Stroke outcome research

Determination of Five Sit-to-Stand Test Performance at Discharge of Stroke Patients

The early identification of performance in the five-repetition sit-to-stand test (5-STS) at discharge in stroke patients could be of interest because it can determine independence for community-based activities. This study aimed to determine whether the initial measurement of the 5-STS test can be a determinant of the performance level prediction and amount of change in the 5-STS test at discharge in stroke patients. A prospective cohort study was conducted with a sample of 56 patients aged ≤60 d post-stroke. The 5-STS test results, as well as changes in patient condition, were measured at admission (T0) to an outpatient rehabilitation program, after the first month (T1), and at discharge (T2). The mean age was 62.7 (SD = 13.0), 58.9% of the subjects were male, and 75% had suffered an ischemic stroke. A multivariate linear regression model using the 5-STS test at T0 explained 57.7% of the variance in the performance at discharge. Using the 5-STS at T1 increased the variance to 75.5% (p < 0.001). Only the time from stroke onset at T0 significantly contributed to the two models. The measurement of the 5-STS at T0 and the amount of change in its performance at T2 explained 60.2% (p < 0.001) of the variance, while reassessment at T1 explained only 19.3% (p < 0.001). The level of patient performance on the 5-STS test at discharge, as well as any potential change, can be predicted by the admission measure of 5-STS in stroke patients.

Validation of the Longshi scale in assessment of function in patients from different economic, educational and regional backgrounds in China

OBJECTIVE

This study validates performance of the Longshi scale against modified Barthel index in assessment of function in patients from different economic, educational and regional backgrounds in China.

DESIGN

This is a cross-sectional study.

SETTING

One hundred and three hospitals and rehabilitation institutions across China.

PARTICIPANTS

A total of 14,752 patients with physical and cognitive impairments were enrolled and classified to five educational levels and five family income levels; 8060 participants were further selected from five regions to study regional influences.

MAIN MEASURES

Activities of daily living were assessed with two evaluation tools, the Longshi scale and modified Barthel index. Results of evaluation with Longshi scale performed by non-healthcare workers were validated against modified Barthel index performed by healthcare workers using Pearson's correlation test.

RESULTS

There were significant positive correlations between the findings of the Longshi scale administered by non-healthcare professionals and the modified Barthel index administered by healthcare professionals. This was true for level of education (correlations ranged from 0.697 to 0.822), family income level (correlations ranged from 0.724 to 0.761) and region (correlations ranged from 0.737 to 0.776).

CONCLUSION

In a large dataset of 14,752 patients, positive correlations were found between Longshi scale and modified Barthel index measures of function. Positive correlations persisted across subgroup analysis of groups from different social, economic and regional backgrounds, and with administration by non-healthcare professionals.

CLINICAL TRIAL REGISTRATION

ChiCTR2000034067, www.chictr.org.cn.

Effect and Safety of Transcutaneous Auricular Vagus Nerve Stimulation on Recovery of Upper Limb Motor Function in Subacute Ischemic Stroke Patients: A Randomized Pilot Study

Background

Transcutaneous auricular vagus nerve stimulation (taVNS) is regarded as a potential method for recovery in stroke. The effectiveness of taVNS in acute and subacute stroke should be further discussed as previously, only a few small-scale trials have focused on chronic stroke patients. The objective of this study is to investigate the effect and safety of taVNS on upper limb motor function in subacute ischemic stroke patients.

Methods

Twenty-one subacute ischemia stroke patients with single upper limb motor function impairment were enrolled and randomly assigned to conventional rehabilitation training with real or sham taVNS, delivered for 15 consecutive days. Electrodes were fixed to the cymba conchae of the left ear with or without electrical stimulation. Conventional rehabilitation training was performed immediately after the end of real or sham taVNS by the same therapists. Baseline assessments were performed on day 0 of enrollment, and posttreatment evaluations were performed at 15 days, 4 weeks, and 12 weeks after the first intervention. The assessment included the upper limb Fugl-Meyer assessment (FMA-U), the Wolf motor function test (WMFT), the Functional Independence Measurement (FIM), and Brunnstrom stage. Heart rate (HR) and blood pressure (BP) were measured before and after each taVNS intervention. At the same time, any adverse effects were observed during the procedure. Outcomes were assessed by a blind evaluator.

Results

There were no significant differences in FMA-U, WMFT, FIM, and Brunnstrom scores between the two groups at baseline (P > 0.05). At the endpoint, the FMA-U, WMFT, and FIM scores were significantly higher than before treatment (P < 0.05), and there was a significantly greater improvement of those measurements in taVNS group compared with sham-taVNS group (P < 0.05). Significant improvements in FMA-U score were found between groups at follow-up. Only one case of skin redness occurred during the study.

Conclusions

This study revealed that taVNS appeared to be beneficial to the recovery of upper limb motor function in subacute ischemia stroke patients without obvious adverse effects. Trial registration. This trial is registered with ChiCTR1800019635 on 20 November 2018 (http://www.chictr.org.cn/showproj.aspx?proj=32961).

Predicting Upper Limb Motor Impairment Recovery after Stroke: A Mixture Model

OBJECTIVE

Spontaneous recovery is an important determinant of upper extremity recovery after stroke and has been described by the 70% proportional recovery rule for the Fugl-Meyer motor upper extremity (FM-UE) scale. However, this rule is criticized for overestimating the predictability of FM-UE recovery. Our objectives were to develop a longitudinal mixture model of FM-UE recovery, identify FM-UE recovery subgroups, and internally validate the model predictions.

METHODS

We developed an exponential recovery function with the following parameters: subgroup assignment probability, proportional recovery coefficient r k , time constant in weeks τ k , and distribution of the initial FM-UE scores. We fitted the model to FM-UE measurements of 412 first-ever ischemic stroke patients and cross-validated endpoint predictions and FM-UE recovery cluster assignment.

RESULTS

The model distinguished 5 subgroups with different recovery parameters ( r1 = 0.09, τ1 = 5.3, r2 = 0.46, τ2 = 10.1, r3 = 0.86, τ3 = 9.8, r4 = 0.89, τ4 = 2.7, r5 = 0.93, τ5 = 1.2). Endpoint FM-UE was predicted with a median absolute error of 4.8 (interquartile range [IQR] = 1.3-12.8) at 1 week poststroke and 4.2 (IQR = 1.3-9.8) at 2 weeks. Overall accuracy of assignment to the poor (subgroup 1), moderate (subgroups 2 and 3), and good (subgroups 4 and 5) FM-UE recovery clusters was 0.79 (95% equal-tailed interval [ETI] = 0.78-0.80) at 1 week poststroke and 0.81 (95% ETI = 0.80-0.82) at 2 weeks.

INTERPRETATION

FM-UE recovery reflects different subgroups, each with its own recovery profile. Cross-validation indicates that FM-UE endpoints and FM-UE recovery clusters can be well predicted. Results will contribute to the understanding of upper limb recovery patterns in the first 6 months after stroke. ANN NEUROL 2020;87:383-393 Ann Neurol 2020;87:383-393.

Effect of verticalization with Erigo® in the acute rehabilitation of severe acquired brain injury

The recovery of the orthostatism after a severe acquired brain injury (sABI) is an essential objective to pursue in order to avoid the occurrence of secondary complications resulting from prolonged immobilization to which the patient is subjected during the acute phase. This randomized controlled trial aims to evaluate the effect of verticalization with the lower limb robot-assisted training system Erigo® versus conventional neurorehabilitation in 44 adult subjects affected by sequelae of sABI in the acute rehabilitation phase, related to cardiorespiratory signs and measures of impairment and activity. At the end of the study (20 treatment sessions, 5 sessions per week), in both groups of patients, there were no dropouts nor adverse events. In subject verticalized with Erigo®, there were no episodes of (pre)syncope from orthostatic hypotension nor postural orthostatic tachycardia and cardiorespiratory signs remained stable; moreover, there were no increase in muscle tone nor reduction in range of motion at lower limbs. Results obtained show improved outcomes on the whole and in a similar way in both groups; however, the improvement in scores of the National Institutes of Health Stroke Scale, the Tinetti scale, and the Functional Independence Measure from the enrollment to the end of the treatment cycle being equal, the evaluation performed at the 10th session allows to establish that the improvement appears earlier in the intervention group and later in the control group. The more rapid recovery of impairments and some activities in subjects treated with Erigo® could allow a "time-saver" to devote to the rehabilitation of sensory-motor functions which are more complex and subordinated to the preliminary reacquisition of elementary postures and motor strategies.

Importance and Difficulties of Pursuing rTMS Research in Acute Stroke

Although much research has been done on repetitive transcranial magnetic stimulation (rTMS) in chronic stroke, only sparse research has been done in acute stroke despite the particularly rich potential for neuroplasticity in this stage. We attempted a preliminary clinical trial in one active, high-quality inpatient rehabilitation facility (IRF) in the -United States. But after enrolling only 4 patients in the grant period, the study was stopped because of low enrollment. The purpose of this paper is to offer a perspective describing the important physiologic rationale for including rTMS in the early phase of stroke, the reasons for our poor patient enrollment in our attempted study, and recommendations to help future studies succeed. We conclude that, if scientists and clinicians hope to enhance stroke outcomes, more attention must be directed to leveraging conventional rehabilitation with neuromodulation in the acute phase of stroke when the capacity for neuroplasticity is optimal. Difficulties with patient enrollment must be addressed by reassessing traditional inclusion and exclusion criteria. Factors that shorten patients' length of stay in the IRF must also be reassessed at all policy-making levels to make ethical decisions that promote higher functional outcomes while retaining cost consciousness.

The Outcome of Therapy in Stroke Rehabilitation: Do We Know What We are Doing?

How successful are current therapy methods in the rehabilitation of stroke patients? This, the first of two articles, reviews research studies on the outcome of therapy. It focuses, in particular, upon the influence of therapy on the restoration of patients' independence in activities of daily living. It seems that there is little consistent evidence that therapy has any long-term effect in this area.

Documentation for Measuring Stroke Rehabilitation Outcomes

Stroke is the third commonest cause of hospital admission in Australia. Approximately 71% of patients with an acute stroke are likely to be admitted to public and private hospitals. With no advanced clinical information system in place in Australia, it is difficult to determine who is likely to benefit, what type of inpatient care is efficient and effective in providing maximum potential to the stroke patients. This paper highlights some of the problems encountered with the current medical records, in conducting a prospective, multi-institutional, population based stroke rehabilitation outcome study in Brisbane. The paper also discusses how these deficiencies affect health professionals such as occupational therapists, and how one can work with the medical record administrators of today as key resource people in health information management. To illustrate this, a pro forma rectifying some of the current deficiencies in the medical records is provided as a guide. (AMRJ, 1991, 21(3), 88–95).

Can Neurological Biomarkers of Brain Impairment Be Used to Predict Poststroke Motor Recovery? A Systematic Review

Background There is growing interest to establish recovery biomarkers, especially neurological biomarkers, in order to develop new therapies and prediction models for the promotion of stroke rehabilitation and recovery. However, there is no consensus among the neurorehabilitation community about which biomarker(s) have the highest predictive value for motor recovery. Objective To review the evidence and determine which neurological biomarker(s) meet the high evidence quality criteria for use in predicting motor recovery. Methods We searched databases for prognostic neuroimaging/neurophysiological studies. Methodological quality of each study was assessed using a previously employed comprehensive 15-item rating system. Furthermore, we used the GRADE approach and ranked the overall evidence quality for each category of neurologic biomarker. Results Seventy-one articles met our inclusion criteria; 5 categories of neurologic biomarkers were identified: diffusion tensor imaging (DTI), transcranial magnetic stimulation (TMS), functional magnetic resonance imaging (fMRI), conventional structural MRI (sMRI), and a combination of these biomarkers. Most studies were conducted with individuals after ischemic stroke in the acute and/or subacute stage (~70%). Less than one-third of the studies (21/71) were assessed with satisfactory methodological quality (80% or more of total quality score). Conventional structural MRI and the combination biomarker categories ranked "high" in overall evidence quality. Conclusions There were 3 prevalent methodological limitations: (a) lack of cross-validation, (b) lack of minimal clinically important difference (MCID) for motor outcomes, and (c) small sample size. More high-quality studies are needed to establish which neurological biomarkers are the best predictors of motor recovery after stroke. Finally, the quarter-century old methodological quality tool used here should be updated by inclusion of more contemporary methods and statistical approaches.

Audiological findings in aphasic patients after stroke

Objective

To outline the audiological findings of aphasic patients after cerebrovascular accidents.

Methods

This is a cross-sectional study performed between March 2011 and August 2012 in the Speech, Language, and Hearing Pathology Department of the Universidade Federal de São Paulo. A total of 43 aphasic subjects (27 men) were referred for audiological evaluation after stroke, with mean age of 54.48 years. Basic audiological evaluation tests were performed, including pure tone audiometry, speech audiometry (speech recognition threshold and word recognition score), immittance measures (tympanometry and contralateral acoustic reflex), and transient otoacoustic emissions.

Results

Sensorineural hearing loss was prevalent (78.6%). Speech recognition threshold and word recognition score were not obtained in some patients because they were unable to perform the task. Hearing loss was a common finding in this population.

Conclusion

Comprehension and/or oral emission disruptions in aphasic patients after stroke compromised conventional speech audiometry, resulting in the need for changes in the evaluation procedures for these patients.

Generalizability of the Proportional Recovery Model for the Upper Extremity After an Ischemic Stroke

BACKGROUND AND OBJECTIVE

Spontaneous neurological recovery after stroke is a poorly understood process. The aim of the present article was to test the proportional recovery model for the upper extremity poststroke and to identify clinical characteristics of patients who do not fit this model.

METHODS

A change in the Fugl-Meyer Assessment Upper Extremity score (FMA-UE) measured within 72 hours and at 6 months poststroke served to define motor recovery. Recovery on FMA-UE was predicted using the proportional recovery model: ΔFMA-UEpredicted = 0.7·(66 - FMA-UEinitial) + 0.4. Hierarchical cluster analysis on 211 patients was used to separate nonfitters (outliers) from fitters, and differences between these groups were studied using clinical determinants measured within 72 hours poststroke. Subsequent logistic regression analysis served to predict patients who may not fit the model.

RESULTS

The majority of patients (~70%; n = 146) showed a fixed proportional upper extremity motor recovery of about 78%; 65 patients had substantially less improvement than predicted. These nonfitters had more severe neurological impairments within 72 hours poststroke (P values <.01). Logistic regression analysis revealed that absence of finger extension, presence of facial palsy, more severe lower extremity paresis, and more severe type of stroke as defined by the Bamford classification were significant predictors of not fitting the proportional recovery model.

CONCLUSIONS

These results confirm in an independent sample that stroke patients with mild to moderate initial impairments show an almost fixed proportional upper extremity motor recovery. Patients who will most likely not achieve the predicted amount of recovery were identified using clinical determinants measured within 72 hours poststroke.

Brain connectivity plasticity in the motor network after ischemic stroke

The motor function is controlled by the motor system that comprises a series of cortical and subcortical areas interacting via anatomical connections. The motor function will be disturbed when the stroke lesion impairs either any of these areas or their connections. More and more evidence indicates that the reorganization of the motor network including both areas and their anatomical and functional connectivity might contribute to the motor recovery after stroke. Here, we review recent studies employing models of anatomical, functional, and effective connectivity on neuroimaging data to investigate how ischemic stroke influences the connectivity of motor areas and how changes in connectivity relate to impaired function and functional recovery. We suggest that connectivity changes constitute an important pathophysiological aspect of motor impairment after stroke and important mechanisms of motor recovery. We also demonstrate that therapeutic interventions may facilitate motor recovery after stroke by modulating the connectivity among the motor areas. In conclusion, connectivity analyses improved our understanding of the mechanisms of motor recovery after stroke and may help to design hypothesis-driven treatment strategies and sensitive measures for outcome prediction in stroke patients.

Predicting Activities after Stroke: What is Clinically Relevant?

Knowledge about factors that determine the final outcome after stroke is important for early stroke management, rehabilitation goals, and discharge planning. This narrative review provides an overview of current knowledge about the prediction of activities after stroke. We reviewed the pattern of stroke recovery for functions and activities, the impact of spontaneous recovery on activities, and the measurement of improvement in general. We explored the activities profiles during the chronic phase and predictors for activities of daily living independence after stroke, and finally, we discussed where to from here? Mathematical regularities explain the nonlinear patterns of recovery, making the outcome of activities of daily living highly predictable. Initial severity of disability and extent of improvement observed within the first weeks poststroke are important indicators of the outcome at six-months. The sequence of progress in activities is almost fixed in time. Studies showed that most motor recovery is almost completed within 10 weeks poststroke. On average, stroke recovery plateaus three- to six-months after onset. Strong evidence was found that age and scores on scales assessing severity of neurological deficits in the early poststroke phase are strongly associated with the final basic activities of daily living outcome after three-months poststroke. The validated prediction models using simple algorithms, such as National Institutes of Health Stroke Scale or Barthel Index, need to be implemented in rehabilitation services and used for stratifying stroke patients in trials. Future studies should investigate the accuracy of dynamic models that includes time poststroke to optimize the application of prediction rules in individuals with stroke.

Time course of visuospatial neglect early after stroke: a longitudinal cohort study

The aim of the current study was to investigate recovery of visuospatial neglect during the first year after stroke. Visuospatial neglect was measured using two frequently and widely used tests: the letter cancellation test (LCT) and the line bisection test (LBT). This was a prospective cohort study of 101 stroke patients. Of these 101 patients, 51 patients showed visuospatial neglect. All time-dependent measures were taken weekly, starting from within 14 days after stroke onset. From week 10-20 biweekly measurements were obtained. Follow-up measurements were performed at weeks 26, 38, and finally 52. For the present study, number of misses in the LCT, split on contralesional versus ipsilesional side, as well as the deviation from the actual midpoint in mm in the LBT were used. The longitudinal relationship of (bi)weekly time on improvement in LBT and LCT were investigated using random coefficient analysis and joinpoint analyses. Results indicated that progress of time is an independent covariate that reflects neurological recovery of visuospatial neglect. Additionally, trend changes were obtained in between 12 and 14 weeks post-stroke with respect to the neglected side. This is the first prospective cohort study in which the time course of neglect is investigated by using intensive serial measurements in the early months post-stroke.

The EXCITE Trial: analysis of "noncompleted" Wolf Motor Function Test items

OBJECTIVE

This is the first study to examine Wolf Motor Function Test (WMFT) tasks among EXCITE Trial participants that could not be completed at baseline or 2 weeks later.

METHODS

Data were collected from participants who received constraint-induced movement therapy (CIMT) immediately at the time of randomization (CIMT-I, n = 106) and from those for whom there was a delay of 1 year in receiving this intervention (CIMT-D, n = 116). Data were collected at baseline and at a 2-week time point, during which the CIMT-I group received the CIMT intervention and the CIMT-D group did not. Generalized estimating equation (GEE) analyses were used to examine repeated binary data and count values. Group and visit interactions were assessed, adjusting for functional level, affected side, dominant side, age, and gender covariates.

RESULTS

In CIMT-I participants, there was an increase in the proportion of completed tasks at posttest compared with CIMT-D participants, particularly with respect to those tasks requiring dexterity with small objects and total incompletes (P < .0033). Compared with baseline, 120 tasks governing distal limb use for CIMT-I and 58 tasks dispersed across the WMFT for CIMT-D could be completed after 2 weeks. Common movement components that may have contributed to incomplete tasks include shoulder stabilization and flexion, elbow flexion and extension, wrist pronation, supination and ulnar deviation, and pincer grip.

CONCLUSION

CIMT training should emphasize therapy for those specific movement components in patients who meet the EXCITE criteria for baseline motor control.

Estimating the Accuracy of the Chedoke-McMaster Stroke Assessment Predictive Equations for Stroke Rehabilitation

PURPOSE

To estimate the predictive accuracy and clinical usefulness of the Chedoke-McMaster Stroke Assessment (CMSA) predictive equations.

METHOD

A longitudinal prognostic study using historical data obtained from 104 patients admitted post cerebrovascular accident was undertaken. Data were abstracted for all patients undergoing rehabilitation post stroke who also had documented admission and discharge CMSA scores. Published predictive equations were used to determine predicted outcomes. To determine the accuracy and clinical usefulness of the predictive model, shrinkage coefficients and predictions with 95% confidence bands were calculated.

RESULTS

Complete data were available for 74 patients with a mean age of 65.3±12.4 years. The shrinkage values for the six Impairment Inventory (II) dimensions varied from -0.05 to 0.09; the shrinkage value for the Activity Inventory (AI) was 0.21. The error associated with predictive values was greater than ±1.5 stages for the II dimensions and greater than ±24 points for the AI.

CONCLUSIONS

This study shows that the large error associated with the predictions (as defined by the confidence band) for the CMSA II and AI limits their clinical usefulness as a predictive measure. Further research to establish predictive models using alternative statistical procedures is warranted.

Changes of elbow kinematics and kinetics during 1 year after stroke

A precise description of the natural history of motor recovery after stroke provides a framework for understanding the mechanisms underlying this improvement and for tracking the efficacy of rehabilitation treatments. To characterize the time course of this change in motor impairment, we examined voluntary elbow movements in hemiparetic stroke survivors over a period of 1 year after stroke. Based on the possibility that both central nervous system and muscle factors could contribute to the observed clinical state, we hypothesized that we should observe at least two major recovery patterns of motor impairment. To explore these predictions, we assessed elbow movement range, movement speed, and isometric force generation. Subjects were examined five times over the 12-month period. We used the "growth mixture" model to characterize recovery of these measures, and the Fugl-Meyer scale (FMS) of upper-extremity function at 1 month to predict the recovery. We observed two distinct recovery classes. Class 1 started with low values for the physiological measures, and these increased over time, whereas class 2 tended to start with higher values and showed widely divergent recovery patterns. Using the logistic regression model, the impact of FMS on class membership was estimated for each parameter. Based on these data, we were able to accurately predict arm impairment recovery at different time-points in the first year, information of great potential value for planning targeted therapeutic interventions.

Gait reveals bilateral adaptation of motor control in patients with chronic unilateral stroke

BACKGROUND AND AIMS

Functional brain imaging has shown that bilateral brain reorganization may occur after unilateral cerebral damage. The present study searched for evidence of bilateral motor control changes in gait in patients with chronic unilateral stroke.

METHODS

Gait variables (temporal and spatial parameters, footprint peak times (FPPT) and footfall times (FFT)) were recorded in 48 patients with chronic unilateral stroke at their preferred speed, and in 10 healthy volunteers walking from very slowly to very fast on a pressure sensor walkway. The data were divided into 4 groups according to gait velocity. The functional outcome of stroke was measured by the Barthel Index.

RESULTS

Patients' gait variables reflected their hemiparetic gait pattern. Slower patients had prolonged stance, FPPT and FFT on the non-affected side (NS), and prolonged swing and shorter FPPT and FFT on the affected side (AS). The magnitude of the asymmetry index of these parameters was inversely associated with velocity performance and, at the same time, it characterized how much the control of the clinically healthy (NS) side was altered during walking. Bilateral changes in kinetic and footfall variables in the chronic stage of unilateral stroke were present.

CONCLUSIONS

Patients chose their preferred walking velocity using stereotyped, alternative gait patterns, in which the contribution of the NS was larger than that of the AS. Alternative gait patterns may partly demonstrate compensatory behavioral strategies adapted by patients.

Activity-based therapies

Therapeutic activity is a mainstay of clinical neurorehabilitation, but is typically unstructured and directed at compensation rather than restoration of central nervous system function. Newer activity-based therapies (ABTs) are in early stages of development and testing. The ABTs attempt to restore function via standardized therapeutic activity based on principles of experimental psychology, exercise physiology, and neuroscience. Three of the best developed ABTs are constraint-induced therapy, robotic therapy directed at the hemiplegic arm, and treadmill training techniques aimed at improving gait in persons with stroke and spinal cord injury. These treatments appear effective in improving arm function and gait, but they have not yet been clearly demonstrated to be more effective than equal amounts of traditional techniques. Resistance training is clearly demonstrated to improve strength in persons with stroke and brain injury, and most studies show that it does not increase hypertonia. Clinical trials of ABTs face several methodological challenges. These challenges include defining dosage, standardizing treatment parameters across subjects and within treatment sessions, and determining what constitutes clinically significant treatment effects. The long-term goal is to develop prescriptive ABT, where specific activities are proven to treat specific motor system disorders. Activity-based therapies are not a cure, but are likely to play an important role in future treatment cocktails for stroke and spinal cord injury.

Timing of Initiation of Rehabilitation After Stroke

Maulden SA, Gassaway J, Horn SD, Smout RJ, DeJong G. Timing of initiation of rehabilitation after stroke.

OBJECTIVE

To study associations between days from stroke symptom onset to rehabilitation admission and rehabilitation outcomes, controlling for a variety of confounding variables.

DESIGN

Observational cohort study of 200 consecutive post-stroke rehabilitation patients in each of 6 inpatient rehabilitation facilities.

SETTING

Six U.S. inpatient rehabilitation hospitals.

PARTICIPANTS

Patients (N=969) with moderate or severe strokes who had days from stroke symptom onset to rehabilitation admission recorded in their medical records.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Discharge total FIM, discharge motor FIM, discharge activities of daily living (ADL) FIM, and discharge mobility FIM scores, as well as rehabilitation length of stay (LOS).

RESULTS

Fewer days from stroke symptom onset to rehabilitation admission was associated significantly with better functional outcomes: higher total, motor, mobility, and ADL discharge FIM scores, controlling for confounding variables. For severely impaired patients with stroke in case-mix groups (CMGs) 108-114, the relation was strongest, with F statistics greater than 24.1 for each functional outcome. For patients with moderately severe stroke in CMGs 104-107, fewer days from stroke symptom onset to rehabilitation admission was associated significantly with shorter rehabilitation LOS.

CONCLUSIONS

Fewer days from stroke symptom onset to rehabilitation admission is associated with better functional outcomes at discharge and shorter LOS.

Accuracy of physical and occupational therapists' early predictions of recovery after severe middle cerebral artery stroke

INTRODUCTION

The ability of physical therapists (PTs) and occupational therapists (OTs) to predict level of outcome accurately was investigated prospectively in 91 severely disabled stroke patients with a first-ever middle cerebral artery (MCA) stroke.

METHODS

Within the second and fifth week after stroke onset, 364 predictions were made by 59 PTs and 47 OTs about walking ability, dexterity, activities of daily living (ADL), need for additional care in ADL, time required to achieve independent walking ability and maximal level of ADL, and destination of discharge at six months after stroke. The functional recovery patterns of stroke patients were assessed by an independent observer. The accuracy of the therapists' predictions was compared with that of derived prediction models. In addition, the influence of characteristics of patients and therapists on the accuracy of the predictions was investigated.

RESULTS

Compared to observed outcomes at six months after stroke, therapists' lowest accuracies of prediction were found for the moment at which maximal ADL score was achieved (rs = 0.07; p = NS), and highest accuracy was for level of dexterity of the hemiplegic arm (rs = 0.78; p <0.01). Therapists' predictions of functional outcome at six months tended to be too pessimistic. No significant differences were observed for dexterity and walking ability when the predictions by PTs and OTs were compared with those of regression models, whereas significant differences were found for the accuracies of OTs' and PTs' first prediction of destination of discharge and second predictions of outcome in ADL and need for additional care in ADL. No significant differences were found between the accuracy of PTs' and OTs' predictions, and their ability to predict functional outcome was not significantly influenced by the characteristics of patient and therapists.

CONCLUSIONS

At two and five weeks after stroke, OTs and PTs can accurately predict level of walking ability and dexterity at six months. The prediction of time required for achieving maximal level of recovery, destination of discharge, outcome of ADL as well as need for additional care in ADL leaves room for improvement.

Intensity of leg and arm training after primary middle-cerebral-artery stroke: a randomised trial

BACKGROUND

We investigated the effects of different intensities of arm and leg rehabilitation training on the functional recovery of activities of daily living (ADL), walking ability, and dexterity of the paretic arm, in a single-blind randomised controlled trial.

METHODS

Within 14 days after stroke onset, 101 severely disabled patients with a primary middle-cerebral-artery stroke were randomly assigned to: a rehabilitation programme with emphasis on arm training; a rehabilitation programme with emphasis on leg training; or a control programme in which the arm and leg were immobilised with an inflatable pressure splint. Each treatment regimen was applied for 30 min, 5 days a week during the first 20 weeks after stroke. In addition, all patients underwent a basic rehabilitation programme. The main outcome measures were ability in ADL (Barthel index), walking ability (functional ambulation categories), and dexterity of the paretic arm (Action Research arm test) at 6, 12, 20, and 26 weeks. Analyses were by intention to treat.

FINDINGS

At week 20, the leg-training group (n=31) had higher scores than the control group (n=37) for ADL ability (median 19 [IQR 16-20] vs 16 [10-19], p<0.05), walking ability (4 [3-5] vs 3 [1-4], p<0.05), and dexterity (2 [0-56] vs 0 [0-2], p<0.01). The arm-training group (n=33) differed significantly from the control group only in dexterity (9 [0-39] vs 0 [0-2], p<0.01). There were no significant differences in these endpoints at 20 weeks between the arm-training and leg-training groups.

INTERPRETATION

Greater intensity of leg rehabilitation improves functional recovery and health-related functional status, whereas greater intensity of arm rehabilitation results in small improvements in dexterity, providing further evidence that exercise therapy primarily induces treatment effects on the abilities at which training is specifically aimed.

Discharge destination and motor function outcome in severe stroke as measured by the functional independence measure/function-related group classification system

OBJECTIVES

Function-related groups based on the Functional Independence Measure have been proposed as a model for a prospective payment system for medical rehabilitation. This study describes discharge destination and motor function outcomes in a sample of patients with stroke from the FIM-FRG STR1 classification.

STUDY DESIGN

A retrospective review of 293 cases of stroke from the years 1993 to 1995. The demographic and outcome characteristics of this sample were described.

RESULTS/CONCLUSIONS

Forty-five percent of the patients were discharged to home after a mean length of stay of 23.8 days in acute medical rehabilitation. Patients who were discharged home had higher admission and discharge motor FIM scores than those discharged to a subacute facility or long-term care facility, although the correlation between motor FIM score and discharge destination was low to moderate. Median discharge motor FIM scores indicate considerable residual disability in this classification after rehabilitation. Research problems that address methods to improve the usefulness of the FIM-FRG system in a prospective payment system are discussed.

Treatment strength in rehabilitation

OBJECTIVE

To propose treatment strength as central to an understanding of rehabilitation treatment, to delineate its features, to examine related research, and to suggest ways to improve the specification and conceptualization of treatment.

DATA SOURCES

Published literature.

STUDY SELECTION

Definitions were proposed for treatment strength components: purity, specificity, dose, intensity, duration, timing, and treater characteristics and organization. Three measures of treatment exposure were selected as having the most research: length of inpatient stay, treatment intensity, and treatment specificity (using as example the stroke rehabilitation unit). Length of stay information was selected primarily from studies using multifacility data systems. All studies identified as using greater treatment intensity or augmented treatment were selected. Because of the large literature on stroke units, selected studies were chosen that used randomized controlled trials or community-based data.

RESULTS

Greater treatment exposure, as measured by length of stay, generally results in greater benefit, although there are wide variations for a given condition over time and across countries. Research on treatment intensity uses various definitions for intensity with mixed results. Specialization, in the form of the stroke rehabilitation unit, generally produces superior outcomes than other types of care, although there is little investigation of the reasons for benefit.

CONCLUSIONS

Understanding of rehabilitation treatment would be improved by (1) routinely reporting hours of service by discipline, (2) using treatment strength concepts, (3) analyzing the relation of naturally occurring variations of treatment strength to outcomes, and (4) developing a taxonomy of treatment types.

Therapists and the rehabilitation process after stroke

Therapists working in an experimental stroke unit were interviewed about how they set goals for rehabilitation, how they measure progress, and about problems of discharging patients. In addition the interview covered the topics of quality in rehabilitation, the relationship between patient and therapist, and therapists' evaluation of the stroke unit. The therapists felt that current outcome measurement instruments did not capture the kinds of results that they felt were important. They were process-oriented, and not only outcome-oriented as in traditional studies of stroke rehabilitation. This explorative study provides an insight into how therapists view the stroke rehabilitation process, and elaborates themes for future studies of physical and occupational therapy in rehabilitation.

Patients' experience of rehabilitation after stroke

In this study patients were interviewed concerning their experience of rehabilitation in an experimental stroke unit. The patients reported positive effects of being together with other stroke patients and used the unit in a self-help group fashion. They felt that they could have used more rehabilitation, even though they were hospitalized for longer than reported in other studies. Patients felt that there were important non-physical problems in connection with their rehabilitation, and that sufficient attention was not given to all of these. Finally patients underlined the positive effects of the rehabilitation process in helping them organize their coming life in the community.

An integrated system for multidisciplinary assessments in stroke rehabilitation

BACKGROUND AND PURPOSE

There is increasing emphasis on the use of integrated systems for timely, accurate, and efficient data collection for a range of service, audit, quality, and research applications. The present study evaluates the acceptability and the quality of data collected on a ward-based system over a 6-month period.

METHODS

A multidisciplinary system specific for stroke rehabilitation was used. Members of each discipline were required to enter demographic, medical, nursing, therapy, and psychosocial data as appropriate to their specialty. A users' survey was undertaken at the beginning and at the end of the study. The quality and completeness of data entry were assessed by a "snapshot" of the database at the end of the study period. Primary users (n = 13) included physicians, nurses, and therapists.

RESULTS

The user survey at the end of the evaluation showed a significant increase in confidence in using the system. Although the frequency of use had increased, the time spent in data entry had decreased significantly. The increase in work load, estimated at 15 to 60 minutes per week, was considered to be balanced by the benefits in patient care, audit, and research. There were 67 medical and 1046 other assessments on 67 patients entered into the system. Seven patients (11%) had incomplete medical records. Nursing and therapy assessments had been entered for all patients at admission and on discharge, with more than 95% of all possible assessments monitoring recovery being recorded accurately compared with conventional records.

CONCLUSIONS

The study showed that it was possible to introduce a computerized multidisciplinary assessment system on rehabilitation wards as a part of day-to-day work without the need for significant extra resources.

Stroke: a family dilemma

Research studying the clinical effectiveness of stroke rehabilitation has focused on managing acute stages and on evaluating short-term treatment programmes. However, many studies suggest that stroke affects long-term quality of life and the well-being of the family. This article reviews the stroke literature relative to aging, disability, and rehabilitation. The social effects of stroke in terms of clinical problems which make rehabilitation a family dilemma are discussed. Issues identified include the need for family assessment, education, advocacy, and counselling to foster treatment compliance and social support.

The Frenchay Activities Index. Assessment of functional status in stroke patients

BACKGROUND AND PURPOSE

Assessment of functional status in stroke patients is of major importance in both clinical practice and outcome studies. The Frenchay Activities Index has been developed specifically for measuring disability and handicap in stroke patients. The purpose of the study was to evaluate the metric properties of this instrument and to obtain normal values in a group of unselected elderly subjects.

METHODS

The Frenchay Activities Index was tested in a group of stroke patients and a group of unselected subjects aged 65 or older. The functional status of the stroke patients was measured 26 weeks after stroke. Their prestroke status was registered retrospectively. Reliability and validity of the instrument were assessed.

RESULTS

The mean scores in the prestroke, poststroke, and control group demonstrated differences in functional status. The reliability of unweighted scores (range of Cronbach's alpha-coefficients, 0.78 to 0.87) was sufficient. The construct validity was supported by meaningful correlations between the Frenchay Activities Index and scores on the Barthel Index and Sickness Impact Profile. Principal-components analysis indicated that the Frenchay Activities Index showed two traits: instrumental disability and some aspects of handicap. The reliability of the instrument could be improved by deleting two items and by creating two subscale scores: domestic and outdoors activities.

CONCLUSIONS

The Frenchay Activities Index is a useful stroke-specific instrument to assess functional status. Completion of the questionnaire is easy and takes only a few minutes. Currently, the instrument is suitable for use in patient care and cross-sectional, descriptive studies.

Heart disease in patients with stroke: incidence, impact, and implications for rehabilitation. Part 1: Classification and prevalence

Heart disease is found in about 75% of patients who have suffered a stroke. Cardiovascular diseases can be risk factors, etiologic mechanisms, associated conditions, or direct consequences of stroke. Cardiac comorbidity may delay initiation of rehabilitation, complicate the course and care of the patient with stroke, inhibit participation in a therapeutic exercise program, limit functional outcomes, and contribute to early mortality in the individual with cerebrovascular disease. Part 1 of this two-part article describes the various forms of heart disease that may be seen in stroke patients, and reviews the incidence figures for each type of associated cardiac condition.

Measuring functional status of stroke patients with the Sickness Impact Profile

Measuring outcome of stroke treatment has focused mostly on Activities of Daily Living. In our study we investigated the impact of stroke on the patient's daily life and the course of functional status over time. A community-based cohort of stroke patients was examined with the Barthel ADL Index and the Sickness Impact Profile at fixed intervals post-stroke. Data were compared with those of an elderly control group in the community. The scores of the stroke group on all the subscales of the SIP were much worse than in the control group. The differences were greatest for house management, recreation/pastime and mobility. While there was significant improvement of the mean Barthel score between 8 and 26 weeks post-stroke, the mean SIP scores at these intervals did not change, with the exception of the subscale house management, which showed some improvement. It would appear that the impact of stroke on daily life is greatest in the fields of house management, recreation/pastime and mobility.

Evaluation of stroke rehabilitation by randomized controlled studies: a review

In all, 22 reports of 20 randomized, controlled rehabilitation studies were evaluated. In 18 of these, the design of the trial was parallel, with a cross-over format being employed in the remaining 2 instances. Seven studies related to intensive rehabilitation during the early post-acute period. In six others, specific techniques--sometimes associated with traditional physiotherapy procedures--were compared: biofeedback, perceptual retraining, and amphetamine treatment. Eight experiments evaluated speech therapy in aphasia. Frequently, methodological considerations limited the interpretation of the results. The review showed that: 1) as regards activities of daily life and motor function, differences as between rehabilitation in stroke units on the one hand and non-rehabilitation or rehabilitation in medical wards on the other, were detected in relatively few quality studies and remained particularly inconclusive insofar as life in the home environment was concerned; 2) rehabilitation for aphasia and perceptual dysfunction proved effective for at least several months after acute stroke; 3) in general, examination of the reports cited revealed no differences in the effects of biofeedback and perceptual retraining vs conventional physiotherapy; 4) rehabilitation, whether administered by specialists or amateur caregivers purpose-trained by specialists, proved equally effective for aphasia. These conclusions constitute a valuable basis for the development and evaluation of modern rehabilitation programs for stroke patients.

Short-term prognosis of stroke due to occlusion of internal carotid artery based on transcranial Doppler ultrasonography

BACKGROUND AND PURPOSE

The clinical course of stroke due to occlusion of the internal carotid artery is influenced by amount of collateral flow. We measured mean frequency shifts in the middle cerebral artery by transcranial Doppler ultrasonography to determine its prognostic value.

METHODS

Patients with proven extracranial occlusion of the internal carotid artery and ipsilateral hemispheral stroke were enrolled in our study. We performed transcranial Doppler ultrasonography on 31 patients within 48 hours after the stroke onset and followed up 25 patients in 28 days. At the same time, neurological examination with quantification of neurological deficit was done. We correlated values of flow frequency shifts on the side of stroke with degree of neurological deficit at the onset and at 28 days as well as the degree of clinical improvement and the value of frequency shifts.

RESULTS

We found a negative correlation between blood flow frequency shifts in the middle cerebral artery and degree of neurological deficit at the onset (Spearman rank correlation coefficient, -0.567; p less than 0.001). We also found a positive correlation between the change of the neurological deficit during follow-up and frequency shifts at the onset (Spearman rank coefficient, 0.548; p less than 0.05).

CONCLUSIONS

Diminished blood flow velocity (mean frequency shift) in the area of stroke is a negative prognostic factor for the degree of neurological deficit at the onset and a negative prognostic factor for possible improvement. Knowledge of hemodynamic conditions in the stroke area may help to improve therapeutic decisions.

The quality and quantity of social support: stroke recovery as psycho-social transition

The impact of various types and amounts of social support is examined in the context of recovery from first stroke. We conceptualize the rehabilitation process as a psychosocial transition. In a longitudinal design, 44 patients were followed for 6 months following first stroke. Growth-curve analysis (repeated measures MANOVA) was utilized to examine the impact of three types of social support on changes in functional status during recovery. While all three types of support (emotional, instrumental and informational) were shown to be significantly related to recovery of functional capacity, substantial differences were found in the nature of those effects. The impact of social support does not appear during the first month of rehabilitation, indicating the importance of longitudinal designs and longer observation. Patients reporting high level of emotional support showed dramatic improvement despite having the lowest baseline functional status. Instrumental support is most closely related to positive outcomes when provided in moderate amounts. Unlike the other two types, the effect of informational support is mediated by disease severity.

Utilization of health care resources after stroke. A population-based study of 258 hospitalized cases followed during the first year

In a prospective population-based study the cumulative utilization of health care resources (and the rehabilitation outcome) was followed in consecutive stroke patients 3, 6 and 12 months after the onset of the disease. The study group comprised 258 patients diseased during the period February 1st 1986-January 31th 1987. The pattern of various forms of hospital beds and non-hospital facilities in open care utilized during the first post-stroke year was analysed at 1986 year's cost level. The mean utilization of acute hospital beds during the initial phase was 15 days; at an expenditure cost of 26,670 SEK ($3,683). The mean utilization of acute hospital and of geriatric beds during the first year was 19 and 59 days respectively. Thus the total hospital bed days amounted to a mean of 78 days; at a mean expenditure of 87,0000 SEK ($12,000); 70% of the patients were discharged from hospital care to independent living after 36 days. The acute care hospital provided 36% and geriatric care 64% of the beds needed before discharge. The expenditure of non-hospital facilities was mean 19,000 SEK ($2600); thus total expenditure for health care amounted to 106,000 SEK ($14,600). The relation between non-hospital and hospital care was approximately 1 to 5. Severity of the stroke influenced markedly the pattern and the total utilization of both hospital and non-hospital care. Patients with major stroke utilized health care resources at an expenditure 3.5 times that used by patients with minor stroke. Age of the patient also influenced health care utilization.(ABSTRACT TRUNCATED AT 250 WORDS)

Stroke rehabilitation: Australian patient profile and functional outcome

A prospective, multi-institutional, population based study identified 1274 non-surgical stroke admissions to all hospitals in a major Australian city during 1984. The demographic and diagnostic profile and the nature of functional recovery of all 258 first stroke survivors who were referred for inpatient rehabilitation are presented. The median duration of rehabilitation stay was 49 days. The mean functional independence score, as measured on a modified Barthel Index at admission was 44, compared with 78 on discharge, a mean improvement of 34. Stair climbing had the lowest mean value on admission (12), while bowel control had the lowest residual deficit on discharge (95). The stroke study group was representative of the unimpaired aged population in all respects except ethnicity, where differences are attributed to age. The variables identified as significant are; side and severity of paralysis, age and sex, marital status and ethnicity. Stroke rehabilitation outcome was not influenced by etiology, site of lesion, arterial distribution, occupation or education.

Stroke: evaluation of long-term rehabilitation effects

A planned prospective documentation of the course of rehabilitation of 303 stroke patients was undertaken using the Bathel-Index as a measure of basic everyday functions and the Guttman-Scale as a measure of complex activities of daily living. These were determined at the beginning of rehabilitation, after an average of 7 weeks of in-patient treatment and one year following the stroke. Four patterns in the course of rehabilitation could be differentiated. The causes of the differing functional results were investigated. Besides a positive spontaneous progress of the underlaying disease with an early reparation of the neurological deficits it is the premorbid status, the overprotection of the physically disabled and the determinative cognitive and mental functions that decide the long term fate of stroke patients.

Functional outcome measures in stroke rehabilitation

I examine statistical considerations in the analysis of functional outcome following stroke and discuss the mathematical relation between improvement in function and discharge functional score. I demonstrate mathematically that the predictor variables of improvement and discharge functional score are the same and that the regression coefficients for improvement and discharge functional score will be equal, except for the admission functional score, for which a mathematically defined relation exists. I argue that the relation between admission functional score and discharge functional score must be positive and strong and that the relation between admission functional score and improvement must be negative for the stroke population. I believe that an ignorance of statistical concepts, especially confounding, and of the differences between raw correlations, partial correlations, and predictors have led to much confusion in functional outcome research.