Post-stroke urinary incontinence

Urinary incontinence indicates mortality, disability, and infections in hospitalised stroke patients

OBJECTIVES

To assess the impact of urinary incontinence (UI) on health outcomes over the entire spectrum of acute stroke severity (National Institutes of Health Stroke Scale [NIHSS] scores: 0-42), due to a paucity of data on patients with milder strokes.

PATIENTS AND METHODS

Data were prospectively collected (2014-2016) from the Sentinel Stroke National Audit Programme (1593 men, 1591 women; mean [SD] age 76.8 [13.3] years) admitted to four UK hyperacute stroke units (HASUs). Relationships between variables were assessed by multivariable logistic regression. Data were adjusted for age, sex, comorbidities, pre-stroke disability and intra-cranial haemorrhage, and presented as odds ratios with 95% confidence intervals.

RESULTS

Amongst patients with no symptoms or a minor stroke (NIHSS scores of 0-4), compared to patients without UI, patients with UI had significantly greater risks of poor outcomes including: in-hospital mortality; disability at discharge; in-hospital pneumonia; urinary tract infection within 7 days of admission; prolonged length of stay on the HASU; palliative care by discharge; activity of daily living (ADL) support, and new discharge to care home. In patients with more moderate stroke (NIHSS score of 5-15) the same outcomes were identified; being at greater risk for patients with UI, except for palliative care by discharge and ADL support. With the highest stroke severity group (NIHSS score of 16-48) all outcomes were identified except in-patient mortality, pneumonia, and ADL support. However, odds ratios diminished as NIHSS scores increased.

CONCLUSIONS

Urinary incontinence is a useful indicator of poor short-term outcomes in older patients with an acute stroke, but irrespective of stroke severity. This provides valuable information to healthcare professionals to identify at-risk individuals.

Patient, Family, and Peer Engagement in Nursing Care as an Effort to Improve the Functional Independence of Post-stroke Urinary Incontinence Patients: A Cross-Sectional Study

Introduction

The engagement of patients, family members, and peers is one approach that can be taken to improve the patient’s health status. This study aimed to investigate the relationship between patient, family, and peer involvement in nursing care to improve the functional independence of post-stroke urinary incontinence (UI) patients.

Methods

This cross-sectional descriptive design study was conducted in three hospitals in Kota Kendari, Sulawesi Tenggara, Indonesia. A total of 104 patients were selected using a simple random sampling method. Data were collected during the research period through a survey and observation. Data were analyzed using descriptive analysis and the Mann-Whitney test.

Results

There was a statistically significant difference in the motor subscale of the Functional Independence Measure (motor-FIM) domain (p<0.05). Based on the results of the analysis, there was a relationship between each motor-FIM domain in the engagement group.

Conclusions

The involvement of patients, families, and peers in patient care needs to be comprehensively improved in an effort to increase patient independence, which in turn can improve the quality of life of post-stroke urinary incontinence patients.

Effect of pelvic floor muscle training on pelvic floor muscle function and lower urinary tract symptoms in stroke patients: a systematic review

BACKGROUND

Pelvic floor muscle (PFM) dysfunction and lower urinary tract symptoms (LUTS) are common in stroke patients. Although pelvic floor muscle training (PFMT) is a promising intervention, its effects on stroke patients have not been fully studied.

OBJECTIVE

The goal of this study was to conduct a systematic review of the effect of PFMT on PFM and urinary function of stroke patients.

METHODS

The databases AMED, MEDLINE, CINAHL, Cochrane Library, and PEDro were searched for title/abstract on PFMT and stroke. RCTs and quasi-experimental trials that compared the effects of PFMT to a control intervention in stroke patients were included. The RoB 2.0 and ROBINS-I were used to assess the methodological quality of the included studies. The Standardized mean difference (SMD) and its 95% confidence interval (CI) were calculated.

RESULTS

The current review included three RCTs and one quasi-experimental study, all of which were moderate to high quality. The analysis revealed that PFMT significantly improved PFM contraction (SMD: 0.92; 95% CI, 0.47 to 1.38; p < .0001), dynamic endurance (SMD: 0.61; 95% CI, 0.06 to 1.16; p = .030), daytime frequency (SMD: -0.81; 95% CI, -1.37 to -0.25; p = .004), ICIQ-SF (SMD: -1.64; 95% CI, -2.39 to -0.89; p < .0001), and LUTS (SMD: -1.82; 95% CI, -2.67 to -0.96; p < .0001). Differences in PFM strength, static endurance, nocturia, UI frequency, and 24-hour pad weight were insignificant or non-existent between the two groups.

CONCLUSION

This review demonstrates that PFMT improves PFM contraction, PFM dynamic endurance, daytime frequency, and overall LUTS in stroke patients. To validate these findings, well-designed RCTs with large sample sizes and reliable outcome measures should be conducted.

Experience of the patient's success in facing post-stroke urinary incontinence: the patient's perspective

Objective

Post-stroke urinary incontinence (UI) is one of the sequelae of stroke. This situation affects all aspects of the patient's life – physically, psychologically, socially, and spiritually. This study aimed to investigate the experience of patients’ success in facing a post-stroke UI.

Methods

A qualitative study using the Rapid Assessment Procedure (RAP) approach was used in this study. Informants were selected using purposive sampling. In-depth interviews with as many as 8 patients who had recovered from post-stroke UI and living in the greater area of Southeast Sulawesi (Indonesia) were conducted. In-depth interviews were also conducted with 8 caregivers and 2 nurses. Data were analyzed using a thematic analysis approach and interpretation of data was based on Humanbecoming theory and Self-care deficit theory of nursing.

Results

Five successful things the patients experienced during post-stroke UI were identified. The five successes were as follows: they provided information to get to know and understand post-stroke UI, followed the procedures to overcome post-stroke UI, conducted self-control exercises and stayed motivated, performed daily activities independently according to ability, and made use of family support and peers’ attention.

Conclusions

These findings indicated that persistence, belief, independence, and social support (family and peer) made patients to successfully face their post-stroke UI and improved their quality of life. These findings also became the basis for developing a post-stroke UI management model based on Humanbecoming theory and Self-care deficit theory of nursing.

Prognostic factors of functional outcome in post-acute stroke in the rehabilitation unit

BACKGROUND/PURPOSE

This retrospective study aimed to determine which factors, such as cognition, motor recovery, swallowing function, and bladder and bowel functions, significantly predicted independence in the activities of daily living (ADL) at hospital discharge in a domestic population of patients experiencing post-acute stroke who received in-hospital rehabilitation.

METHODS

We reviewed medical records that were retrieved from the Integrated Medical Database, National Taiwan University Hospital (NTUH-iMD) of 3000 patients who suffered from stroke and were admitted to NTUH from 2014 to 2017. The main outcome measure was independence in the basic ADL (modified Barthel index [mBI]) at discharge. Regression analyses were used to identify prognostic factors for the basic ADL (mBI).

RESULTS

The total mBI improved from 40.7 ± 33.0 to 63.1 ± 34.1 in eligible 2538 patients during their hospital stay. The baseline daily activity function (R² change = 0.042) was the most important prognostic factor associated with independence at discharge, followed by dependence in sitting up (R² change = 0.014), impaired sitting balance (R² change = 0.010), the Brunnstrom stage of hemiplegic lower limb (R² change = 0.006), and the presence of bladder incontinence (R² change = 0.006) assessed by physician upon rehabilitation admission (R² = 0.53, p < 0.05). Dependency in sitting up, impaired sitting balance, and the presence of urinary incontinence were negative prognostic factors of ADL independence at discharge (p < 0.05). By contrast, the Brunnstrom stage of hemiplegic lower limb and baseline mBI scores at rehabilitation admission were positive prognostic factors of ADL independence at discharge (p < 0.05).

CONCLUSION

Baseline ADL function was the most important prognostic factor of functional independence in post-acute stroke. Moreover, the activity limitation of dependency on sitting up and motor function impairment of hemiplegic lower limb prognosticated functional independence.

Moxibustion for post-stroke urinary incontinence in adults: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND AND PURPOSE

Urinary incontinence (UI) is a frequently identified complication among stroke survivors. Moxibustion is commonly used to treat post-stroke UI in Asian countries. This study aimed to synthesize the evidence of using moxibustion for post-stroke UI management.

METHODS

Twelve databases were searched to identify randomized controlled trials (RCTs) using moxibustion to improve post-stroke UI management. Four Chinese journals were also manually screened for potentially eligible articles.

RESULTS

Ten studies with a total of 719 participants and one completed trial without published results were included. Compared with "routine methods of treatment and/or care," the meta-analyses revealed that moxibustion had superior effects in improving UI symptoms and alleviating the severity of UI.

CONCLUSION

This systematic review identified preliminary research evidence that moxibustion may be effective in managing the symptoms of post-stroke UI. More rigorously designed, large-scale RCTs are warranted to provide more robust evidence in this area.

Prevalence of Comorbid Spasticity and Urinary Incontinence in Residents of a Long-Term Care Facility

The current study evaluated the prevalence of comorbid spasticity and urinary incontinence (UI) in a long-term care facility. Medical history, presence of UI, and activities of daily living (ADL) dependency were obtained from medical records and Minimum Data Set 3.0. Quality of life was assessed with the EuroQoL-5D-5L (EQ-5D). Comorbid spasticity and UI presented in 29% of participants (14 of 49). Participants with spasticity and UI had higher ADL dependency and lower EQ-5D than participants without both conditions (4.9, 95% confidence interval [CI] [1.6, 80.], p = 0.003; -0.17, 95% CI [-0.33, 0.00], p = 0.044; respectively). More than one half of participants with lower limb spasticity had severe UI, compared to only 10% without lower limb spasticity (relative risk = 5.5; 95% CI [1.9, 15.9]; p = 0.006). Comorbid spasticity and UI may be common in the long-term care setting and negatively associated with ADL and quality of life. Further investigation is needed to confirm these findings. [Journal of Gerontological Nursing, 46(10), 35-42.].

The efficacy and safety of electroacupuncture against urinary incontinence after stroke: A protocol for systematic review and meta analysis

BACKGROUND

Urinary incontinence (UI) is still a persistent challenge in many stroke survivors, affecting the quality of life and emotional being of these individuals. Numerous studies have demonstrated the curative effect of electroacupuncture on post-stroke incontinence, however they were mired with questionable quality and inconsistencies in safety and efficacy. Therefore, the main objective of this meta-analysis is to provide a comprehensive evaluation of the efficacy and safety of electroacupuncture against urinary incontinence after stroke, with a view of providing more reliable evidence-based solutions for UI.

METHODS

A systematic literature search will be conducted using PubMed, EMBASE, the Cochrane Central Register of Controlled Trials, Web of Science, and 4 Chinese databases from inception to June 2020 to identify randomized control trials that report on electroacupuncture against urinary incontinence after stroke. Two reviewers will independently identify eligible studies and extract data. The risk of bias of the included randomized control trials will be evaluated according to the Cochrane tool. Risk ratio and 95% confidence intervals will be used to estimate the efficacy of treatment,. and the grading of recommendations, assessment, development, and evaluation approach to rate the certainty of evidence. The statistical heterogeneity will be evaluated by Cochran's Q and the I. Data will be analyzed using Stata software (Version 13.0, Stata Corp, College Station, TX, USA).

RESULTS

This study will provide a comprehensive evaluation of the efficacy and safety of electroacupuncture against UI after stroke, with a view of providing more reliable evidence-based solutions for UI.

ETHICS AND DISSEMINATION

This work synthesises evidence from previously published studies and does not require ethics review or approval. A manuscript describing the findings will be submitted for publication in a peer-reviewed scientific journal.

INPLASY REGISTRATION NUMBER

INPLASY202050073.

Electroacupuncture for post-stroke overactive bladder: a multi-centre pilot randomized controlled trial

BACKGROUND

Although acupuncture has been shown to be effective at treating overactive bladder (OAB) following stroke, to our knowledge, no randomized controlled trial (RCT) examining the effects of acupuncture on patients with post-stroke OAB has been conducted. The aim of this preliminary study was to explore the effects of electroacupuncture (EA) in the treatment of post-stroke OAB.

METHODS

This study was a multi-site randomized, assessor-blind, controlled pilot trial of patients with post-stroke OAB. In all, 34 post-stroke subjects (mean age: 71.0 years; 32.4% female) with OAB symptoms were randomly assigned to the treatment group or control group in a 1:1 ratio. The subjects in the treatment group were treated with six sessions of EA for 4 weeks, while the subjects in the control group received usual care. The primary outcome measure was the overactive bladder symptom scale (OABSS). Secondary outcome measures included a three day bladder diary and the stroke-specific quality-of-life scale (SSQoL).

RESULTS

EA showed a moderate effect size (ES) on the perceived severity of OAB symptoms as measured by the OABSS at week 5 (one week post-treatment, ES 0.57; p = 0.034) and week 8 (three weeks post-treatment, ES 0.60; p = 0.021), although the results did not remain statistically significant after Bonferroni correction for multiple testing. No significant differences in bladder diary parameters or SSQoL score were found. The EA treatment was well tolerated by the post-stroke subjects.

CONCLUSION

A six-session EA treatment was feasible and appeared to reduce OAB symptoms in post-stroke patients. Further fully powered trials are warranted to confirm the efficacy of EA for those with post-stroke OAB.

Lower urinary tract dysfunction in common neurological diseases

The lower urinary tract has the main function of urine storage and voiding. The integrity of the lower urinary tract nerve supply is necessary for its proper function. Neurological disorders can lead to lower urinary tract dysfunction (LUTD) and cause lower urinary tract symptoms (LUTS). Common causes of neurogenic LUTS or LUTD include spinal cord injury, multiple sclerosis, Parkinson's disease, cerebrovascular accidents, cauda equina syndrome, diabetes mellitus, and multiple system atrophy. The pathophysiology is categorized according to the nature of the onset of neurological disease. Assessment requires clinical evaluation, laboratory tests, imaging, and urodynamic studies. Impaired voiding is most often managed by clean intermittent self-catheterization if the postvoid residual urine exceeds 100 ml, whereas storage symptoms are most often managed by antimuscarinic medications. Intradetrusor injection of botulinum toxin type A is emerging as an effective treatment for managing refractory neurogenic detrusor overactivity. This review provides an overview of the clinical characteristics, diagnosis, and management of LUTD in patients with central and peripheral common neurological diseases.

Urinary and fecal incontinence in stroke survivors followed in general practice: A retrospective cohort study

BACKGROUND

Investigating the short- and long-term health outcomes after stroke is a public health priority.

OBJECTIVES

We aimed to analyse the incidence of urinary and fecal incontinence within 10 years of stroke in individuals followed in general practice in Germany.

METHODS

Individuals who had received an initial stroke diagnosis at one of 1262 general practices in Germany between January 2006 and December 2015 were included (index date). Individuals without stroke were matched (1:1) to those with stroke based on propensity scores by using a "greedy" algorithm and logistic regression with sex, age, index year, and 17 comorbidities diagnosed in the 12 months before the index date. The main outcome of the study was the incidence of urinary and fecal incontinence within 10 years of stroke.

RESULTS

This study analysed data for 16,181 individuals with stroke and 16,181 without stroke. Within 10 years of the index date, 22% and 11% of men with and without stroke received a diagnosis of urinary incontinence (log-rank P<0.001); the prevalence of urinary incontinence was 34% in female stroke survivors and 17% in females with no history of stroke (log-rank P<0.001). The respective proportions of fecal incontinence were 5% and 2% for men (log-rank P<0.001) and 6% and 3% for women (log-rank P<0.001). Overall, stroke was positively associated with both urinary incontinence (men: hazard ratio [HR] 2.34, 95% confidence interval [CI] 2.10-2.61; women: HR 2.36, 95% CI 2.14-2.61) and fecal incontinence (men: HR 2.43, 95% CI 1.88-3.13; women: HR 2.60, 95% CI 1.98-3.41).

CONCLUSION

This study, using data from Germany, suggests that general practitioners should regularly screen for urinary and fecal incontinence in the decade following stroke.

Identifying Sub-Acute Rehabilitation Needs Among Individuals After Transient Ischaemic Attack Using Rehab-Compass as a Simple Screening Tool in the Outpatient Clinic

Objective

To evaluate comprehensive unmet rehabilitation needs by using a novel graphic screening tool, Rehab-Compass, among individuals in the sub-acute stage after first-ever transient ischaemic attack.

Methods

A pilot prospective cohort study investigated 47 individuals with first-ever transient ischaemic attack in an outpatient clinic setting. By using Rehab-Compass, based on well-validated patient-reported outcome measure questionnaires, this study examined comprehensive unmet rehabilitation needs among individuals at 4-month follow-up after the onset of transient ischaemic attack.

Results

Rehab-Compass identified that most participants were independent in their daily lives (modified Rankin Scale; mRS 0-1) with a relatively good quality of life (median EuroQol 5 dimensions (EQ-5D) 0.85), but certain limitations in participation in their daily lives. Rehab-Compass showed that, at 4 months after transient ischaemic attack, the most common condition affected was mood (reported by 89% of participants), followed by bladder function (70%), sexual life (52%), strength (51%) and fatigue (26%). Symptoms of depression and anxiety were reported by 6% and 17% of participants, respectively.

Conclusion

This pilot study indicates that RehabCompass might be a suitable simple screening tool for use in the outpatient clinic setting to identify the multidimensional rehabilitation needs of individuals after transient ischaemic attack.

IoT-Based Home Monitoring: Supporting Practitioners' Assessment by Behavioral Analysis

This paper introduces technical solutions devised to support the Deployment Site - Regione Emilia Romagna (DS-RER) of the ACTIVAGE project. The ACTIVAGE project aims at promoting IoT (Internet of Things)-based solutions for Active and Healthy ageing. DS-RER focuses on improving continuity of care for older adults (65+) suffering from aftereffects of a stroke event. A Wireless Sensor Kit based on Wi-Fi connectivity was suitably engineered and realized to monitor behavioral aspects, possibly relevant to health and wellbeing assessment. This includes bed/rests patterns, toilet usage, room presence and many others. Besides hardware design and validation, cloud-based analytics services are introduced, suitable for automatic extraction of relevant information (trends and anomalies) from raw sensor data streams. The approach is general and applicable to a wider range of use cases; however, for readability’s sake, two simple cases are analyzed, related to bed and toilet usage patterns. In particular, a regression framework is introduced, suitable for detecting trends (long and short-term) and labeling anomalies. A methodology for assessing multi-modal daily behavioral profiles is introduced, based on unsupervised clustering techniques. The proposed framework has been successfully deployed at several real-users’ homes, allowing for its functional validation. Clinical effectiveness will be assessed instead through a Randomized Control Trial study, currently being carried out.

Lower urinary tract symptoms in male patients with stroke: A nationwide population-based study

BACKGROUND AND OBJECTIVES

There is a scarcity of large population-based studies investigating lower urinary tract symptoms (LUTS) using the International Prostate Symptom Score (IPSS) in stroke survivors. We investigated the prevalence and severity of LUTS in male stroke survivors and determined the independent effect of stroke on LUTS using data from a nationwide population-based survey.

METHODS

Cross-sectional data obtained from the 2011 Korean Community Health Survey were analyzed. The prevalence and severity of LUTS were compared between 1936 male stroke patients and 90,506 male non-stroke participants. Multivariable logistic regression was used to identify the independent effect of stroke on LUTS.

RESULTS

Male stroke patients more frequently reported both storage symptoms (frequency, urgency, and nocturia) and voiding symptoms (straining, weak stream, intermittency, and incomplete emptying) compared to male non-stroke population. The storage and voiding subscores of IPSS and quality of life score were higher in male stroke patients than in male non-stroke population. Multivariable logistic regression adjusted for age, socioeconomic factors, physical and mental health measures, and comorbidities, found stroke to be an independent risk factor for all 7 symptoms of LUTS.

CONCLUSION

The present study confirmed a high prevalence of LUTS in male stroke survivors that cannot be attributed only to potential confounders, implying that stroke may independently contribute to the development of LUTS. Our findings warrant the need for timely detection by physicians and proper management of LUTS to promote functional outcomes and quality of life in stroke population.

Autonomic Disturbances in Acute Cerebrovascular Disease

Autonomic disturbances often occur in patients with acute cerebrovascular disease due to damage of the central autonomic network. We summarize the structures of the central autonomic network and the clinical tests used to evaluate the functions of the autonomic nervous system. We review the clinical and experimental findings as well as management strategies of post-stroke autonomic disturbances including electrocardiographic changes, cardiac arrhythmias, myocardial damage, thermoregulatory dysfunction, gastrointestinal dysfunction, urinary incontinence, sexual disorders, and hyperglycemia. The occurrence of autonomic disturbances has been associated with poor outcomes in stroke patients. Autonomic nervous system modulation appears to be an emerging therapeutic strategy for stroke management in addition to treatments for sensorimotor dysfunction.

Effects on urinary outcome of patients and caregivers' burden of pelvic floor muscle exercises based on the health belief model done at home by post-stroke patients

OBJECTIVE

The purpose of this study is to investigate the effects of pelvic floor muscle exercises (PFMEs) done by stroke patients at home in line with the health belief model (HBM) on patient care outcomes and caregivers' burdens.

METHOD

In the study, a quasi-experimental design with a pre- and post-test control group was used. The study was conducted with 20 patients in the experimental group and 18 patients in the control group. The patients and caregivers were evaluated at baseline and after the 12-week PFME intervention performed at home. The data were analyzed with the chi-square, Mann-Whitney U, Wilcoxon signed rank test and multiple regression analysis.

RESULTS

A statistically significant difference was found between the two groups in terms of the mean scores they obtained from the ICIQ-SF and I-QOL, the number of urinary incontinence episodes, pad test after interventions and quality of life scores (p < 0.05), while no statistically significant difference was found between the groups in terms of the mean scores for the Burden Interview (p > 0.05). An increase was determined in the self-efficacy of the patients in the experimental group after the PFMEs (p < 0.05).

CONCLUSIONS

Given the results of the present study, it is recommended that in the management of post-stroke urinary incontinence, post-stroke patients should be encouraged to do PFME at home in line with the HBM, and they should be monitored periodically.

Effectiveness of neuromuscular electrical stimulation therapy in patients with urinary incontinence after stroke: A randomized sham controlled trial

BACKGROUND

This study aimed to evaluate the effectiveness of neuromuscular electrical stimulation (NMES) therapy in patients with urinary incontinence after stroke (UIAS).

METHODS

A total of 82 patients with UIAS were randomly assigned to 2 groups that received NMES therapy (NMES group) or sham NMES (sham group) for 10 weeks. The primary efficacy endpoints were measured by urodynamic values, and Overactive Bladder Symptom Score (OABSS). The secondary efficacy endpoints were assessed by International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) score, Barthel Index (BI) scale, and adverse events. All outcomes were evaluated at baseline and at the end of 10 weeks treatment.

RESULTS

After 10-week treatment, the patients received NMES therapy showed better efficacy in primary endpoints of urodynamic values (P <.01) and OABSS (P <.01), and secondary endpoints of ICIQ-SF (P <.01) and BI (P <.01), compared with patients who underwent sham NMES. No adverse events were recorded in both groups.

CONCLUSIONS

In summary, we demonstrated that 10 weeks of NMES therapy was efficacious in patients with UIAS.

Comparison of efficacy and safety between electroacupuncture at 'four sacral points' and conventional electroacupuncture for the treatment of urinary incontinence after stroke: study protocol for a randomised controlled trial

INTRODUCTION

Electroacupuncture at 'four sacral points', also known as electrical pudendal nerve stimulation therapy, combines the advantages of pudendal nerve neuromodulation and the technique of deep insertion of long acupuncture needles. It has been used to treat stress urinary incontinence, female urgency-frequency syndrome, idiopathic urgency urinary incontinence and neurological bladders in previous studies. Here, we describe the protocol for a randomised controlled trial for evaluation of the efficacy and safety of electroacupuncture at 'four sacral points' for the management of urinary incontinence after stroke.

METHODS AND ANALYSIS

This is an open-label randomised controlled trial with blinded assessments and analyses. A total of 140 eligible patients will be randomly allocated to two groups. The treatment group (n=70) will receive electroacupuncture at 'four sacral points' along with routine medical care, while the control group will receive conventional electroacupuncture along with routine medical care. Twenty treatment sessions will occur over a period of 4 weeks. The primary outcome measures will be the self-recorded findings in an incontinent episode diary at baseline and at 4 weeks after baseline. The secondary outcome measures will be the International Consultation on Incontinence Questionnaire Urinary Incontinence-Short Form (ICIQ-UI SF) score and the Barthel Activities of Daily Living Index (Barthel ADL Index) score at baseline and at 4 and 28 weeks after baseline.

ETHICS AND DISSEMINATION

This protocol has been approved by the Ethics Committee of the First Affiliated Hospital of Zhejiang Chinese Medical University (approval No. 2018-K-059-01). Written informed consent will be obtained from each participant. The results of the study will be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ChiCTR-IOR-17012847; Pre-result.

Role of the nurse in stroke rehabilitation

Stroke is a leading cause of death and adult disability in the UK. A stroke can have significant negative effects on the lives of patients and their families and carers. While improved stroke management has contributed to a reduction in mortality and improved outcomes following rehabilitation, the incidence of stroke continues to rise in the UK, partly because of the ageing population. Stroke rehabilitation involves a multidisciplinary approach, with nurses performing a central role. This article describes the risk factors and types of stroke, the main areas of stroke rehabilitation and the role of the nurse. It emphasises that providing support to families and carers is a particularly important element of caring for people who have experienced a stroke.

A case of probable oxybutynin-induced increase in liver enzymes

We describe the case of a 49-year-old male who presented to the emergency department with right-sided weakness and inability to speak. He was diagnosed with stroke and was admitted to Qatar Rehabilitation Institute after he was treated for the acute phase at Hamad General Hospital. As part of his management, he was started on oxybutynin 5 mg orally twice daily for the treatment of overactive bladder. Within a week, his liver enzymes started to increase. After a thorough medication review, oxybutynin was suspended as it was the only suspected medication to be responsible of this elevation in liver enzymes. When Naranjo Adverse Drug Reaction Probability Scale was used to assess the probability of an adverse drug reaction (ADR), a score of 6 was obtained indicating a “Probable” ADR. In conclusion, this is the first published report of oxybutynin-induced elevation in liver enzymes. Further reports are required to highlight this probable ADR and alert all health professionals about it.

Association between urinary incontinence and physical frailty in Korea

OBJECTIVE

The purpose of this study was to investigate the associations between urinary incontinence (UI) and physical frailty (PF).

METHODS

The study participants (n = 404) who visited the geriatric clinic were divided into two groups according to the presence or absence of UI based on questionnaire results. We analysed the relationship between each factor associated with PF and the risk of UI according to the number of factors associated with PF.

RESULTS

Urinary incontinence was associated with grip strength and history of falls (P = 0.01, 0.02, respectively). The risk of UI increased as the patients' number of PF-related factors increased (P for trend = 0.04).

CONCLUSIONS

The risk of UI increased as the severity of PF increased. Strength and the experiences of falls were associated with UI.

Elderly Stroke Rehabilitation: Overcoming the Complications and Its Associated Challenges

There have been many advances in management of cerebrovascular diseases. However, stroke is still one of the leading causes of disabilities and mortality worldwide with significant socioeconomic burden. This review summarizes the consequences of stroke in the elderly, predictors of stroke rehabilitation outcomes, role of rehabilitation in neuronal recovery, importance of stroke rehabilitation units, and types of rehabilitation resources and services available in Singapore. We also present the challenges faced by the elderly stroke survivors in the local setting and propose strategies to overcome the barriers to rehabilitation in this aging population.

Association of Urinary Incontinence with Cognition, Transfers and Discharge Destination in Acute Stroke Inpatient Rehabilitation

BACKGROUND

Acute-stroke prognostic indicators remain controversial including relationship of urinary incontinence with outcomes in cognition, transfers, and discharge destination.

OBJECTIVE

To examine if urinary incontinence is associated with inpatient-rehabilitation (IR) outcomes in cognition, transfers, and discharge destinations.

DESIGN

Retrospective observational study of 303 of 579(52%) acute-stroke patients admitted to IR 2012-2015 with complete urinary incontinence (total assistance for bladder management). Discharge Functional Independence Measure (FIM) scores were correlated for continence, cognition, transfers-(bed/chair/wheelchair), and discharge destination.

RESULTS

Patients were admitted to IR on average 7.4 days after acute stroke. Average length-of-stay in IR was 14 days. At discharge 118 of 303(39%) remained urinary incontinent (total assistance). Continence/bladder-management FIM scores at discharge were associated with cognition FIM scores at discharge (chi square =105.8; P < .0001), and associated with transfer FIM scores at discharge (chi square = 153.1; P < .0001). Patients total to moderate assistance for continence at discharge included greater percentage that were dependent to moderate assistance for cognition and transfers than those minimal assistance to independent for continence. Continence/bladder-management FIM scores at discharge were associated with discharge disposition destinations (chi square = 29.98; P < .002). Patients total to moderate assistance for continence at discharge included greater percentage of acute care transfers, and skilled-nursing-facility dispositions, than patients that recovered to minimal assist to independent for continence. Urinary-incontinence recovery to minimal assistance to independent was associated with a home/community disposition rate of 82%.

CONCLUSIONS

52% stroke patients were total assistance with bladder management for urinary incontinence on IR admission. Partial to complete continence recovery occurred in 61%. Continence/bladder-management FIM scores at discharge were associated with cognition and transfer FIM scores, and discharge destinations.

Infections Diagnosed after Admission to a Stroke Unit and Their Impact on Hospital Mortality in Poland from 1995 to 2015

BACKGROUND

Implementation of modern stroke unit care might have attenuated the negative effect of infections on stroke outcome. Our aim was to investigate changes in the occurrence of pneumonia and urinary infections diagnosed after admission to experienced Polish stroke center between 1995 and 2015, and their association with hospital mortality.

MATERIALS AND METHODS

This is a retrospective registry-based analysis of consecutive patients with acute stroke from highly urbanized area (Warsaw, Poland) in years 1995-2015. A total of 5174 patients were divided to 4 time periods: 1995-2000 (n = 883), 2001-2006 (n = 1567), 2006-2010 (n = 1539), and 2011-2015 (n = 1183). Odds ratios (ORs) for hospital death were calculated after adjustment for age, congestive heart failure, preexisting disability, stroke type, and baseline neurological deficit, separately in years 1995-2015, 1995-2000, and 2011-2015.

RESULTS

Over time there was a significant decrease in the proportion of patients diagnosed with pneumonia (20%, 19%, 9%, and 15%, respectively) or urinary tract infection (29%, 21%, 24%, and 18%, respectively) and in the proportion of patients having body temperature of 38.0°C or higher at least once within first 7 days of hospital stay (20%, 20%, 13%, and 13%, respectively), without significant change in the use of antibiotics (range 35%-37%). Hospital mortality was strongly predicted by pneumonia (OR 3.6-4.2) and fever (OR 2.7-4.7) but not urinary infections.

CONCLUSIONS

Over the last 2 decades there was a decrease in the proportion of patients with acute stroke diagnosed with pneumonia or urinary tract infection during stroke unit stay. Hospital death was strongly predicted by pneumonia and fever but no by urinary infections.

Using population-based routinely collected data from the Sentinel Stroke National Audit Programme to investigate factors associated with discharge to care home after rehabilitation

Objectives:

We investigated factors associated with Care Home (CH) discharge following stroke using routinely collected data in unselected patients and assessed the relevance of previous research findings to such patients seen in routine clinical practice.

Design:

Retrospective analysis of data from the Sentinel Stroke National Audit Programme using univariate analysis and logistic regression.

Setting:

A large acute and rehabilitation UK stroke unit with access to early supported discharge.

Subjects:

All patients with stroke treated from 1 January 2014 to 1 January 2017.

Main measures:

National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS).

Results:

Of 2584 patients (median age 78 years, interquartile range (IQR) 69–86; 50.6% male; 86.7% infarcts; median admission NIHSS 4, IQR 2–9), 401 (15.5%) died in hospital and 203 patients (7.9%) were permanently discharged to CH for the first time. Most had pre-discharge mRS scores of 4/5. Factors (odds ratios; 95% confidence intervals) associated with CH discharge included age (1.07; 1.05–1.10), incontinence (11.5; 7.13–19.25), dysphagia (2.13; 1.39–3.29), severe weakness (1.93; 1.28–2.92), pneumonia (1.68; 1.13–2.50), urinary tract infection (UTI) (1.70; 1.04–2.75) and depression (1.65; 1.00–2.72). In a subgroup of all patients with a pre-discharge mRS of 4/5, age (1.04; 1.02–1.06), incontinence (4.87; 2.39–11.02), UTI (2.0; 1.09–3.71) and pneumonia (1.59; 1.02–2.50) were the only factors associated with CH discharge.

Conclusion:

Potentially modifiable variables like incontinence, UTI and pneumonia were associated with CH discharge, particularly in the severely disabled.

Reliability and validity of the Turkish version of the Danish Prostatic Symptom Score to assess lower urinary tract symptoms in stroke patients

BACKGROUND

Lower urinary tract dysfunction (LUTD) is one of the most frequently encountered problems in stroke.OBJECTİVE:To assess the validity and reliability of the Turkish Danish Prostatic Symptom Score (DAN-PSS) in stroke patients with LUTD.

METHODS

A total of 50 patients were included in the study. The reliability was assessed using Cronbach α and intraclass correlation coefficient (ICC) methods, and the validity using the correlations between the subgroup and overall scores of DAN-PSS and the scores of the Barthel Index (BI), International Consultation on Incontinence Questionnaire Short Form (ICIQ-SF), and Short Form 36 (SF-36).

RESULTS

The Cronbach α values were found >0.97 and ICC 0.953-0.990 for all subgroup scores. We found a significant negative correlation between all the sub-scores of DAN-PSS and the BI, and a significant positive correlation between all the sub-scores of DAN-PSS and ICIQ-SF (p < 0.05). The symptom score of DAN-PSS had a significant negative correlation with the physical functioning, physical and emotional role subdomains of the SF-36 survey (p < 0.05).

CONCLUSIONS

We have shown the reliability and validity of the Turkish DAN-PSS, and we think that it will be useful to utilize it in the monitoring of patients with stroke and in clinical studies.

Rupture of a non-traumatic anterior communicating artery aneurysm: Does location of aneurysm associate with functional independence following post-acute in-patient neurorehabilitation?

OBJECTIVE

Patients with non-traumatic rupture of an aneurysm located at the anterior communicating artery (ACoA) often experience cognitive disabilities. It is unknown whether location of aneurysm also affects the possibility for improvement in functional independence compared to patients with an aneurysmal subarachnoid hemorrhage (a-SAH) located elsewhere. The aim was to explore the association between location of aneurysm (ACoA versus other) and level of functional independence, measured by Functional Independence Measure (FIM), at discharge from rehabilitation. Additionally, age and FIM at admission were explored.

METHOD

Historical cohort study among 107 patients with a-SAH based on data from a clinical database and a population-based register. Data were analyzed using multivariable logistic regression.

RESULTS

Patients with ACoA were admitted with poorer cognitive FIM (median 6 (IQR 5-14) compared to patients with aneurysms located elsewhere (median 12 (IQR 6-23) (p = 0.0129); no difference at discharge. No association between aneurysm location and functional independence was observed. Higher age was associated with poorer outcome in bowel management OR 0.54 (95% CI 0.31-0.92), bladder management OR 0.59 (95% CI 0.35-0.98), comprehension OR 0.53 (95% CI 0.30-0.94), and memory OR 0.48 (95% CI 0.25-0.93). Overall, FIM at admission was associated with functional independence at discharge with the exception of stair walking and bladder management which did not reach statistical significance.

CONCLUSION

ACoA was not associated with poorer level of functional independence compared to patients with a-SAH located elsewhere. Higher age was associated with poorer outcome in continence, comprehension, and memory, whereas higher FIM was associated with better functional independence across items at discharge.

Effectiveness and Safety of Electroacupuncture on Poststroke Urinary Incontinence: Study Protocol of a Pilot Multicentered, Randomized, Parallel, Sham-Controlled Trial

This pilot multicentered, randomized, parallel, sham-controlled trial is intended to evaluate the effectiveness and safety of electroacupuncture therapy for poststroke patients with urinary incontinence. Forty stroke survivors aged >19 years will be recruited in 2 hospitals in the Republic of Korea. Patients who experienced stroke within 2 years and satisfy criteria of urinary frequencies ≥2 with either 3 to 4 points on the Patient Perception of Intensity of Urgency Scale or 13 points or more on the Korean version of the International Prostate Symptom Scale (K-IPSS) will be identified, along with other eligibility criteria. Patients will be randomly allocated to either a treatment or control group to receive 10 sessions of electroacupuncture or sham therapies, respectively. Patients and outcome assessors will be blinded. The primary outcome is the change of Total Urgency and Frequency Score between the baseline and the trial endpoint. The K-IPSS, the International Consultation on Incontinence Questionnaire for Urinary Incontinence Short Form, and the Lower Urinary Tract Symptoms Outcome Score will be evaluated for effectiveness assessment. Adverse events will be reported after every session. The Blinding Index will also be calculated. Data will be statistically analyzed with 0.05 significance levels by 2-sided testing.

Evidence-Based Continence Care: An Integrative Review

PURPOSE

The purpose of this integrative review is to identify the best nurse-managed continence care strategies among rehabilitation patients from the current body of evidence.

DESIGN

The newly designed 2015 Competency Model for Professional Rehabilitation Nursing serves as a conceptual framework to categorize evidence-based recommendations for continence care into the four domains of the model.

METHODS

A search of the evidence was completed in December 2015. Literature reviewed was limited to articles published from 2005-2015 in the English language. Search priority was given to systematic reviews and randomized controlled trials.

FINDINGS

Nurse-led interventions include evidence-based clinical assessments with use of validated instruments following step-wise algorithms derived from clinical practice guidelines. The interprofessional team emphasizes role-based continence interventions with shared work to reach goals. Leadership recommendations call for administrative support and allocation of resources for continence care and also empower select bedside nurses to become continence champions. Finally, nurse-patient education and caregiver training target the promotion of successful living. System-based continence recommendations are identified to include rehab-oriented electronic documentation systems, written continence policies and procedures, and ongoing nursing education emphasizing accountability to high performance standards.

CONCLUSIONS

Rehabilitation nurses are the team leaders in promoting continence in the rehabilitation setting. They are the cultivators of hope and foster resilience among patients to move forward despite acute or chronic illness and disability. This article is intended to support rehabilitation nurses in their review of clinical evidence in effort to move toward a more uniform approach to bowel and bladder management.

CLINICAL RELEVANCE

This review equips rehabilitation nurses who seek to improve their practice by identifying the best evidence-based approaches to continence care.

Effects of Transcutaneous Electrical Nerve Stimulation at Two Frequencies on Urinary Incontinence in Poststroke Patients: A Randomized Controlled Trial

OBJECTIVE

The objective of this study was to compare the effects of two frequencies of transcutaneous electrical nerve stimulation (TENS) on urinary incontinence caused by stroke.

METHODS

Eighty-one patients with poststroke urinary incontinence were recruited and randomized into the following three groups with a 1:1 ratio: a 20-Hz TENS group, a 75-Hz TENS group, and a no-treatment control group (n = 27 per group). TENS currents were biphasic square waves with pulse durations of 150 μsecs and pulse frequencies of 20 Hz or 75 Hz and were applied for 30 mins once per day for 90 days. The positive electrodes were placed in the region of the second sacral level on opposite sides of the vertebral column; the negative electrodes were placed on the inside of the middle and lower third of the junction between the posterior superior iliac spine and the ischial node. Overactive Bladder Symptom Scores, Barthel Index, urodynamic values, and voiding diary parameters were assessed before and after 90 days.

RESULTS

The patients treated with 20 Hz had superior Overactive Bladder Symptom Scores, Barthel Index totals, urodynamic values, and voiding diary parameters (P < 0.05). In the 75-Hz group, values were statistically improved compared with the no-treatment group (P < 0.05), but the results were significantly inferior to those of the 20-Hz group (P < 0.05).

CONCLUSIONS

Twenty-hertz TENS improved incontinence symptoms and promoted activities of daily living better than 75-Hz TENS. These results will aid future research regarding TENS parameters.

Prevalence and risk factors of urinary incontinence for post-stroke inpatients in Southern China

AIMS

The prevalence and risk factors of urinary incontinence (UI) for post-stroke inpatients remain unclear. In this study, we aimed to investigate the risk factors associated with the development of UI for post-stroke inpatients in southern China.

DESIGN

Cross-sectional survey.

SUBJECTS AND METHODS

A total of 711 post-stroke patients from neurological units at 8 different hospitals in Guangzhou, a city in southern China, were interviewed face to face. Data were collected by a self-designed questionnaire which includes sociodemographic variables, characteristics of stroke, and medical history.

RESULTS

The prevalence of UI among post-stroke inpatients was 44.3%. By multivariate logistic regression, we found that major risk factors for UI included health care assistant care (OR = 3.935), hemorrhagic stroke (OR = 1.755), mixed stroke (OR = 2.802), parietal lobe lesion (OR = 1.737), chronic cough (OR = 2.099), aphasia (OR = 3.541), and post-stroke depression (OR = 3.398).

CONCLUSIONS

The prevalence of UI among post-stroke inpatients is high. Stroke inpatients looked after by health care assistant, hemorrhagic stroke, mixed stroke, parietal lobe lesion, chronic cough, aphasia, and post-stroke depression were high-risk groups for UI. These patients should be targeted when planning intervention programs.