Functional recovery of older stroke patients discharged from hospital to home: The effects of cognitive status and different levels of therapy intensity

The association between inpatient rehabilitation intensity and outcomes after stroke in Ontario, Canada

BACKGROUND

Several studies have demonstrated improved outcomes poststroke when higher intensity rehabilitation is provided. Canadian Stroke Best Practice Recommendations advise patients receive 180 min of therapy time per day; however, the exact amount required to reach benefit is unknown.

AIMS

The primary aim of this study was to determine the association between rehabilitation intensity (RI) and total Functional Independence Measure (FIM) Instrument change. Secondary aims included determining the association between RI and discharge location, 90-day home time, rehabilitation effectiveness, and motor and cognitive FIM change.

METHODS

A retrospective cohort study was conducted using available administrative databases of acute stroke patients discharged to inpatient rehabilitation facilities in Ontario, Canada, from January 2017 to December 2021. RI was defined as number of minutes per day of direct therapy by all providers divided by rehabilitation length of stay. The association between RI and the outcomes of interest were analyzed using regression models with restricted cubic splines.

RESULTS

A total of 12,770 individuals were included. Mean age of the sample was 72.6 years, 46.0% of individuals were female, and 87.6% had an ischemic stroke. Mean RI was 74.7 min (range: 5-162 min) per day. Increased RI was associated with an increase in mean FIM change. However, there was diminishing incremental increase after reaching 95 min/day. Increased RI was positively associated with motor and cognitive FIM change, rehabilitation effectiveness, 90-day home time, and discharge to preadmission setting. Higher RI was associated with a lower likelihood of discharge to long-term care.

CONCLUSIONS

None of the patients met the recommended RI of 180 min/day based on the Canadian Stroke Best Practice Recommendations. Despite this, higher intensity was associated with better outcomes. Given that most positive associations were observed with a RI ⩾95 min/day, this may be a more feasible target.

Identifying profiles of stroke patients benefitting from additional training: a latent class analysis approach

OBJECTIVE

To identify profiles of stroke patient benefitting from additional training, using latent class analysis.

DESIGN

Retrospective observational study.

PATIENTS

Patients with stroke (n = 6,875) admitted to 42 recovery rehabilitation units in Japan between January 2005 and March 2016 who were registered in the Japan Association of Rehabilitation Database.

METHODS

The main outcome measure was the difference in Functional Independence Measure (FIM) scores between admission and discharge (referred to as "gain"). The effect of additional training, categorized as usual care (no additional training), self-exercise, training with hospital staff, or both exercise (combining self-exercise and training with hospital staff), was assessed through multiple regression analyses of latent classes.

RESULTS

Applying inclusion and exclusion criteria, 1185 patients were classified into 7 latent classes based on their admission characteristics (class size n = 82 (7%) to n = 226 (19%)). Patients with class 2 characteristics (right hemiparesis and modified dependence in the motor-FIM and cognitive-FIM) had positive FIM gain with additional training (95% confidence interval (95% CI) 0.49-3.29; p < 0.01). One-way analysis of variance revealed that training with hospital staff (95% CI 0.07-16.94; p < 0.05) and both exercises (95% CI 5.38-15.13; p < 0.01) led to a significantly higher mean FIM gain than after usual care.

CONCLUSION

Additional training in patients with stroke with right hemiparesis and modified dependence in activities of daily living was shown to improve activities of daily living. Training with hospital staff combined with self-exercise is a promising rehabilitation strategy for these patients.

Clock Drawing Test Performance of Young Adults Based on a One-Shot Case Study

OBJECTIVE

The clock drawing test (CDT) is being used regularly by medical professionals in a variety of settings to aid in assessing cognitive functioning in adults of all ages. As our technological environment has changed significantly, because of the inception of this measure, the use of and exposure to the analog clock have diminished. We investigated whether young adults, who have grown up in a mainly digital world, can draw and tell time on an analog clock.

METHOD

Participants aged 18-30 years (N = 80, Mage = 24.2, SD = 3.93), who self-identified as having normal cognition, completed the CDT, as well as setting hands on a pre-drawn clock and identifying analog clock times.

RESULTS

About 25% of participants received a CDT score below the expected range. There was a moderate, positive correlation between analog clock hand setting and time identification in the group who scored below the expected range on the CDT only (rs(16) = 0.472, p = .048). Most participants reported not wearing an analog watch.

CONCLUSIONS

Based on these findings, the CDT should be used with caution to screen cognitive functioning in young adults (i.e., aged 18-30 years). Consideration of an alternative approach to screening cognition and modifying cognitive assessments in which the CDT is embedded is recommended for this population. These findings warrant further investigation into CDT performance in the young adult population.

Apathy mediates the association between age and cognition after stroke

PURPOSE

To examine if the association between age and post-stroke cognition is mediated by apathy.

METHODS

A cross-sectional investigation was carried out with 389 stroke survivors and informants. Data were collected through the Apathy Evaluation Scale (AES-C) and the Informant Questionnaire for Cognitive Decline in the Elderly (IQCODE). Bivariate analyses were conducted between the IQCODE total score and each of the demographic and clinical characteristics as well as apathy, while Baron and Kenny's 4-step approach was used to examine the mediating effect of apathy on the association between age and post-stroke cognition.

RESULTS

Participants were aged 64.3 years on average, with a mean IQCODE score of 97.6 (SD: 14.8) and a mean AES-C score of 41.3 (SD: 8.0). IQCODE scores were positively correlated with age (r = 0.32, p < 0.001) and apathy (r = 0.54, p < 0.001). Apathy contributed to 24% of the total effect of age on post-stroke cognition, exerting a significant mediating effect on the relationship between age and post-stroke cognition.

CONCLUSIONS

Apathy may have a significant impact on the cognitive health of stroke survivors. Therefore, the early identification of apathy symptoms could facilitate consideration of potential interventions, such as multisensory and cognitive stimulation, designed to improve cognitive outcomes in this population.

Predictive Factors Associated With Short-Term Clinical Outcomes and Time to Return to Activity After Arthroscopic Partial Meniscectomy in Nonathletes

Background:

Although arthroscopic partial meniscectomy is a widely implemented surgical procedure, studies investigating the time to return to activity (RTA) are rare.

Purpose:

To explore which factors are associated with the RTA times after arthroscopic partial meniscectomy and to investigate whether those factors can also improve short-term patient-reported outcomes.

Study Design:

Case-control study; Level of evidence, 3.

Methods:

The authors reviewed the records of patients who underwent isolated partial meniscectomy in their institution from January 2017 to December 2019. Patient and injury characteristics were documented, and time to RTA was obtained via phone interview in January 2021. Pre- and postoperative outcomes were assessed with the Lysholm score and International Knee Documentation Committee (IKDC) score. The chi-square test and independent-samples t test were used to evaluate differences in outcome scores and time to RTA according to the patient and injury characteristics, and risk factors with a P value <.1 in the univariate analysis were used in the binary regression.

Results:

Included were 215 patients (87 men and 128 women; mean age, 33.7 years [range, 24-75 years]). Of these patients, 204 provided information on time to RTA (mean, 3.3 months). By 3 months postoperatively, 49.5% (101/204) of patients could perform activities without knee-related restriction; this improved to 69.6% (142/204) at 6 months and 90.2% (184/204) at 12 months. On multivariate logistic regression analysis, age (OR, 0.39; 95% CI, 0.21-1.19; P = .044) and injury duration (OR, 0.20; 95% CI, 0.19-1.07; P = .032) were significantly associated with the time to RTA. IKDC scores improved significantly from 41.2 preoperatively to 76.7 postoperatively, and in the multivariate logistic regression model, female sex (OR, 2.67; 95% CI, 1.10-6.47; P = .030), body mass index (BMI) ≥27 kg/m² (OR, 2.96; 95% CI, 1.02-8.66; P = .047), and medial meniscal tear (OR, 0.20; 95% CI, 0.04-1.00; P = .050) were associated with inferior outcome scores.

Conclusion:

Patients aged 40 years and younger who underwent partial meniscectomy surgery within 6 months after a meniscal tear were more likely to have a shorter time to RTA, and female patients with obesity (BMI ≥27 kg/m2), especially those with medial meniscal tears, tended to have inferior clinical outcomes.

Medical Costs and Readmissions After Intensive Poststroke Rehabilitation: Japanese Claims Data

OBJECTIVES

This study examined the association between intensive rehabilitation for subacute stroke patients and medical costs and readmission ratio during the year after discharge.

DESIGN

This was a natural experiment study.

SETTING AND PARTICIPANTS

We identified individuals with a diagnosis of cerebrovascular disorder (ICD-10: I60-I69 cerebrovascular disease) in an insurance claims database in Japan from January 2005 to December 2017. From the database, 980 patients who were admitted to a convalescent rehabilitation unit with stroke were identified. After excluding 575 patients, 405 were eligible for the study.

METHODS

In Japan, from April 2011, a new policy was established that allows special costs to be added as rehabilitation time increases. This policy provides an additional medical fee for inpatients in a convalescent rehabilitation unit who receive more than 120 minutes of rehabilitation therapy. We defined high-intensity rehabilitation as transfer from hospitalization to a convalescent rehabilitation unit after April 2011. Outcomes were total direct medical costs and readmission ratio during the year after discharge from the convalescent rehabilitation unit.

RESULTS

Daily rehabilitation time, total rehabilitation time, and total medical costs of the high-intensity rehabilitation group were significantly higher than those of the low-intensity rehabilitation group (P < .001, P < .001, P = .011, respectively). However, there was no significant difference in the medical costs during the year after discharge (P = .653) or in the readmission ratio (hazard ratio: 1.09, 95% confidence interval: 0.55-2.18, P = .804).

CONCLUSIONS AND IMPLICATIONS

Intensive rehabilitation did not reduce medical costs or the readmission ratio during the first year after discharge. Future studies should consider the necessary rehabilitation intensity given the severity of the patient's condition, using large sample sizes.

Exercise-based interventions for post-stroke social participation: A systematic review and network meta-analysis

BACKGROUND

Resuming participation in society is an important goal of post-stroke rehabilitation. Exercise-based interventions have been shown to be effective non-pharmacological methods for improving social participation in post-stroke survivors, however it is unclear what the most effective types of exercise interventions are.

OBJECTIVE

To assess the comparative effects and ranks of all exercise-based interventions in improving social participations in patients after a stroke.

METHODS

A random-effects network meta-analysis was performed to identify evidence from relevant randomized control trials. We searched MEDLINE, CINAHL, EMBASE, PsycINFO, CINHAL, Cochrane Library, AMED, SPORTDiscus, Web of Science and Clinical Trials.gov from their earliest records to January 2020. Included trials must include at least one types of exercise for patients with stroke. The primary e was social participation. Bias will be assessed according to the revised Cochrane risk of bias tool. Data were analysed using Stata v14.0. Registration number of this study is CRD42020152523.

RESULTS

A total of 16 randomized control trials involving 1704 patients and 12 intervention arms were included in our study. We performed three subgroup analyses divided based on follow up time (1 to <6 months post-treatment, and ≥6 months post-treatment), and intervention adherence. Based on the ranking probabilities, motor relearning programme was ranked as the most effective among all exercise interventions (surface under cumulative ranking curve values [SUCRCV]: 95.6%, standardized mean difference [SMD]: 2.72, 95% confidence interval [CI]: 1.76 to 3.69) in overall and short-term treatment efficacy. In the long-term subgroup, home-based combined exercise ranked the best for the efficacy of social participation improvements among stroke survivors (SUCRCV: 71.8%, SMD: -0.23, 95% CI: -0.61 to 0.15). In the analysis of all interventions with adherence of >90%, cognitive-based exercise ranked the best (SUCRCV: 100%, SMD: 2.64, 95% CI: 1.62 to 3.66).

CONCLUSIONS

Interventions that emerged with the highest ranks in our analysis might be considered in practice when resources allow. More large, well-designed multicentre trials are needed to support the conclusion of this study.

Factors affecting the performance of activities of daily living in patients with advanced cancer undergoing inpatient rehabilitation: results from a retrospective observational study

[Purpose] Many clinicians believe that rehabilitation for patients with advanced cancer is futile. We determined factors affecting the performance of activities of daily living in patients with advanced cancer based on age, gender, marital status, living arrangement, rehabilitation intensity, type of cancer, impairment, metastasis, and active cancer treatment. [Participants and Methods] We assessed the Barthel Index to evaluate the performance of activities of daily living. Of the 120 adult patients with cancer who underwent inpatient rehabilitation, we analyzed the Barthel Index scores, consisting of 10 items, and reviewed the clinical characteristics from the medical records of 48 patients who completed supportive or palliative rehabilitation according to Dietz and showed an increased or maintained total Barthel Index score at final evaluation. [Results] The median total Barthel Index score increased from 45 (5–95) to 72.5 (5–100); the rehabilitation intensity was 320 (40–1,240) minutes. The analytical results showed that the increase of total Barthel Index score was positively associated with rehabilitation intensity (β=0.350) and negatively associated with the initial grooming score (β=−0.277). [Conclusion] Adequate rehabilitation positively affects performance of activities of daily living, especially in patients with advanced cancer who lost their grooming ability at the onset of rehabilitation. Importantly, rehabilitation may be beneficial for patients with advanced cancer.

Clinical Validation of Nursing Diagnoses Related to Self-Care Deficits in Patients with Stroke

To clinically validate the defining characteristics of nursing diagnoses related to self-care deficits in feeding, bathing, toileting, and dressing in patients with stroke. A diagnostic accuracy study was conducted with a sample of 135 patients with stroke. Sensitivity and specificity were calculated based on the latent class analysis method using the random effects model. The prevalence of diagnoses was 23.5% for Bathing self-care deficit, 18.5% for Dressing self-care deficit, 13.3% for Toileting self-care deficit, and 7.5% for Feeding self-care deficit. Fourteen defining characteristics were sensitive, and 17 were specific. Hemorrhagic stroke and note 4 on the Rankin scale was associated with self-care deficits. Of the 37 defining characteristics of the four diagnoses studied, 19 were clinically validated according to the latent class analysis model. These most accurate clinical indicators contribute to the development of the care plan for patients with stroke.