: age and hematoma volume (p < 0.05 each). The presence of spot sign was associated with unfavorable outcomes at discharge and hematoma growth after admission (p < 0.05 each). Adverse events related to CTA occurred in 17 patients (5.2 %), including transient renal dysfunction in 16 patients and allergy to contrast medium in one patient. All adverse events completely resolved within 1 week.

CONCLUSIONS

Presence of the spot sign indicated the possibility of hematoma growth and unfavorable outcomes. A small number of adverse events occurred in association with CTA, but without any permanent deficits. Given the potential benefits and risks, we believe that CTA performed at admission in all patients with ICH is beneficial to improve the outcomes.

Rehabilitation impact indices and their independent predictors: a systematic review

OBJECTIVES

To (1) identify all available rehabilitation impact indices (RIIs) based on their mathematical formula, (2) assess the evidence for independent predictors of each RII and (3) propose a nomenclature system to harmonise the names of RIIs.

DESIGN

Systematic review.

DATA SOURCES

PubMed and references in primary articles.

STUDY SELECTION

First, we identified all available RII through preliminary literature review. Then, various names of the same formula were used to identify studies, limited to articles in English and up to 31 December 2011, including case-control and cohort studies, and controlled interventional trials where RIIs were outcome variable and matching or multivariate analysis was performed.

RESULTS

The five RIIs identified were (1) absolute functional gain (AFG)/absolute efficacy/total gain, (2) rehabilitation effectiveness (REs)/Montebello Rehabilitation Factor Score (MRFS)/relative functional gain (RFG), (3) rehabilitation efficiency (REy)/length of stay-efficiency (LOS-EFF)/efficiency, (4) relative functional efficiency (RFE)/MRFS efficiency and (5) revised MRFS (MRFS-R). REy/LOS-EFF/efficiency had the most number of supporting studies, followed by REs and AFG. Although evidence for different predictors of RIIs varied according to the RII and study population, there is good evidence that older age, lower prerehabilitation functional status and cognitive impairment are predictive of poorer AFG, REs and REy.

CONCLUSIONS

5 RIIs have been developed in the past two decades as composite rehabilitation outcome measures controlling premorbid and prerehabilitation functional status, rate of functional improvement, each with varying levels of evidence for its predictors. To address the issue of multiple names for the same RII, a new nomenclature system is proposed to harmonise the names based on common mathematical formula and a first-named basis.

Assessment and modulation of neural plasticity in rehabilitation with transcranial magnetic stimulation

Despite intensive efforts to improve outcomes after acquired brain injury, functional recovery is often limited. One reason for this limitation is the challenge in assessing and guiding plasticity after brain injury. In this context, transcranial magnetic stimulation (TMS), a noninvasive tool of brain stimulation, could play a major role. TMS has been shown to be a reliable tool for measuring plastic changes in the motor cortex associated with interventions in the motor system, such as motor training and motor cortex stimulation. In addition, as illustrated by the experience in promoting recovery from stroke, TMS is a promising therapeutic tool to minimize motor, speech, cognitive, and mood deficits. In this review, we will focus on stroke to discuss how TMS can provide insights into the mechanisms of neurologic recovery and how it can be used for measurement and modulation of plasticity after an acquired brain insult.

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.

Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association

PURPOSE

The aim of this guideline is to present current and comprehensive recommendations for the diagnosis and treatment of acute spontaneous intracerebral hemorrhage.

METHODS

A formal literature search of MEDLINE was performed. Data were synthesized with the use of evidence tables. Writing committee members met by teleconference to discuss data-derived recommendations. The American Heart Association Stroke Council's Levels of Evidence grading algorithm was used to grade each recommendation. Prerelease review of the draft guideline was performed by 6 expert peer reviewers and by the members of the Stroke Council Scientific Statements Oversight Committee and Stroke Council Leadership Committee. It is intended that this guideline be fully updated in 3 years' time.

RESULTS

Evidence-based guidelines are presented for the care of patients presenting with intracerebral hemorrhage. The focus was subdivided into diagnosis, hemostasis, blood pressure management, inpatient and nursing management, preventing medical comorbidities, surgical treatment, outcome prediction, rehabilitation, prevention of recurrence, and future considerations.

CONCLUSIONS

Intracerebral hemorrhage is a serious medical condition for which outcome can be impacted by early, aggressive care. The guidelines offer a framework for goal-directed treatment of the patient with intracerebral hemorrhage.

Comparison of outcomes after intracerebral hemorrhage and ischemic stroke

BACKGROUND

Intracerebral hemorrhage (ICH) is associated with a greater average initial stroke severity, higher mortality, and poorer long-term neurologic outcomes than ischemic stroke. The purpose of this study was to determine whether the poorer prognosis of ICH is independent of initial stroke severity.

METHODS

We analyzed data from the Glycine Antagonist in Neuroprotection (GAIN) Americas trial, in which 1604 non-obtunded patients with acute stroke were treated within 6 hours of symptom onset irrespective of hemorrhagic (N = 237) versus ischemic (N = 1367) subtype. Multiple logistic regression analysis was performed to evaluate predictors of mortality and neurologic outcome (modified Rankin scale [mRS] score of 0-1 v 2-6 at 3 months) adjusting for baseline National Institutes of Health Stroke Scale score, stroke risk factors, clinical and demographic characteristics, and gavestinel treatment group. Multiple linear regression techniques were used to assess the impact of various predictors on the full mRS score at 3 months.

RESULTS

ICH significantly increased the odds of a poor neurologic outcome (odds ratio 1.94, 95% confidence interval 1.23-3.06) and was independently associated with a mean 0.25-point increase in the 3-month mRS score (P = .04). ICH had no effect on mortality compared with ischemic stroke (odds ratio 1.01, 95% confidence interval .68-1.49) after adjusting for initial stroke severity (National Institutes of Health Stroke Scale score) and other baseline characteristics.

CONCLUSIONS

Among conscious stroke patients, ICH is an independent predictor of poor neurologic outcome, nearly doubling the odds of long-term disability. However, ICH is not associated with higher mortality compared with ischemic stroke after adjusting for initial stroke severity and other baseline characteristics.

Do stroke patients with intracerebral hemorrhage have a better functional outcome than patients with cerebral infarction?

OBJECTIVE

To compare the functional outcome of stroke patients with cerebral infarction (CI) and intracerebral hemorrhage (ICH) after rehabilitation.

DESIGN

Review of a prospectively maintained database of all stroke patients admitted to a rehabilitation unit during a 9.5-year period.

SETTING

Rehabilitation unit in a university hospital in Australia.

PATIENTS

A total of 718 consecutive stroke admissions (589 CI and 129 ICH) who met the inclusion criteria.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASUREMENTS

Functional Independence Measure (FIM) gain, FIM efficiency, Motor Assessment Scale (MAS) change, gait velocity, and discharge destination.

RESULTS

Patients who had ICH were more severely disabled on admission compared with patients who had CI and achieved a greater functional improvement with rehabilitation, ie, a greater FIM efficiency and a greater MAS change. Admission FIM score, admission MAS score, and length of stay were significant explanatory variables for the discharge FIM and FIM gain in both ICH and CI patients. On general linear model analyses, stroke type remained a significant explanatory factor for FIM gain, after adjusting for admission FIM, length of stay, age, and days from stroke onset to rehabilitation admission, ie, stroke patients with ICH obtained a better functional outcome than patients with CI. Admission motor FIM, admission MAS, younger age, and increasing length of stay were independent predictors for FIM gain and discharge FIM for both CI and ICH groups. Admission cognitive FIM score predicted discharge FIM for both the CI and ICH groups and FIM gain in the ICH group but was not a predictor of FIM gain for the CI group. The majority of patients in both groups went home at discharge.

CONCLUSIONS

Although patients with ICH had a greater level of disability on admission to rehabilitation, they achieved significantly greater gains in function than patients with CI after rehabilitation. This was found regardless of the severity of disability on admission.

Post-acute brain injury rehabilitation for patients with stroke

PRIMARY OBJECTIVE

Conduct an investigation of post-acute brain injury rehabilitation (PABIR) for persons with stroke.

RESEARCH DESIGN

Pre-post-treatment observation study.

METHODS AND PROCEDURES

Demographic and medical data for 127 persons with stroke admitted for PABIR at a median interval of 87 days post-stroke were abstracted from medical records. Participants' levels of independence and productivity were assessed at admission and discharge. Follow-up data were available for 90 participants at a median interval of 346 days post-discharge.

EXPERIMENTAL INTERVENTIONS

Not applicable.

MAIN OUTCOMES AND RESULTS

Participants showed improvements in productivity and independence level from admission to discharge and these gains were maintained at follow-up. Predictors of productivity at discharge were gender and level of independence at admission (Model R(2) = 0.28). Predictors of independence at discharge were similar (Model R(2) = 0.37).

CONCLUSION

While this investigation has limitations, findings suggest that PABIR is beneficial for some persons with strokes.

Guidelines for management of ischaemic stroke and transient ischaemic attack 2008

This article represents the update of the European Stroke Initiative Recommendations for Stroke Management. These guidelines cover both ischaemic stroke and transient ischaemic attacks, which are now considered to be a single entity. The article covers referral and emergency management, Stroke Unit service, diagnostics, primary and secondary prevention, general stroke treatment, specific treatment including acute management, management of complications, and rehabilitation.

The Hopkins Rehabilitation Engagement Rating Scale: development and psychometric properties

OBJECTIVE

To conduct an initial investigation of the psychometric properties of the Hopkins Rehabilitation Engagement Rating Scale (HRERS), a 5-item, clinician-rated measure developed to quantify engagement in acute rehabilitation services.

DESIGN

We used a cross-sectional design to conduct correlational and multivariate analyses to establish the measure's internal consistency, interrater reliability, construct validity, and criterion validity.

SETTING

Acute inpatient rehabilitation in 3 metropolitan hospitals.

PARTICIPANTS

A total of 206 subjects with spinal cord injury, ischemic or hemorrhagic stroke, amputation, or hip or knee replacement.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The HRERS, Positive and Negative Affect Schedule, Brief Symptom Inventory, Levine's Denial of Illness Scale, Craig Handicap Assessment and Reporting Technique, and FIM instrument.

RESULTS

The HRERS has good internal consistency (alpha=.91) and interrater reliability (intraclass correlation coefficient, .73) and represents a unidimensional construct. It correlated negatively with symptoms of depression (r=-.24, P<.01), higher ratings of denial of illness (r=-.30, P<.001), and self-rated negative affect (r=-.23, P<.01), and correlated positively with self-rated positive affect (r=.36, P<.001) and level of functioning 3 months postdischarge (r=.22, P<.01).

CONCLUSIONS

The HRERS is a valid and reliable measure of rehabilitation engagement that relates to intermediate-term functional outcomes.

Functional performance of Alzheimer's disease and vascular dementia in southern Taiwan

This study investigated the functional performance of two major subtypes of dementia, Alzheimer's disease (AD) and vascular dementia (VaD), by the Functional Independence Measure (FIM), and to understand the need for assistance in performing activities of daily living. The subjects comprised 64 AD and 21 VaD patients who were recruited from two epidemiologic studies of dementia with a total of 3,931 community residents aged 65 years and above in southern Taiwan. The results showed that the severity of dementia was similar between the two groups. The mean score for AD was 82.7 and for VaD was 56.5 for total FIM (p < 0.05), 61.6 and 41.7 for the motor dimension (p < 0.05), and 21.1 and 15.7 for the cognitive dimension (p < 0.05). There were significant differences (p < 0.01) between AD and VaD in six FIM items and borderline or marginal significance (p < 0.05) in most of the FIM items. For AD patients, stairs, lower dressing, bathing, and tub/shower transfer were the most difficult items in the motor dimension, and it was memory in the cognitive dimension. For VaD patients, bathing, upper and lower dressing, and grooming were the most difficult items in the motor dimension, and it was problem solving in the cognitive dimension. VaD patients were more dependent on all FIM items and required more assistance than AD patients. The functional performances of dementia patients were significantly associated with dementia severity and subtypes, together accounting for 40% of the variability in total FIM. In conclusion, most dementia patients are dependent in daily activities and different types and severity of dementia lead to different disability profiles; individualized care is, therefore, most appropriate.

Efficiency of specialist rehabilitation in reducing dependency and costs of continuing care for adults with complex acquired brain injuries

OBJECTIVES

To examine functional outcomes from a rehabilitation programme and to compare two methods for evaluating cost efficiency of rehabilitation in patients with severe complex disability.

SUBJECTS AND SETTING

Two hundred and ninety seven consecutive admissions to a specialist inpatient rehabilitation unit following severe acquired brain injury.

METHODS

Retrospective analysis of routinely collected data, including the Functional Independence Measure (FIM), Barthel Index, and Northwick Park Dependency Score and Care Needs Assessment (NPDS/NPCNA), which provides a generic estimation of dependency, care hours. and weekly cost of continuing care in the community. Patients were analysed in three groups according to dependency on admission: "low" (NPDS<10 (n=83)); "medium" (NPDS10-24 (n=112)); "high" (NPDS>24 (n=102)).

RESULTS

Mean length of stay (LOS) 112 (SD 66) days. All groups showed significant reduction in dependency between admission and discharge on all measures (paired t tests: p<0.001). Mean reduction in "weekly cost of care" was greatest in the high dependency group at pound639 per week (95% CI 488 to 789)), as compared with the medium (pound323/week (95% CI 217 to 428)), and low (pound111/week (95% CI 42 to 179)) dependency groups. Despite their longer LOS, time taken to offset the initial cost of rehabilitation was only 16.3 months in the high dependency group, compared with 21.5 months (medium dependency) and 38.8 months (low dependency). FIM efficiency (FIM gain/LOS) appeared greatest in the medium dependency group (0.25), compared with the low (0.17) and high (0.16) dependency groups.

CONCLUSIONS

The NPDS/NPCNA detected changes in dependency potentially associated with substantial savings in the cost of ongoing care, especially in high dependency patients. Floor effects in responsiveness of the FIM may lead to underestimation of efficiency of rehabilitation in higher dependency patients.

FIM Scores, FIM Efficiency, and Discharge Disposition Following Inpatient Stroke Rehabilitation

The Functional Independence Measure (FIM) is a widely accepted scale used to measure the functional abilities of patients undergoing rehabilitation. Scores at the extremes of this scale correlate with discharge disposition, while midrange scores are less well understood. This study evaluated the rate of FIM change with time ("efficiency"), admission and discharge FIM scores, and discharge disposition of 748 patients who underwent stroke inpatient rehabilitation. Patients with low scores at admission or discharge were likely to be discharged to a facility (63% and 78%, respectively), and those with high scores at admission or discharge almost always returned home (88% and 81%, respectively). Those with midrange scores at admission were more likely to return home (62%) than those with similar scores at discharge (33%). Greater FIM efficiency scores were associated with home discharge. Findings provide insight into discharge planning for stroke patients and indicate the need for more detailed evaluation of the midrange group.

An evidence-based review of stroke rehabilitation

A comprehensive evidence-based review of stroke rehabilitation was created to be an up-to-date review of the current evidence in stroke rehabilitation and to provide specific conclusions based on evidence that could be used to help direct stroke care at the bedside and at home. A literature search using multiple data-bases was used to identify all trials from 1968 to 2001. Methodological quality of the individual randomized controlled trials was assessed using the Physiotherapy Evidence Database (PEDro) quality assessment scale. A five-stage level-of-evidence approach was used to determine the best practice in stroke rehabilitation. Over 403 treatment-based articles investigating of various areas of stroke rehabilitation were identified. This included 272 randomized controlled trials.

Rehabilitation outcome of Turkish stroke patients: in a team approach setting

The aim of this study was to identify the efficacy of in-patient stroke rehabilitation, to evaluate the relationship between clinical characteristics and functional outcome, and to determine factors predicting functional outcome at discharge in Turkish stroke patients with a team approach. Retrospective data were collected from 102 of 116 patients with first stroke who were admitted to our rehabilitation unit at Ankara University. Demographic data, length of hospital stay (LOHS), onset to admission interval (OAI), type, side and location of stroke lesion, and most common medical complications were recorded. Functional Independence Measure (FIM) and Brunnstrom's motor recovery stages (BMRS) were assessed on admission and at discharge. The mean age was 61.6 +/- 10.9 years and the mean LOHS was 69.7 +/- 28.2 days. The mean FIM total scores were 69.2 +/- 27.4 and 83.2 +/- 25.7 on admission, and at discharge, respectively. The mean FIM total score was significantly correlated to age, LOHS and motor recovery. The FIM total scores of patients with aphasia and depression were found to be lower than those of patients without aphasia and depression. In a stepwise multiple regression analysis, FIM total score on admission, age and OAI were found to be valid predictors of FIM total score at discharge. Functional Independence Measure total score on admission was the strongest variable. Our results suggest that knowledge of the poor prognostic factors effecting functional outcome on admission can provide information to clinicians in identifying severity of stroke. Admission FIM total score, can be used to predict the patients' functional recovery. Advanced age, aphasia and post-stroke depression contribute to lower FIM scores.

Functional outcome of ischemic and hemorrhagic stroke patients after inpatient rehabilitation: a matched comparison

BACKGROUND AND PURPOSE

The goal of this study was to assess the specific influence of stroke etiology on rehabilitation results.

METHODS

This was a case-control study of 270 inpatients with sequelae of first stroke who were enrolled in homogeneous subgroups and matched for stroke severity, basal disability, age (within 1 year), sex, and onset admission interval (within 3 days) who were different only in terms of stroke origin, infarction versus hemorrhage. We compared the groups' length of stay, efficiency and effectiveness of treatment, and percentage of low and high responder patients. Odds ratios of dropouts and of low and high therapeutic response were also quantified.

RESULTS

Compared with ischemic patients, hemorrhagic patients had significantly higher Canadian Neurological Scale and Rivermead Mobility Index scores at discharge; higher effectiveness and efficiency on the Canadian Neurological Scale, Barthel Index, and Rivermead Mobility Index; and a higher percentage of high responders on the Barthel Index. Hemorrhagic patients showed a probability of a high therapeutic response on the Barthel Index that was approximately 2.5 times greater than that of ischemic patients (odds ratio, 2.48; 95% confidence interval, 1.19 to 5.20; accuracy on prediction, 87.06%).

CONCLUSIONS

The results of this study provide further evidence of better functional prognosis in stroke survivors with hemorrhagic stroke.

A model to aid in the prediction of discharge location for stroke rehabilitation patients

OBJECTIVE

To determine which demographic and medical factors recorded on admission to a rehabilitation unit best predict discharge accommodation outcomes.

DESIGN

Retrospective chart review.

SETTING

Inpatient rehabilitation unit in an academic hospital in southwestern Ontario, Canada.

PARTICIPANTS

One hundred four stroke patients (54 women, 50 men; mean age, 72.0y) admitted to the rehabilitation unit over a 4-year period.

INTERVENTIONS

All patients underwent evaluations by the physical therapy, occupational therapy, social work, speech pathology, and psychology departments. Patients were divided into 2 groups: (1) no change in premorbid accommodation and (2) change in premorbid accommodation.

MAIN OUTCOME MEASURES

Demographic, clinical, and housing information (premorbid, discharge) and functional data (FIM trade mark instrument, Chedoke-McMaster Stroke Assessment [CMSA] Impairment Inventory, Berg Balance Scale [BBS]) were recorded for each patient.

RESULTS

Of 104 patients, 24 were discharged with a change in premorbid accommodation. Change in discharge location was significantly associated with age, gender, and the presence of premorbid social support (P<.01), but not with type of premorbid living arrangement. Statistically significant differences were noted between total FIM scores (P<.001), BBS scores (P<.001), and the postural component of the CMSA Impairment Inventory (P<.03). A logistic regression model, predicting 67% of the variance, was created to predict discharge accommodations.

CONCLUSIONS

Patients admitted to the rehabilitation unit can be scored to obtain their predicted chance of being discharged with a change from their premorbid accommodations. The equation is relatively easy to calculate and is based on data that are commonly collected in rehabilitation.

Functional recovery following rehabilitation after hemorrhagic and ischemic stroke

OBJECTIVES

To quantify recovery after rehabilitation therapy and to identify factors that predicted functional outcome in survivors of intracerebral hemorrhage (ICH) compared with cerebral infarction.

DESIGN

Retrospective study of consecutive ICH and cerebral infarction admissions to a rehabilitation hospital over a 4-year period.

SETTING

Free-standing urban rehabilitation hospital.

PARTICIPANTS

A total of 1064 cases met the inclusion criteria (545 women, 519 men; 871 with cerebral infarction, 193 with ICH).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Functional status was measured using the FIM trade mark instrument, recorded at admission and discharge. Recovery was quantified by the change in FIM total score (DeltaFIM total score). Outcome measures were total discharge FIM score and DeltaFIM total score. Univariate and multivariate analyses were performed.

RESULTS

Total admission FIM score was higher in patients with cerebral infarction than in patients with ICH (59 vs 51, P=.0001). No difference in total discharge FIM score was present. Patients with ICH made a significantly greater recovery than those with cerebral infarction (DeltaFIM total score, 28 vs 23.3; P=.002). On multivariate analysis, younger age, longer length of stay, and admission FIM cognitive subscore independently predicted total discharge FIM and DeltaFIM total score. The severity of disability at admission, indicated by total admission FIM score, independently predicted total discharge FIM score, but not DeltaFIM total score. The ICH patients with the most severely disabling strokes had significantly greater recovery than cerebral infarction patients with stroke of similar severity.

CONCLUSIONS

The patients with ICH had greater functional impairment than the cerebral infarction patients at admission, but made greater gains. Patients with the most severely disabling ICH improved more than those with cerebral infarction of comparable severity. Initial severity of disability, age, and duration of therapy best predicted functional outcome after rehabilitation.

Muscle weakness and cocontraction in upper limb hemiparesis: relationship to motor impairment and physical disability

The purpose of this article is to describe the relationship between poststroke upper limb muscle weakness and cocontraction, and clinical measures of upper limb motor impairment and physical disability. Electrormyographic (EMG) activity of the paretic and nonparetic wrist flexors and extensors of 26 chronic stroke survivors were recorded during isometric wrist flexion and extension. The root mean square (RMS) of the EMG signal was used as a measure of strength of contraction. A ratio of RMS of antagonist and agonist muscles was used as a measure of cocontraction. Upper limb motor impairment and physical disability were assessed with the Fugl-Meyer motor assessment (FMA) and the arm motor ability test (AMAT), respectively. The strength of muscle contraction was significantly stronger in the nonparetic limb (P < 0.001). The degree of cocontraction was significantly greater in the paretic limb (P < 0.001). The strength of muscle contraction in the paretic limb correlated significantly with FMA (r = 0.62 to 0.87, P < or = 0.001) and AMAT (r = 0.66 to 0.80, P < or = 0.001) scores. Similarly, the degree of cocontraction correlated significantly with FMA (r = -0. 70 to -0.64, P < or = 0.001) and AMAT (r = -0. 72 to -0.62, P < or = 0.001) scores. Muscle weakness and degree of cocontraction correlate significantly with motor impairment and physical disability in upper limb hemiplegia. This relationship may provide insights toward development of specific interventions. However, additional studies are needed to demonstrate a cause and effect relationship.

Rehabilitation outcome of elderly patients after a first stroke: effect of cognitive status at admission on the functional outcome

OBJECTIVE

To assess whether, and to what extent, cognitive outcome relates to overall functional outcome among elderly stroke patients.

DESIGN

Nonconcurrent prospective study.

SETTING

Geriatric rehabilitation division at a large, urban, academic, freestanding hospital in Israel.

PARTICIPANTS

Three hundred thirty-six patients aged 60 years and older admitted consecutively for rehabilitation after first acute stroke. Inclusion criteria were met by 315 patients, who were included in the final analysis. Average age was 75.3 years. The stroke was right sided in 44.1%.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The motor subscale of the FIM instrument assessed functional status. Absolute functional gain was determined by the FIM motor gain. Relative functional gain was calculated according to the Montebello Rehabilitation Factor Score. Cognitive status was assessed with the Mini-Mental State Examination (MMSE) and the FIM cognitive subscale.

RESULTS

FIM scores increased significantly during rehabilitation, mainly due to improvement in motor functioning. A strong association was found between the cognitive scales (r=.853, P<.001). Better rehabilitation outcomes were observed in patients with higher admission cognitive status, adjusting for the effect of age, sex, onset to admission interval, length of stay, and severity of stroke (odds ratio = 2.0; 95% confidence interval, 1.5-2.5).

CONCLUSIONS

Impaired cognitive status at admission negatively affects the rehabilitation outcome of elderly stroke patients. The utility of routinely using a cognitive test for all patients before admission to rehabilitation, preferably the MMSE, is emphasized. The time, cost, and effort involved in performing such a test are negligible, and the potential benefits are considerable.

Functional outcome after inpatient rehabilitation in persons with subarachnoid hemorrhage

OBJECTIVES

To describe inpatient rehabilitation outcome in persons with nontraumatic subarachnoid hemorrhage (SAH) and to explore the predictive capacity of acute measures of SAH severity and demographic and disease variables.

DESIGN

Retrospective with descriptive and relational analyses.

SETTING

Free-standing, acute, inpatient brain injury rehabilitation unit.

PARTICIPANTS

Forty-two consecutive persons with nontraumatic SAH and for whom complete data were available were studied. Mean age of the group was 56.5 years, mean acute hospital stay was 26.2 days, and 60% were women. Over 40% experienced rupture of an anterior communicating artery aneurysm. The time from injury to rehabilitation admission varied from 11 to 227 days (mean, 43.8d).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Change in FIMtrade mark instrument scores, home discharge rate, and rehabilitation length of stay (LOS.)

RESULTS

The mean admission and discharge FIM scores were 57.7 and 85.5 points, respectively. There was a 27.8-point mean change in FIM score over a 24.1-day mean rehabilitation LOS for a FIM efficiency (points/day) of 1.15. Over 80% of the sample was discharged home. No demographic or disease characteristic variables, including acute severity measures, were statistically significant predictors of outcome.

CONCLUSIONS

Functional gains during inpatient rehabilitation made in this group of 42 persons with SAH are in line with earlier studies. Our rehabilitation LOS is the shortest reported among 4 studies to date and is probably a reflection of managed care in the United States. A small sample, uneven cell sizes, and variability of patients might have contributed to a lack of significant findings. Future study should explore the prediction of rehabilitation outcome using larger sample sizes and longer follow-up periods.

Delay in initiation and termination of muscle contraction, motor impairment, and physical disability in upper limb hemiparesis

The purpose of this study was to describe the relationship between the delay in initiation and termination of muscle contraction and clinical measures of motor impairment and physical disability in the affected upper limb of patients with hemiparesis. Electromyographic (EMG) activity of 26 long-term survivors of stroke was recorded during isometric wrist flexion and extension. Upper limb motor impairment and disability were assessed with the Fugl-Meyer motor assessment (FMA) and arm motor ability test (AMAT), respectively. Delay in initiation and termination of muscle contraction was significantly prolonged in the paretic arm. However, the delay was not significantly affected by stroke type, stroke level, side of hemiparesis, or presence of aphasia. Delay in initiation and termination of muscle contraction correlated significantly with FMA and AMAT. Abnormally delayed initiation and termination of muscle contraction may contribute to hemiparetic upper limb motor impairment and physical disability in hemiparetic patients.

Rehabilitation outcomes in patients with full weight-bearing hip fractures

Evaluation of the functional outcome for hip fractured elderly patients has been controversial due to a typical casemix containing both weight bearing and non weight bearing postoperative fractures. The purpose of this study was to investigate factors associated with rehabilitation outcomes in patients who are able to fully weight bearing following surgical repair of femoral neck fracture. We studied 217 consecutive patients admitted for rehabilitation after surgery for hip fracture. Age, gender, marital status, type of fracture and admission Functional Independence Measure (FIM) were evaluated as possible predictors of rehabilitation outcome. Functional gains were evaluated according to FIM. Dependent outcome variables were calculated as absolute (total FIM gain and daily FIM gain) as well as relative (to potential). Results showed a significant improvement in absolute total and daily FIM gains (19.32+/-8.29, and 0.87+/-0.44, respectively). Relative total functional gain was 0.40+/-0.19. Absolute total functional gain did not depend on FIM admission, whereas all other parameters were significantly correlated with FIM scores on admission, indicating a relatively adverse rehabilitation in patients with an admission FIM of 40 points or lower. The majority (83.9%) of patients were discharged home. A significant association exists between the ability to go home and marital status (P=0.009), as well as with admission FIM (P<0.0001). We conclude that encouraging outcome results are achieved in the elderly with full weight bearing fractures. The absolute functional gains do not depend on FIM admission scores and argues for inclusion of patients with low admission FIM scores to rehabilitation programs. However, the relative gains are significantly better in patients with higher admission FIM scores, thus supporting inclusion of selected patients. This poses serious ethical issues for healthcare policy-makers.

Perceptual differences between stroke patients with cerebral infarction and intracerebral hemorrhage

OBJECTIVE

To assess perceptual performances of patients with intracerebral hemorrhage (ICH) compared with those of ischemic patients early after stroke and to analyze the psychometric properties of three perceptual tests used in the study.

DESIGN

Cross-sectional study.

SETTING

A rehabilitation unit at a teaching hospital.

PATIENTS

Twenty-two stroke patients with ICH and 22 demographically matched stroke patients with infarction.

MAIN OUTCOME MEASURES

Loewenstein Occupational Therapy Cognitive Assessment (LOTCA), Rivermead Perceptual Assessment Battery (RPAB), and Motor-Free Visual Perception Test (MVPT).

RESULTS

Stroke patients with ICH had significantly more severe deficits on a task of thinking operations than did patients with infarction. A significant lateralized effect of stroke existed in the ICH group, with patients with right-hemisphere strokes scoring lower than patients with left-hemisphere strokes on the figure-ground discrimination subtest of the RPAB. A considerable overlap among the three instruments was found. Yet, the observed correlations between supposedly similar subtests from the tests proved to be moderate, indicating that to a certain extent these test measures tap different perceptual processes. Four factors were generated from a joint LOTCA-RPAB-MVPT factor analysis. They assessed different facets of perceptual functioning, including higher-level and lower-level perceptual skills, part/whole conceptual integration, and color perception. This factor pattern accounted for 75.5% of the variance.

CONCLUSIONS

Higher-level perceptual functions tend to be relatively susceptible to ICH stroke pathology early in the course of the disease. This information has important clinical implications in the early treatment planning for the stroke patients with ICH, such that specific compensatory strategies for these deficiencies should be devised to facilitate a successful rehabilitation. Knowledge regarding the influences of specific deficits on the performance of daily activities may also be useful to the patients' family.

Effects of subdural haematoma on sensorimotor functioning and spatial learning in rats

Twenty per cent of all strokes are haemorrhagic in character and are associated with severe disturbances in sensorimotor behaviour and cognition. Although spontaneous recovery of pre-stroke functioning occurs in some cases, the process is demanding, slow, and often incomplete. A first step in the preclinical testing of new putative, neuroprotective and recovery-supporting therapeutics is to validate animal models of brain injury. In a series of four experiments we evaluated the behavioural impairments and the time course of recovery of functional deficits in rats with an experimentally induced subdural haematoma. We found that unilateral subdural haematoma resulted in dysfunction in both simple reflexive (experiment 1) and skilled sensorimotor behaviour (experiment 2). Reflexive behaviour did not recover, or recovered only marginally, and neither did the deficits in skilled forepaw use. Bilateral subdural haematoma impaired the learning and memory performance of adult (experiment 3) and old rats (experiment 4) in the Morris water escape task. Considering the diversity of the deficits found in our experiments, we conclude that different models are needed to cover the broad range of deficits seen in stroke patients.

Functional outcome of inpatient rehabilitation in persons with brain tumors

OBJECTIVE

To document functional outcome in persons with brain tumors undergoing inpatient rehabilitation and to compare outcomes with a group of traumatically brain injured patients.

DESIGN

Retrospective, descriptive, and case-matched.

SETTING

A free-standing inpatient brain injury rehabilitation unit.

PARTICIPANTS

Forty consecutive patients with a variety of tumor types (40% were either glioblastoma multiforme or meningioma) and a mean age of 53.1 (SD 15.4) years. Sixty percent were men, 25% had recurrent tumors, and 15% had metastatic disease. Also, 40 patients with traumatic brain injury (TBI) matched for age, gender, and admission functional status.

MAIN OUTCOME MEASURES

Change in Functional Independence Measure (FIM) scores, length of rehabilitation stay (LOS), and discharge disposition.

RESULTS

The mean LOS for the tumor group was 17.8 (SD 9.9) days, mean FIM gain was 25.4 (SD 20.1) points, and 82.5% were discharged home. No demographic or tumor characteristic was statistically significant in predicting functional outcome at discharge, but greater gains were seen for persons with the diagnosis of meningioma, those with left-sided cerebral lesions, and those not receiving radiation therapy. TBI patients made statistically significant greater gains in total FIM change (34.6 vs 25.4), self-care (12.3 vs 8.5), and social cognition (5.2 vs 3.6). However, FIM efficiency and LOS were not statistically different between the TBI and tumor groups (1.9 vs 1.5 FIM points/day and 22.1 vs 17.8 days, respectively).

CONCLUSIONS

Daily functional gains made by persons with brain tumor undergoing rehabilitation were similar to those made by a group of persons with TBI matched by age, gender, and admission functional status. Further research should use larger samples and address the impact of psychosocial and team factors on LOS and discharge disposition.

Effect of a therapeutic intervention for the hemiplegic upper limb in the acute phase after stroke: a single-blind, randomized, controlled multicenter trial

BACKGROUND AND PURPOSE

Arm function recovery is notoriously poor in stroke patients. The effect of treatment modalities, particularly those directed at improving upper limb function, has been studied primarily in chronic stroke patients. The purpose of this study was to investigate the effect of a specific therapeutic intervention on arm function in the acute phase after stroke.

METHODS

In a single-blind, randomized, controlled multicenter trial, 100 consecutive patients were allocated to either an experimental group that received an additional treatment of sensorimotor stimulation or to a control group. The intervention was applied for 6 weeks. Patients were evaluated for level of impairment (Brunnström-Fugl-Meyer test) and disability (Action Research Arm test, Barthel Index) before, midway, and after the intervention period and at follow-up 6 and 12 months after stroke.

RESULTS

Patients in the experimental group performed better on the Brunnström-Fugl-Meyer test than those in the control group throughout the study period, but differences were significant only at follow-up. Results on the Action Research Arm test and Barthel Index revealed no effect at the level of disability. The effect of the therapy was attributed to the repetitive stimulation of muscle activity. The treatment was most effective in patients with a severe motor deficit and hemianopia or hemi-inattention. No adverse effects due to the intervention were found.

CONCLUSIONS

Adding a specific intervention during the acute phase after stroke improved motor recovery, which was apparent 1 year later. These results emphasize the potential beneficial effect of therapeutic interventions for the arm.