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Mehrabi S, Cameron L, Bowman A, Fleet JL, Eng J, Bayley MT, Teasell R. A Systematic Review of Female Participation in Randomized Controlled Trials of Post-Stroke Upper Extremity Rehabilitation in Low- to Middle-Income Countries and High-Income Countries and Regions. Cerebrovasc Dis 2024:1-10. [PMID: 38583429 DOI: 10.1159/000538610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 03/25/2024] [Indexed: 04/09/2024] Open
Abstract
INTRODUCTION Female participation is lower than males in both acute stroke and stroke rehabilitation trials. However, less is known about how female participation differs across countries and regions. This study aimed to assess the percentage of female participants in randomized controlled trials (RCTs) of post-stroke rehabilitation of upper extremity (UE) motor disorders in low-middle-income (LMICs) and high-income countries (HICs) as well as different high-income world regions. METHODS CINAHL, Embase, PubMed, Scopus, and Web of Science were searched from 1960 to April 1, 2021. Studies were eligible for inclusion if they (1) were RCTs or crossovers published in English; (2) ≥50% of participants were diagnosed with stroke; 3) included adults ≥18 years old; and (4) applied an intervention to the hemiparetic UE as the primary objective of the study. Countries were divided into HICs and LMICs based on their growth national incomes. The HICs were further divided into the three high-income regions of North America, Europe, and Asia and Oceania. Data analysis was performed using SPSS and RStudio v.4.3.1. RESULTS A total of 1,276 RCTs met inclusion criteria. Of them, 298 RCTs were in LMICs and 978 were in HICs. The percentage of female participants was significantly higher in HICs (39.5%) than LMICs (36.9%). Comparing high-income regions, there was a significant difference in the overall female percentages in favor of RCTs in Europe compared to LMICs but not North America or Asia and Oceania. There was no significant change in the percentage of female participants in all countries and regions over the last 2 decades, with no differences in trends between the groups. CONCLUSIONS Sufficient female representation in clinical trials is required for the generalizability of results. Despite differences in overall percentage of female participation between countries and regions, females have been underrepresented in both HICs and LMICs with no considerable change over 2 decades.
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Affiliation(s)
- Sarvenaz Mehrabi
- Parkwood Institute Research, Parkwood Institute, London, Ontario, Canada,
| | - Lindsay Cameron
- Parkwood Institute Research, Parkwood Institute, London, Ontario, Canada
| | - Andrew Bowman
- Parkwood Institute Research, Parkwood Institute, London, Ontario, Canada
| | - Jamie L Fleet
- Parkwood Institute Research, Parkwood Institute, London, Ontario, Canada
- St. Joseph's Health Care London, London, Ontario, Canada
- Physical Medicine and Rehabilitation, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
| | - Janice Eng
- Department of Physical Therapy, University of British Columbia, Vancouver, British Columbia, Canada
- Rehabilitation Research Program, Centre for Aging SMART, Vancouver, British Columbia, Canada
| | - Mark Theodore Bayley
- KITE Research Institute, UHN-Toronto Rehabilitation institute, Toronto, Ontario, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Robert Teasell
- Parkwood Institute Research, Parkwood Institute, London, Ontario, Canada
- St. Joseph's Health Care London, London, Ontario, Canada
- Physical Medicine and Rehabilitation, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
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Kumar A, Khurana D, Pattanaik S, Kumar M, Kaur S, Krishnan NC, Ghai S, Modi M, Nagi M, Chellappa R, Gairolla J, Munjal DK, Kumar P. A mobile application-based post-stroke care strategy for survivors and their caregivers for prevention and management of post-stroke complications - "Stroke Home Care:" Development and feasibility. J Neurosci Rural Pract 2024; 15:217-226. [PMID: 38746514 PMCID: PMC11090587 DOI: 10.25259/jnrp_411_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 09/10/2023] [Indexed: 05/16/2024] Open
Abstract
Objectives In developing nations such as India, a disparity exists between the available resources for stroke rehabilitation and the substantial burden of stroke cases. Consequently, the provision of cost-effective and multidisciplinary post-stroke rehabilitation care to stroke survivors becomes of paramount importance. The utilization of mobile applications (apps) for stroke care has been on the rise, offering a personalized and pragmatic solution with the potential for wider reach in settings constrained by limited resources. To address the unmet needs in the prevention and management of post-stroke complications, we conceptualized a strategy known as a mobile application-based post-stroke care strategy for both survivors and their caregivers. Materials and Methods The scope of the app's focus was determined based on the incidence of post-stroke complications within a prospective cohort of stroke patients, in conjunction with existing literature. An initial "web-based mobile app" prototype was crafted to align with the identified focus area. Before the development of the final app version, a feasibility study was conducted involving 30 participant dyads (comprising a patient and a caregiver). Content validity was evaluated by a panel of 20 stroke experts encompassing neurologists, nurses, physiotherapists, and psychologists. Results The "Stroke Home Care" (SHC) mobile app was conceived as a web-based educational tool aimed at preventing and managing post-stroke complications. It seeks to train caregivers of immobile stroke patients in the administration of preventive and therapeutic care procedures, thereby potentially enhancing survivors' quality of life and alleviating caregivers' burden. The feasibility and validity studies indicated "high satisfaction" levels among most caregivers and experts (>75%), with the remainder expressing "satisfaction" and no "dissatisfaction" regarding app utilities. Stroke experts unanimously deemed the app "appropriate", with consensus on contents, video quality, video length, and voice clarity. Caregivers reported "satisfactory" user experiences, encountering no issues during app installation or operation. Suggestions from both caregivers and experts were integrated into the final app version. Conclusion The "SHC" app represents a feasible and well-received innovation tailored for the use by caregivers of stroke survivors. Consequently, the initial feasibility of the developed app serves as a precursor to a randomized controlled clinical trial aimed at substantiating its effectiveness within the post-stroke survivor and caregiver population. Notably, within resource-constrained contexts, this app has the potential to be a pivotal tool for post-stroke care.
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Affiliation(s)
- Ashok Kumar
- National Institute of Nursing Education, Chandigarh, India
| | - Dheeraj Khurana
- Department of Neurology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Smita Pattanaik
- Department of Pharmacology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Mukesh Kumar
- Department of Industrial Engineering, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Sukhpal Kaur
- National Institute of Nursing Education, Chandigarh, India
| | | | - Sandhya Ghai
- National Institute of Nursing Education, Chandigarh, India
| | - Manish Modi
- Department of Neurology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Manisha Nagi
- National Institute of Nursing Education, Chandigarh, India
| | - Rajan Chellappa
- Department of Physical Medicine and Rehabilitation, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | | | - Divesh Kumar Munjal
- Department of Neurology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Pramod Kumar
- Department of Nursing, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Htun HL, Wong LH, Lian W, Koh J, Lee LT, Lim JP, Leong I, Lim WY. Functional improvement after inpatient rehabilitation in community hospitals following acute hospital care. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2022; 51:357-369. [PMID: 35786756 DOI: 10.47102/annals-acadmedsg.2021507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
INTRODUCTION There are limited studies exploring functional improvement in relation to characteristics of patients who, following acute hospital care, receive inpatient rehabilitation in community hospitals. We evaluated the association of acute hospital admission-related factors with functional improvement on community hospital discharge. METHODS We conducted a retrospective cohort study among patients who were transferred to community hospitals within 14-day post-discharge from acute hospital between 2016 and 2018. Modified Barthel Index (MBI) on a 100-point ordinal scale was used to assess functional status on admission to and discharge from the community hospital. We categorised MBI into 6 bands: 0-24, 25-49, 50-74, 75-90, 91-99 and 100. Multivariable logistic regression models were constructed to determine factors associated with categorical improvement in functional status, defined as an increase in at least one MBI band between admission and discharge. RESULTS A total of 5,641 patients (median age 77 years, interquartile range 69-84; 44.2% men) were included for analysis. After adjusting for potential confounders, factors associated with functional improvement were younger age, a higher MBI on admission, and musculoskeletal diagnosis for the acute hospital admission episode. In contrast, a history of dementia or stroke; lower estimated glomerular filtration rate; abnormal serum albumin or anaemia measured during the acute hospital episode; and diagnoses of stroke, cardiac disease, malignancy, falls or pneumonia; and other chronic respiratory diseases were associated with lower odds of functional improvement. CONCLUSION Clinicians may want to take into account the presence of these high-risk factors in their patients when planning rehabilitation programmes, in order to maximise the likelihood of functional improvement.
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Affiliation(s)
- Htet Lin Htun
- Department of Preventive and Population Medicine, Office of Clinical Epidemiology, Analytics, and Knowledge, Tan Tock Seng Hospital, Singapore
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Shen Y, Cao Q, Zhuo H, Hu M, Chen S. Early Versus Late Tracheostomy in Stroke Patients: A Retrospective Analysis. Neuropsychiatr Dis Treat 2022; 18:2713-2723. [PMID: 36419859 PMCID: PMC9677992 DOI: 10.2147/ndt.s388062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 11/04/2022] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE The timing of tracheostomy (TR) in severe stroke patients receiving mechanical ventilation has not been determined. In this study, we compared some prognostic indicators of early tracheostomy (ET) and late tracheostomy (LT). A meta-analysis was performed to obtain a higher level of evidence of the timing of TR in patients with severe stroke receiving mechanical ventilation. METHODS The study was a retrospective single-center study. We divided the severe stroke patients who received TR from June 2020 to June 2022 into the ET group and LT group. The demographic characteristics, clinical characteristics and prognostic indices were compared. For this meta-analysis, we systematically searched PubMed and other databases. The compared prognostic indicators included mechanical ventilation time, ICU length of stay (LOS), total LOS, ventilator-related pneumonia (VAP) incidence, and mortality. RESULTS A total of 61 patients were included in our study, including 32 patients in the ET group and 29 patients in the LT group. Univariate and multivariate analyses showed that the NIHSS score in the ET group was higher than that in the LT group (P < 0.05). In terms of outcome indicators, compared with the LT group, the median mechanical ventilation time in the ET group was shortened by 5.5 days (P = 0.034). The ICU LOS and total LOS in the ET group were significantly lower than those in the LT group (median 14.5 days vs 22 days, P = 0.004; 21 days vs 27 days, P = 0.019). The meta-analysis showed that ET could significantly shorten the ICU LOS (MD -3.89 [95% CI: -6.86, -0.92]) and the total LOS (MD -7.70 [95% CI: -8.57, -6.83]) and significantly reduce the occurrence of VAP (OR 0.75 [95% CI: 0.64, 0.87]). CONCLUSION The results of our retrospective study and meta-analysis support that ET can shorten the ICU LOS and total LOS and reduce the occurrence of VAP. Therefore, it has a positive effect on the prognosis of patients with severe stroke who need mechanical ventilation support.
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Affiliation(s)
- Yu Shen
- Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People's Republic of China.,Department of Neurology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People's Republic of China
| | - Qian Cao
- Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People's Republic of China
| | - Hou Zhuo
- Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People's Republic of China
| | - Mengyao Hu
- The Medical Imaging Center, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People's Republic of China
| | - Shenjian Chen
- Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People's Republic of China.,Neurology Intensive Care Unit, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People's Republic of China
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Yeo SH, Yau WP. Temporal Trends and Predictors of Drug Utilization and Outcomes in First-Ever Stroke Patients: A Population-Based Study Using the Singapore Stroke Registry. CNS Drugs 2019; 33:791-815. [PMID: 31313138 DOI: 10.1007/s40263-019-00648-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Drug utilization and outcomes research in multi-ethnic Asian stroke populations is lacking. OBJECTIVES Our objective was to examine temporal trends and predictors of drug utilization and outcomes in a multi-ethnic Asian stroke population. METHODS This registry-based study included ischemic and hemorrhagic first-ever stroke patients hospitalized between 2009 and 2016. Utilization of medications included in-hospital thrombolytic agents, early antithrombotics (antiplatelets, anticoagulants) within 48 h of admission, and antithrombotics and statins at discharge. Outcomes analyzed were in-hospital all-cause mortality; 28-day, 90-day, and 1-year case fatality (CF); and discharge destination. RESULTS Of the 36,615 included patients, 81.6% had ischemic stroke and 18.4% had hemorrhagic stroke (15.5% intracerebral hemorrhage [ICH] and 2.8% subarachnoid hemorrhage [SAH]). For ischemic stroke, the combined use of all three guideline medications (in-hospital thrombolytic therapy, as well as antithrombotics and statins at discharge) increased (P = 0.006). Being on the stroke pathway was associated with prescription of all three guideline medications in ischemic stroke. Decreasing trends for in-hospital mortality, 28-day, 90-day, and 1-year CF and proportion of patients discharged home without rehabilitation appointment were observed in ischemic stroke (P < 0.05) but not in ICH or SAH (apart from 28-day CF). Ischemic stroke patients who received guideline medications were less likely to die or be discharged to nursing homes and chronic sick hospitals. Hemorrhagic stroke patients prescribed statins at discharge were less likely to have 28-day and 1-year CF. CONCLUSIONS Prescription of secondary stroke preventive medications (particularly in ischemic stroke) was associated with more favorable outcomes, highlighting the importance of physician adherence to evidence-based pharmacotherapy.
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Affiliation(s)
- See-Hwee Yeo
- Department of Pharmacy, Faculty of Science, National University of Singapore, 18 Science Drive 4, Singapore, 117543, Republic of Singapore
| | - Wai-Ping Yau
- Department of Pharmacy, Faculty of Science, National University of Singapore, 18 Science Drive 4, Singapore, 117543, Republic of Singapore.
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Li J, Thakor N, Bezerianos A. Unilateral Exoskeleton Imposes Significantly Different Hemispherical Effect in Parietooccipital Region, but Not in Other Regions. Sci Rep 2018; 8:13470. [PMID: 30194397 PMCID: PMC6128944 DOI: 10.1038/s41598-018-31828-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 08/28/2018] [Indexed: 11/10/2022] Open
Abstract
In modern society, increasing people suffering from locomotor disabilities need an assistive exoskeleton to help them improve or restore ambulation. When walking is assisted by an exoskeleton, brain activities are altered as the closed-loop between brain and lower limbs is affected by the exoskeleton. Intuitively, a unilateral exoskeleton imposes differential effect on brain hemispheres (i.e., hemispherical effect) according to contralateral control mechanism. However, it is unclear whether hemispherical effect appears in whole hemisphere or particular region. To this end, we explored hemispherical effect on different brain regions using EEG data collected from 30 healthy participants during overground walking. The results showed that hemispherical effect was significantly different between regions when a unilateral exoskeleton was employed for walking assistance and no significance was observed for walking without the exoskeleton. Post-hoc t-test analysis revealed that hemispherical effect in the parietooccipital region significantly differed from other regions. In the parietooccipital region, a greater hemispherical effect was observed in beta band for exoskeleton-assisted walking compared to walking without exoskeleton, which was also found in the source analysis. These findings deepen the understanding of hemispherical effect of unilateral exoskeleton on brain and could aid the development of more efficient and suitable exoskeleton for walking assistance.
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Affiliation(s)
- Junhua Li
- Singapore Institute for Neurotechnology (SINAPSE), Centre for Life Sciences, National University of Singapore, Singapore, 117456, Singapore.
- Laboratory for Brain-bionic Intelligence and Computational Neuroscience, Wuyi University, Jiangmen, 529020, China.
- Centre for Multidisciplinary Convergence Computing (CMCC), School of Computer Science and Engineering, Northwestern Polytechnical University, Xi'an, 710072, China.
| | - Nitish Thakor
- Singapore Institute for Neurotechnology (SINAPSE), Centre for Life Sciences, National University of Singapore, Singapore, 117456, Singapore
| | - Anastasios Bezerianos
- Singapore Institute for Neurotechnology (SINAPSE), Centre for Life Sciences, National University of Singapore, Singapore, 117456, Singapore
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Lo K, Stephenson M, Lockwood C. The economic cost of robotic rehabilitation for adult stroke patients: a systematic review protocol. ACTA ACUST UNITED AC 2018; 16:1593-1598. [PMID: 30113542 DOI: 10.11124/jbisrir-2017-003635] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
REVIEW QUESTION/OBJECTIVE The objective of this review is to identify the best available evidence on the economic cost of robotic rehabilitation for adult stroke patients to improve their motor movement abilities. More specifically, the objective is to identify the evidence on the economic cost of robotic training compared to conventional physiotherapy for adult stroke patients, from the perspective of hospitals.
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Affiliation(s)
- Kenneth Lo
- Joanna Briggs Institute, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, Australia
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Lo K, Stephenson M, Lockwood C. Effectiveness of robotic assisted rehabilitation for mobility and functional ability in adult stroke patients: a systematic review protocol. ACTA ACUST UNITED AC 2018; 15:39-48. [PMID: 28085725 DOI: 10.11124/jbisrir-2016-002957] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
REVIEW QUESTION/OBJECTIVE The objective of this review is to synthesize the best available evidence on the effectiveness of robotic assistive devices in the rehabilitation of adult stroke patients for recovery of impairments in the upper and lower limbs. The secondary objective is to investigate the sustainability of treatment effects associated with use of robotic devices.The specific review question to be addressed is: can robotic assistive devices help adult stroke patients regain motor movement of their upper and lower limbs?
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Affiliation(s)
- Kenneth Lo
- Joanna Briggs Institute, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, Australia
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Lo K, Stephenson M, Lockwood C. Effectiveness of robotic assisted rehabilitation for mobility and functional ability in adult stroke patients: a systematic review. JBI DATABASE OF SYSTEMATIC REVIEWS AND IMPLEMENTATION REPORTS 2017; 15:3049-3091. [PMID: 29219877 DOI: 10.11124/jbisrir-2017-003456] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
BACKGROUND Stroke is a leading cause of long-term disability, and rehabilitation, involving repetitive, high intensity, task-specific exercises, is the pathway to restoring motor skills. Robotic assistive devices are increasingly being used and it is hoped that with robotic devices, rehabilitation progress can be achieved for patients. OBJECTIVES To examine the effectiveness of robotic devices in the rehabilitation of stroke patients for upper limb mobility, lower limb mobility, and activities of daily living. The sustainability of treatment effect was also examined. INCLUSION CRITERIA TYPES OF PARTICIPANTS Adult stroke patients 18 years and over. TYPES OF INTERVENTION(S) Rehabilitation of stroke patients using robotic devices with assistive automation, compared to conventional physiotherapy. OUTCOMES Motor movements of upper limbs, walking movement of lower limbs and activities of daily living, including follow-up measurements to examine the sustainability of treatment effect. TYPES OF STUDIES Randomized and controlled clinical trials. SEARCH STRATEGY Published and unpublished studies in English were searched. METHODOLOGICAL QUALITY All studies meeting the review inclusion criteria were independently assessed for methodological quality by two reviewers. DATA EXTRACTION Quantitative data were extracted using the standardized data extraction tool from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument. DATA SYNTHESIS Quantitative data were pooled in statistical meta-analysis. Effect sizes expressed as standardized mean difference, 95% confidence intervals and levels of heterogeneity (I) were calculated. Where statistical pooling was not possible, the findings were presented in narrative form. RESULTS Fifty-one studies with 1798 patients were included in this review. Thirty studies examined upper limb interventions and 21 studies evaluated lower limb gait training. Non-significant results were found for upper limb (SMD 0.07, 95% CI -0.11 to 0.26, I = 41%, P = 0.45), lower limb (SMD 0.17, 95% CI -0.15 to 0.48, I = 75%, P = 0.31) and activities of daily living (SMD 0.11, 95% CI -0.11 to 0.33, I = 66%, P = 0.32). For patients with severely impaired lower limbs, a significant difference was observed in favor of robotics (SMD 0.41, 95% CI 0.19 to 0.63, I = 28%, P = 0.0003). P-value analysis did not show significant results for the sustainability of treatment effect post intervention. CONCLUSIONS Robotic training is just as effective as conventional training for upper limb motor movement, lower limb walking mobility and for activities of daily living. For lower limb patients with severe impairment, robotic training produces better outcomes than conventional training. The sufficient quantity of studies included and the reasonable quality of Grading of Recommendations Assessment, Development and Evaluation (GRADE) evidence support the findings.For treatment sustainability of upper and lower limbs, robotic training is just as effective as conventional training. However, the low quality of GRADE evidence and the lower number of studies included require caution for this finding. For treatment sustainability of activities of daily living, the better quality of GRADE evidence and the larger number of studies analyzed indicate that robotic training is just as effective as conventional training.
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Affiliation(s)
- Kenneth Lo
- The Joanna Briggs Institute, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, Australia
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Hsu HY, Ke CW, Kuan TS, Yang HC, Tsai CL, Kuo LC. Impacts of Sensation, Perception, and Motor Abilities of the Ipsilesional Upper Limb on Hand Functions in Unilateral Stroke: Quantifications From Biomechanical and Functional Perspectives. PM R 2017; 10:146-153. [PMID: 28729058 DOI: 10.1016/j.pmrj.2017.07.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 06/30/2017] [Accepted: 07/07/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND The presence of subtle losses in hand dexterity after stroke affects the regaining of independence with regard to activities of daily living. Therefore, awareness of ipsilesional upper extremity (UE) function may be of importance when developing a comprehensive rehabilitation program. However, current hand function tests seem to be unable to identify asymptomatic UE impairments. OBJECTIVES To assess the motor coordination as well as the sensory perception of an ipsilesional UE using biomechanical analysis of performance-oriented tasks and conducting a Manual Tactile Test (MTT). DESIGN Case-controlled study. SETTING A university hospital. PARTICIPANTS A total of 21 patients with unilateral stroke, along with 21 matched healthy control subjects, were recruited. METHODS Each participant was requested to perform a pinch-holding-up activity (PHUA) test, object-transport task, and reach-to-grasp task via motion capture, as well as the MTT. MAIN OUTCOME MEASUREMENTS The kinetic data of the PHUA test, kinematics analysis of functional movements, and time requirement of MTT were analyzed. RESULTS Patients with ipsilesional UE had an inferior ability to scale and produce pinch force precisely when conducting the PHUA test compared to the healthy controls (P < .05). The movement time was statistically longer and peak velocity was significantly lower (P < .05) in the performance-oriented tasks for the ipsilesional UE patients. The longer time requirement in 3 MTT subtests showed that the ipsilesional UE patients experienced degradation in sensory perception (P < .001). CONCLUSION Comprehensive sensorimotor assessments based on functional perspectives are valid tools to determine deficits in the sensation-perception-motor system in the ipsilesional UE. Integration of sensorimotor training programs for ipsilesional UE in future neuro-rehabilitation strategies may provide more beneficial effects to regain patients' motor recovery and to promote daily living activity independence than focusing on paretic arm motor training alone. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Hsiu-Yun Hsu
- Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Occupational Therapy, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Medical Device Innovation Center, National Cheng Kung University, Tainan, Taiwan
- Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Occupational Therapy, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Occupational Therapy, College of Medicine, National Cheng Kung University, 1 University Road, Tainan, 701 Taiwan; Medical Device Innovation Center, National Cheng Kung University, Tainan, Taiwan
| | - Chia-Wen Ke
- Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Occupational Therapy, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Medical Device Innovation Center, National Cheng Kung University, Tainan, Taiwan
- Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Occupational Therapy, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Occupational Therapy, College of Medicine, National Cheng Kung University, 1 University Road, Tainan, 701 Taiwan; Medical Device Innovation Center, National Cheng Kung University, Tainan, Taiwan
| | - Ta-Shen Kuan
- Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Occupational Therapy, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Medical Device Innovation Center, National Cheng Kung University, Tainan, Taiwan
- Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Occupational Therapy, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Occupational Therapy, College of Medicine, National Cheng Kung University, 1 University Road, Tainan, 701 Taiwan; Medical Device Innovation Center, National Cheng Kung University, Tainan, Taiwan
| | - Hsiu-Ching Yang
- Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Occupational Therapy, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Medical Device Innovation Center, National Cheng Kung University, Tainan, Taiwan
- Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Occupational Therapy, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Occupational Therapy, College of Medicine, National Cheng Kung University, 1 University Road, Tainan, 701 Taiwan; Medical Device Innovation Center, National Cheng Kung University, Tainan, Taiwan
| | - Ching-Liang Tsai
- Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Occupational Therapy, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Medical Device Innovation Center, National Cheng Kung University, Tainan, Taiwan
- Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Occupational Therapy, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Occupational Therapy, College of Medicine, National Cheng Kung University, 1 University Road, Tainan, 701 Taiwan; Medical Device Innovation Center, National Cheng Kung University, Tainan, Taiwan
| | - Li-Chieh Kuo
- Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Occupational Therapy, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Medical Device Innovation Center, National Cheng Kung University, Tainan, Taiwan
- Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Occupational Therapy, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Occupational Therapy, College of Medicine, National Cheng Kung University, 1 University Road, Tainan, 701 Taiwan; Medical Device Innovation Center, National Cheng Kung University, Tainan, Taiwan
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Sadarangani GP, Menon C. A preliminary investigation on the utility of temporal features of Force Myography in the two-class problem of grasp vs. no-grasp in the presence of upper-extremity movements. Biomed Eng Online 2017; 16:59. [PMID: 28511661 PMCID: PMC5434639 DOI: 10.1186/s12938-017-0349-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 05/10/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In upper-extremity stroke rehabilitation applications, the potential use of Force Myography (FMG) for detecting grasping is especially relevant, as the presence of grasping may be indicative of functional activity, which is a key goal of rehabilitation. To date, most FMG research has focused on the classification of the raw FMG signal (i.e. instantaneous FMG samples) in order to determine the state of the hand. However, given the temporal nature of force generation during grasping, the use of temporal feature extraction techniques may yield increased accuracy. In this study, the effectiveness of classifying temporal features of the FMG signal for the two-class grasp detection problem of "grasp" versus "no grasp" (i.e. no object in hand) was evaluated with ten healthy participants. The experimental protocol comprised grasp and move tasks, requiring the use of six different grasp types frequently used in daily living, in conjunction with arm and hand movements. Data corresponding to arm and hand movements without grasping were also included to evaluate robustness to false positives. The temporal features evaluated were mean absolute value (MAV), root mean squared (RMS), linear fit (LF), parabolic fit (PF), and autoregressive model (AR). Off-line classification performance of the five temporal features, with a 0.5 s extraction window, were determined and compared to that of the raw FMG signal using area under the receiver operating curve (AUC). RESULTS The raw FMG signal yielded AUC of 0.819 ± 0.098. LF and PF resulted in the greatest increases in classification performance, and provided statistically significant increases in performance. The largest increase obtained was with PF, yielding AUC of 0.869 ± 0.061, corresponding to a 6.1% relative increase over the raw FMG signal. Despite the additional fitting term provided by PF, classification performance did not significantly improve with PF when compared to LF. CONCLUSIONS The results obtained indicate that temporal feature extraction techniques that derive models of the data within the window may yield modest improvements in FMG based grasp detection performance. In future studies, the use of model-based temporal features should be evaluated with FMG data from individuals with stroke, who might ultimately benefit from this technology.
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Affiliation(s)
- Gautam P Sadarangani
- Menrva Research Group, Schools of Mechatronic Systems and Engineering Science, Simon Fraser University, Metro Vancouver, BC, Canada
| | - Carlo Menon
- Menrva Research Group, Schools of Mechatronic Systems and Engineering Science, Simon Fraser University, Metro Vancouver, BC, Canada.
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12
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Mahapatra A, Barman A. Rehabilitation of a patient with stroke. INDIAN JOURNAL OF NEUROSURGERY 2017. [DOI: 10.4103/2277-9167.124230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Ashok Mahapatra
- Department of Neurosurgery, All India Institute of Medical Sciences
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14
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Horvath JC, Donoghue GM. A Bridge Too Far - Revisited: Reframing Bruer's Neuroeducation Argument for Modern Science of Learning Practitioners. Front Psychol 2016; 7:377. [PMID: 27014173 PMCID: PMC4792869 DOI: 10.3389/fpsyg.2016.00377] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Accepted: 03/02/2016] [Indexed: 11/15/2022] Open
Abstract
In Education and the Brain: A Bridge Too Far, John Bruer argues that, although current neuroscientific findings must filter through cognitive psychology in order to be applicable to the classroom, with increased knowledge the neuroscience/education bridge can someday be built. Here, we suggest that translation cannot be understood as a single process: rather, we demonstrate that at least four different ‘bridges’ can conceivably be built between these two fields. Following this, we demonstrate that, far from being a matter of information lack, a prescriptive neuroscience/education bridge (the one most relevant to Bruer’s argument) is a practical and philosophical impossibility due to incommensurability between non-adjacent compositional levels-of-organization: a limitation inherent in all sciences. After defining this concept in the context of biology, we apply this concept to the learning sciences and demonstrate why all brain research must be behaviorally translated before prescriptive educational applicability can be elucidated. We conclude by exploring examples of how explicating different forms of translation and adopting a levels-of-organization framework can be used to contextualize and beneficially guide research and practice across all learning sciences.
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Affiliation(s)
- Jared C Horvath
- Science of Learning Research Centre, Melbourne Graduate School of Education, University of Melbourne, Melbourne VIC, Australia
| | - Gregory M Donoghue
- Science of Learning Research Centre, Melbourne Graduate School of Education, University of Melbourne, Melbourne VIC, Australia
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15
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The Neural Correlates of Long-Term Carryover following Functional Electrical Stimulation for Stroke. Neural Plast 2016; 2016:4192718. [PMID: 27073701 PMCID: PMC4814690 DOI: 10.1155/2016/4192718] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Revised: 11/23/2015] [Accepted: 11/25/2015] [Indexed: 01/16/2023] Open
Abstract
Neurorehabilitation effective delivery for stroke is likely to be improved by establishing a mechanistic understanding of how to enhance adaptive plasticity. Functional electrical stimulation is effective at reducing poststroke foot drop; in some patients, the effect persists after therapy has finished with an unknown mechanism. We used fMRI to examine neural correlates of functional electrical stimulation key elements, volitional intent to move and concurrent stimulation, in a group of chronic stroke patients receiving functional electrical stimulation for foot-drop correction. Patients exhibited task-related activation in a complex network, sharing bilateral sensorimotor and supplementary motor activation with age-matched controls. We observed consistent separation of patients with and without carryover effect on the basis of brain responses. Patients who experienced the carryover effect had responses in supplementary motor area that correspond to healthy controls; the interaction between experimental factors in contralateral angular gyrus was seen only in those without carryover. We suggest that the functional electrical stimulation carryover mechanism of action is based on movement prediction and sense of agency/body ownership—the ability of a patient to plan the movement and to perceive the stimulation as a part of his/her own control loop is important for carryover effect to take place.
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Amatachaya S, Chuadthong J, Thaweewannaku T, Srisim K, Phonthee S. Levels of Community Ambulation Ability in Patients with Stroke Who Live in a Rural Area. Malays J Med Sci 2016; 23:56-62. [PMID: 27540326 PMCID: PMC4975589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 10/12/2015] [Indexed: 06/06/2023] Open
Abstract
BACKGROUND Community ambulation is essential for patients with stroke. Apart from treatments, an assessment with a quantitative target criterion is also important for patients to clearly demonstrate their functional alteration and determine how close they are to their goal, as well as for therapists to assess the effectiveness of the treatments. The existing quantitative target criteria for community ambulation were all derived from participants in a developed country and ability was assessed using a single-task test. To explore cutoff scores of the single-task and dual-task 10-meter walk test (10MWT) in ambulatory patients with stroke from rural areas of a developing country. METHODS Ninety-five participants with chronic stroke were interviewed concerning their community ambulation ability, and assessed for their walking ability using the single- and dual-task 10MWT. RESULTS A walking speed of at least 0.47 m/s assessed using the single-task 10MWT, and at least 0.30 m/s assessed using the dual-task 10MWT, could determine the community ambulation ability of the participants. CONCLUSION Distinct contexts and anthropometric characteristics required different target criteria for community walking. Thus, when establishing a target value for community ambulation, it needs to be specific to the demographics and geographical locations of the patients.
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Affiliation(s)
- Sugalya Amatachaya
- School of Physical Therapy, Faculty of Associated Medical Sciences, Khon Kaen University, Khon Kaen, 40002, Thailand
- Improvement of Physical Performance and Quality of Life (IPQ) research group, Khon Kaen University, Khon Kaen, 40002, Thailand
| | - Janya Chuadthong
- Improvement of Physical Performance and Quality of Life (IPQ) research group, Khon Kaen University, Khon Kaen, 40002, Thailand
- Department of Physical Therapy, School of Health Sciences, Mae Fah Luang University, Chiang Rai, 57100, Thailand
| | - Thiwabhorn Thaweewannaku
- School of Physical Therapy, Faculty of Associated Medical Sciences, Khon Kaen University, Khon Kaen, 40002, Thailand
- Improvement of Physical Performance and Quality of Life (IPQ) research group, Khon Kaen University, Khon Kaen, 40002, Thailand
| | - Kitiyawadee Srisim
- School of Physical Therapy, Faculty of Associated Medical Sciences, Khon Kaen University, Khon Kaen, 40002, Thailand
- Improvement of Physical Performance and Quality of Life (IPQ) research group, Khon Kaen University, Khon Kaen, 40002, Thailand
| | - Sirisuda Phonthee
- School of Physical Therapy, Faculty of Associated Medical Sciences, Khon Kaen University, Khon Kaen, 40002, Thailand
- Improvement of Physical Performance and Quality of Life (IPQ) research group, Khon Kaen University, Khon Kaen, 40002, Thailand
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Sureshkumar K, Murthy GVS, Munuswamy S, Goenka S, Kuper H. 'Care for Stroke', a web-based, smartphone-enabled educational intervention for management of physical disabilities following stroke: feasibility in the Indian context. ACTA ACUST UNITED AC 2015; 1:127-136. [PMID: 26246902 PMCID: PMC4516008 DOI: 10.1136/bmjinnov-2015-000056] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Accepted: 05/16/2015] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Stroke rehabilitation is a process targeted towards restoration or maintenance of the physical, mental, intellectual and social abilities of an individual affected by stroke. Unlike high-income countries, the resources for stroke rehabilitation are very limited in many low-income and middle-income countries (LMICs). Provision of cost-effective, post-stroke multidisciplinary rehabilitation services for the stroke survivors therefore becomes crucial to address the unmet needs and growing magnitude of disability experienced by the stroke survivors in LMICs. In order to meet the growing need for post-stroke rehabilitation services in India, we developed a web-based Smartphone-enabled educational intervention for management of physical disabilities following a stroke. METHODS On the basis of the findings from the rehabilitation needs assessment study, guidance from the expert group and available evidence from systematic reviews, the framework of the intervention content was designed. Web-based application designing and development by Professional application developers were subsequently undertaken. RESULTS The application is called 'Care for Stroke'. It is a web-based educational intervention for management of physical disabilities following a stroke. This intervention is developed for use by the Stroke survivors who have any kind of rehabilitation needs to independently participate in his/her family and social roles. DISCUSSION 'Care for stroke' is an innovative intervention which could be tested not just for its feasibility and acceptability but also for its clinical and cost-effectiveness through rigorously designed, randomised clinical trials. It is very important to test this intervention in LMICs where the rehabilitation and information needs of the stroke survivors seem to be substantial and largely unmet.
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Affiliation(s)
- K Sureshkumar
- International Centre for Evidence in Disability, London School of Hygiene and Tropical Medicine , London , UK
| | - G V S Murthy
- International Centre for Evidence in Disability, London School of Hygiene and Tropical Medicine , London , UK
| | - Suresh Munuswamy
- Institute of Public Health-Hyderabad , Hyderabad, Telangana , India
| | | | - Hannah Kuper
- International Centre for Evidence in Disability, London School of Hygiene and Tropical Medicine , London , UK
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Souza WC, Conforto AB, Orsini M, Stern A, André C. Similar Effects of Two Modified Constraint-Induced Therapy Protocols on Motor Impairment, Motor Function and Quality of Life in Patients with Chronic Stroke. Neurol Int 2015; 7:5430. [PMID: 26294941 PMCID: PMC4508540 DOI: 10.4081/ni.2015.5430] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Accepted: 01/03/2015] [Indexed: 01/05/2023] Open
Abstract
Modified constraint-induced movement therapy (CIMT) protocols show motor function and real-world arm use improvement. Meanwhile it usually requires constant supervision by physiotherapists and is therefore more expensive than customary care. This study compared the preliminary efficacy of two modified CIMT protocols. A two-group randomized controlled trial with pre and post treatment measures and six months follow-up was conducted. Nineteen patients with chronic stroke received 10 treatment sessions distributed three to four times a week over 22 days. CIMT3h_direct group received 3 hours of CIMT supervised by a therapist (n=10) while CIMT1.5h_direct group had 1.5 hours of supervised CIMT+1.5 hours home exercises supervised by a caregiver (n=9). Outcome measures were the Fugl-Meyer Assessment, the Motor Activity Log, and the Stroke Specific Quality of Life Scale. The modified CIMT protocols were feasible and well tolerated. Improvements in motor function, real-world arm use and quality of life did not differ significantly between treated groups receiving either 3 or 1.5 hours mCIMT supervised by a therapist.
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Affiliation(s)
- Wilma Costa Souza
- Federal University of Rio de Janeiro, Rehabilitation Center of Rio de Janeiro, Brazil
| | - Adriana B. Conforto
- Neurostimulation Laboratory, Hospital das Cĺinicas/São Paulo University, Brazil
| | - Marco Orsini
- Neurology Department, Centro Universitário Augusto Mottta, UNISUAM, Bonsucesso, Brazil
| | - Annette Stern
- School of Psychology, University of Surrey, Guildford, UK
| | - Charles André
- Department of Neurology, School of Medicine, Federal University of Rio de Janeiro, Brazil
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Rahman MH, Ochoa-Luna C, Saad M. EMG Based Control of a Robotic Exoskeleton for Shoulder and Elbow Motion Assist. ACTA ACUST UNITED AC 2015. [DOI: 10.12720/joace.3.4.270-276] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Koo YX, Kang ML, Auyong A, Liau GZ, Hoe J, Long M, Koh A, Koh F, Liu R, Koh G. Malnutrition in older adults on financial assistance in an urban Asian country: a mixed methods study. Public Health Nutr 2014; 17:2834-43. [PMID: 24008061 PMCID: PMC10282282 DOI: 10.1017/s1368980013002413] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2013] [Revised: 06/20/2013] [Accepted: 08/05/2013] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The objectives of the present study were to assess the nutritional status, identify factors for malnutrition risk and evaluate barriers to adequate nutrition among recipients of the Public Assistance (PA) scheme for socio-economically disadvantaged Singaporeans. DESIGN Using a cross-sectional study design, we assessed PA recipients' malnutrition risk using the DETERMINE Nutritional Health checklist and the full Mini-Nutritional Assessment (MNA), as well as their nutritional knowledge, co-morbidity burden, depression risk, instrumental and basic activities of daily living (IADL and BADL), and awareness and utilization of available food services. In-depth interviews were also conducted on malnourished individuals (MNA score < 17) to understand barriers to adequate nutrition. SETTING Homes of community-living older adults and nursing homes of institutionalized older adults. SUBJECTS All PA recipients aged ≥55 years in Central Singapore District. RESULTS Four hundred and sixty-five of 511 (91·0 %) eligible PA recipients participated in the study. The prevalence of malnutrition in the study population was 2·8 %. However, 50·3 % were at risk of malnutrition. Among community-dwelling respondents, the risk of malnutrition was independently associated with age >75 years, currently unmarried, BADL impairment, depression risk and BMI < 19·0 kg/m2. Qualitative analysis revealed that financial, social and physical barriers and lack of knowledge were the main contributors to poor nutritional status. Only half were aware of subsidized food services and education increased interest in utilizing food services. Among nursing home respondents, those who were BADL impaired were more likely to be at risk of malnutrition. CONCLUSIONS Among PA recipients, the prevalence of malnutrition is low but the risk of malnutrition is high. Education on adequate nutrition and food services are recommended.
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Affiliation(s)
- Yu Xuan Koo
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore
| | - Min Li Kang
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore
| | - Angie Auyong
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore
| | - Glen Zq Liau
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore
| | - Jeremy Hoe
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore
| | - Melody Long
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore
| | - Aaron Koh
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore
| | - Frederick Koh
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore
| | - Rain Liu
- Institute of Technical Education, Singapore
| | - Gerald Koh
- Saw Swee Hock School of Public Health, National University of Singapore, National University Health System, Block MD3, #03-20, 16 Medical Drive, 117597 Singapore
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The one-year attributable cost of post-stroke dysphagia. Dysphagia 2014; 29:545-52. [PMID: 24948438 DOI: 10.1007/s00455-014-9543-8] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2014] [Accepted: 05/22/2014] [Indexed: 10/25/2022]
Abstract
With the recent emphasis on evidence-based practice and healthcare reform, understanding the cost of dysphagia management has never been more important. It is helpful for clinicians to understand and objectively report the costs associated with dysphagia when they advocate for their services in this economy. Having carefully estimated cost of illness, inputs are needed for cost-effectiveness analyses that help support the value of treatments. This study sought to address this issue by examining the 1-year cost associated with a diagnosis of dysphagia post-stroke in South Carolina. Furthermore, this study investigated whether ethnicity and residence differences exist in the cost of dysphagia post-stroke. Data on 3,200 patients in the South Carolina Medicare database from 2004 who had ICD-9 codes for ischemic stroke, 434 and 436, were retrospectively included in this study. Differences between persons with and without dysphagia post-stroke were compared with respect to age, gender, ethnicity, mortality, length of stay, comorbidity, rurality, discharge disposition, and cost to Medicare. Univariate analyses and a gamma-distributed generalized linear multivariable model with a log link function were completed. We found that the 1-year cost to Medicare for persons with dysphagia post ischemic stroke was $4,510 higher than that for persons without dysphagia post ischemic stroke when controlling for age, comorbidities, ethnicity, and proportion of time alive. Univariate analysis revealed that rurality, ethnicity, and gender were not statistically significantly different in comparisons of individuals with or without dysphagia post-stroke. Post-stroke dysphagia significantly increases post-stroke medical expenses. Understanding the expenditures associated with post-stroke dysphagia is helpful for optimal allocation and use of resources. Such information is needed to conduct cost-effectiveness studies.
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Development of a whole arm wearable robotic exoskeleton for rehabilitation and to assist upper limb movements. ROBOTICA 2014. [DOI: 10.1017/s0263574714000034] [Citation(s) in RCA: 113] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
SUMMARYTo assist physically disabled people with impaired upper limb function, we have developed a new 7-DOF exoskeleton-type robot named Motion Assistive Robotic-Exoskeleton for Superior Extremity (ETS-MARSE) to ease daily upper limb movements and to provide effective rehabilitation therapy to the superior extremity. The ETS-MARSE comprises a shoulder motion support part, an elbow and forearm motion support part, and a wrist motion support part. It is designed to be worn on the lateral side of the upper limb in order to provide naturalistic movements of the shoulder (vertical and horizontal flexion/extension and internal/external rotation), elbow (flexion/extension), forearm (pronation/supination), and wrist joint (radial/ulnar deviation and flexion/extension). This paper focuses on the modeling, design, development, and control of the ETS-MARSE. Experiments were carried out with healthy male human subjects in whom trajectory tracking in the form of passive rehabilitation exercises (i.e., pre-programmed trajectories recommended by a therapist/clinician) were carried out. Experimental results show that the ETS-MARSE can efficiently perform passive rehabilitation therapy.
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Rodriguez-de-Pablo C, Perry JC, Cavallaro FI, Zabaleta H, Keller T. Development of computer games for assessment and training in post-stroke arm telerehabilitation. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2013; 2012:4571-4. [PMID: 23366945 DOI: 10.1109/embc.2012.6346984] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Stroke is the leading cause of long term disability among adults in industrialized nations. The majority of these disabilities include deficiencies in arm function, which can make independent living very difficult. Research shows that better results in rehabilitation are obtained when patients receive more intensive therapy. However this intensive therapy is currently too expensive to be provided by the public health system, and at home few patients perform the repetitive exercises recommended by their therapists. Computer games can provide an affordable, enjoyable, and effective way to intensify treatment, while keeping the patient as well as their therapists informed about their progress. This paper presents the study, design, implementation and user-testing of a set of computer games for at-home assessment and training of upper-limb motor impairment after stroke.
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Al Rahim M, Thatipamula S, Hossain MA. Critical role of neuronal pentraxin 1 in mitochondria-mediated hypoxic-ischemic neuronal injury. Neurobiol Dis 2012; 50:59-68. [PMID: 23069675 DOI: 10.1016/j.nbd.2012.10.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2012] [Revised: 09/07/2012] [Accepted: 10/03/2012] [Indexed: 12/24/2022] Open
Abstract
Developing brain is highly susceptible to hypoxic-ischemic (HI) injury leading to severe neurological disabilities in surviving infants and children. Previously, we have reported induction of neuronal pentraxin 1 (NP1), a novel neuronal protein of long-pentraxin family, following HI neuronal injury. Here, we investigated how this specific signal is propagated to cause the HI neuronal death. We used wild-type (WT) and NP1 knockout (NP1-KO) mouse hippocampal cultures, modeled in vitro following exposure to oxygen glucose deprivation (OGD), and in vivo neonatal (P9-10) mouse model of HI brain injury. Our results show induction of NP1 in primary hippocampal neurons following OGD exposure (4-8 h) and in the ipsilateral hippocampal CA1 and CA3 regions at 24-48 h post-HI compared to the contralateral side. We also found increased PTEN activity concurrent with OGD time-dependent (4-8 h) dephosphorylation of Akt (Ser473) and GSK-3β (Ser9). OGD also caused a time-dependent decrease in the phosphorylation of Bad (Ser136), and Bax protein levels. Immunofluorescence staining and subcellular fractionation analyses revealed increased mitochondrial translocation of Bad and Bax proteins from cytoplasm following OGD (4 h) and simultaneously increased release of Cyt C from mitochondria followed by activation of caspase-3. NP1 protein was immunoprecipitated with Bad and Bax proteins; OGD caused increased interactions of NP1 with Bad and Bax, thereby, facilitating their mitochondrial translocation and dissipation of mitochondrial membrane potential (ΔΨ(m)). This NP1 induction preceded the increased mitochondrial release of cytochrome C (Cyt C) into the cytosol, activation of caspase-3 and OGD time-dependent cell death in WT primary hippocampal neurons. In contrast, in NP1-KO neurons there was no translocation of Bad and Bax from cytosol to the mitochondria, and no evidence of ΔΨ(m) loss, increased Cyt C release and caspase-3 activation following OGD; which resulted in significantly reduced neuronal death. Our results indicate a regulatory role of NP1 in Bad/Bax-dependent mitochondrial release of Cyt C and caspase-3 activation. Together our findings demonstrate a novel mechanism by which NP1 regulates mitochondria-driven hippocampal cell death; suggesting NP1 as a potential therapeutic target against HI brain injury in neonates.
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Affiliation(s)
- Md Al Rahim
- Hugo W. Moser Research Institute at Kennedy Krieger, Baltimore, MD 21205, USA
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Effect of duration, participation rate, and supervision during community rehabilitation on functional outcomes in the first poststroke year in Singapore. Arch Phys Med Rehabil 2012; 93:279-86. [PMID: 22289238 DOI: 10.1016/j.apmr.2011.08.017] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2010] [Revised: 08/09/2011] [Accepted: 08/15/2011] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To examine the effect of duration, participation rate, and supervision during community rehabilitation on functional outcome during the first poststroke year. DESIGN Prospective longitudinal study with interviews at admission, discharge, 1 month, 6 months, and 1 year after discharge. SETTING Two subacute inpatient rehabilitation units and the community after discharge in Singapore. PARTICIPANTS Subacute nonaphasic stroke patients (N=215). INTERVENTION Participation rate in supervised therapy (at an outpatient rehabilitation center) and unsupervised therapy (at home) as defined as proportion of time performing therapy as prescribed by the subacute hospital's multidisciplinary rehabilitation team at discharge. MAIN OUTCOME MEASURE Performance of activities of daily living as measured by Barthel Index (BI) score at 1 year and improvement in BI scores between adjacent timepoints. RESULTS At 1 month after discharge, 33.3% were performing supervised therapy more than 25% of the recommended time, and 66.3% of subjects were performing unsupervised therapy more than 75% of the recommended time. On a mixed-model analysis, the independent predictors of lower BI scores were older age, hypertension, greater cognitive impairment, greater depressive symptoms, and greater neurologic impairment. Adjusting for these independent factors, performance of supervised therapy at 1 (β=8.8; 95% confidence interval [CI], 0.5-17.0; P=.039) and 6 (β=20.1; 95% CI, 11.0-29.2; P<.001) months postdischarge, but not unsupervised therapy, predicted better BI score at 1 year. Those who performed supervised therapy more than 25% of the recommended time achieved their maximal functional recovery faster than those who performed supervised therapy 25% or less of the recommended time (1 mo vs 6 mo). CONCLUSIONS Supervised stroke rehabilitation in the community at 1 and 6 months was associated with better functional status at 1 year than unsupervised therapy, and a higher participation rate in supervised therapy was associated with greater and faster functional recovery.
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Smith AL, Staines WR. Externally cued inphase bimanual training enhances preparatory premotor activity. Clin Neurophysiol 2012; 123:1846-57. [PMID: 22401934 DOI: 10.1016/j.clinph.2012.02.060] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2011] [Revised: 02/01/2012] [Accepted: 02/03/2012] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Previous studies have demonstrated that cortical potentials representing motor preparation for visually-cued movements are enhanced following a single session of visually-cued bimanual movement training (BMT). The neuroanatomical sources that contribute to these rapid training-induced adaptations were unclear. To address this, we compared cortical potentials associated with motor preparation for visually-cued (movement-related potential, MRP) and self-paced (Bereitschaftspotential, BP) movements and investigated adaptations of these following BMT. METHODS EEG recorded the cued MRP and self-paced BP during two experiments. In experiment one, pre and post self-paced unimanual trials were interspersed with cued inphase BMT. In experiment two, self-paced and visually-cued movement trials were performed to assess the differences between and the contributing neural sources to the cued MRP and self-paced BP. RESULTS Inphase BMT does not affect the early BP. Source localization analysis revealed that the preparatory portion of the cued MRP and self-paced BP are generated by the lateral premotor cortex and the supplementary motor area, respectively. CONCLUSIONS The early cued MRP and self-paced BP have unique cortical generators and are independently modulated by specific training types. SIGNIFICANCE These novel findings have implications for interpreting rapid, single-session, training adaptations previously observed. These cortical potentials may also be useful measurement tools to gauge within-session cortical modulations in response to specific modes of rehabilitative training in the stroke population.
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Affiliation(s)
- Alison L Smith
- Department of Kinesiology, University of Waterloo, Waterloo, Canada
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Afendulis CC, Kessler DP. Vertical integration and optimal reimbursement policy. INTERNATIONAL JOURNAL OF HEALTH CARE FINANCE AND ECONOMICS 2011; 11:165-79. [PMID: 21850551 PMCID: PMC3195424 DOI: 10.1007/s10754-011-9095-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2010] [Accepted: 07/25/2011] [Indexed: 10/17/2022]
Abstract
Health care providers may vertically integrate not only to facilitate coordination of care, but also for strategic reasons that may not be in patients' best interests. Optimal Medicare reimbursement policy depends upon the extent to which each of these explanations is correct. To investigate, we compare the consequences of the 1997 adoption of prospective payment for skilled nursing facilities (SNF PPS) in geographic areas with high versus low levels of hospital/SNF integration. We find that SNF PPS decreased spending more in high integration areas, with no measurable consequences for patient health outcomes. Our findings suggest that integrated providers should face higher-powered reimbursement incentives, i.e., less cost-sharing. More generally, we conclude that purchasers of health services (and other services subject to agency problems) should consider the organizational form of their suppliers when choosing a reimbursement mechanism.
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Affiliation(s)
| | - Daniel P. Kessler
- Stanford University Law School, Graduate School of Business, and Hoover Institution, Stanford, CA, USA, The National Bureau of Economic Research, Cambridge, MA, USA
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Movement therapy induced neural reorganization and motor recovery in stroke: a review. J Bodyw Mov Ther 2011; 15:528-37. [PMID: 21943628 DOI: 10.1016/j.jbmt.2011.01.023] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2010] [Revised: 01/22/2011] [Accepted: 01/29/2011] [Indexed: 11/22/2022]
Abstract
This paper is a review conducted to provide an overview of accumulated evidence on contemporary rehabilitation methods for stroke survivors. Loss of functional movement is a common consequence of stroke for which a wide range of interventions has been developed. Traditional therapeutic approaches have shown limited results for motor deficits as well as lack evidence for their effectiveness. Stroke rehabilitation is now based on the evidence of neuroplasticity, which is responsible for recovery following stroke. The neuroplastic changes in the structure and function of relevant brain areas are induced primarily by specific rehabilitation methods. The therapeutic method which induces neuroplastic changes, leads to greater motor and functional recovery than traditional methods. Further, the recovery is permanent in nature. During the last decade various novel stroke rehabilitative methods for motor recovery have been developed. This review focuses on the methods that have evidence of associated cortical level reorganization, namely task-specific training, constraint-induced movement therapy, robotic training, mental imaging, and virtual training. All of these methods utilize principles of motor learning. The findings from this review demonstrated convincing evidence both at the neural and functional level in response to such therapies. The main aim of the review was to determine the evidence for these methods and their application into clinical practice.
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Verma R, Arya KN, Sharma P, Garg RK. Understanding gait control in post-stroke: implications for management. J Bodyw Mov Ther 2010; 16:14-21. [PMID: 22196422 DOI: 10.1016/j.jbmt.2010.12.005] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2010] [Revised: 12/02/2010] [Accepted: 12/03/2010] [Indexed: 10/18/2022]
Abstract
The role of the brain in post-stroke gait is not understood properly, although the ability to walk becomes impaired in more than 80% of post-stroke patients. Most, however, regain some ability to walk with either limited mobility or inefficient, asymmetrical or unsafe gait. Conventional intervention focuses on support of weak muscles or body part by use of foot orthosis and walking aids. This review provides an overview of available evidence of neuro-kinesiology & neurophysiology of normal and post-stroke gait. The role of the spinal cord has been explored, more in animals than humans. Mammalian locomotion is based on a rhythmic, "pacemaker" activity of the spinal stepping generators. Bipedal human locomotion is different from quadripedal animal locomotion. However, knowledge derived from the spinal cord investigation of animals, is being applied for management of human gait dysfunction. The potential role of the brain is now recognized in the independent activation of muscles during walking. The brain modifies the gait pattern during the complex demands of daily activities. Though the exact role of the motor cortex in control of gait is unclear, available evidence may be applied to gait rehabilitation of post-stroke patients.
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Affiliation(s)
- Rajesh Verma
- Department of Neurology, CSM Medical University (KGMU), Lucknow 226003, UP, India
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Family functioning is associated with depressive symptoms in caregivers of acute stroke survivors. Arch Phys Med Rehabil 2009; 90:947-55. [PMID: 19480870 DOI: 10.1016/j.apmr.2008.12.014] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2008] [Revised: 12/11/2008] [Accepted: 12/13/2008] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To determine whether family functioning is uniquely associated with caregiver depressive symptoms in the immediate aftermath of stroke. DESIGN Cross-sectional data from the baseline assessment of an intervention study for stroke survivors and their families. SETTING Neurology inpatient service of a large urban hospital. PARTICIPANTS Stroke survivors (n=192), each with a primary caregiver. The mean age of stroke survivors was 66 years, and most, 57%, were men (n=110). The mean age of caregivers was 57 years, and 73% (n=140) of the caregivers were women. Eighty-five percent of caregivers were white. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Measures were chosen to assess caregivers' depressive symptoms (Centers for Epidemiologic Studies Depression Scale), family functioning (Family Assessment Device), and additional factors such as health status (Medical Outcomes Study 36-Item Short-Form Health Survey) and stroke survivors' cognitive abilities (modified Mini-Mental State Examination) and functional impairments (FIM and Frenchay Activities Index). RESULTS Depressive symptoms were mild to moderate in 14% and severe in 27% of caregivers. Family functioning was assessed as unhealthy in 34% of caregiver-patient dyads. In statistical regression models, caregiver depression was associated with patients' sex, caregivers' general health, and family functioning. CONCLUSIONS Forty-one percent of caregivers experienced prominent depressive symptoms after their family member's stroke. Higher depression severity in caregivers was associated with caring for a man, and having worse health and poor family functioning. After stroke, the assessment of caregivers' health and family functioning may help determine which caregivers are most at risk for a depressive syndrome.
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Mas MA, Renom A, Vazquez O, Miralles R, Bayer AJ, Cervera AM. Interruptions to rehabilitation in a geriatric rehabilitation unit: associated factors and consequences. Age Ageing 2009; 38:346-9. [PMID: 19252203 DOI: 10.1093/ageing/afp010] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- M A Mas
- Department of Geriatric Medicine of Institut Municipal d'Assistència Sanitària, Hospital del Mar, Institut d'Atenció Geriàtrica i Sociosanitària, Barcelona, Catalonia, Spain
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Rensink M, Schuurmans M, Lindeman E, Hafsteinsdóttir T. Task-oriented training in rehabilitation after stroke: systematic review. J Adv Nurs 2009; 65:737-54. [PMID: 19228241 DOI: 10.1111/j.1365-2648.2008.04925.x] [Citation(s) in RCA: 125] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIM This paper is a report of a review conducted to provide an overview of the evidence in the literature on task-oriented training of stroke survivors and its relevance in daily nursing practice. BACKGROUND Stroke is the second leading cause of death and one of the leading causes of adult disability in the Western world. The use of neurodevelopmental treatment in the daily nursing care of stroke survivors does not improve clinical outcomes. Nurses are therefore exploring other forms of rehabilitation intervention, including task-oriented rehabilitation. Despite the growing number of studies showing evidence on task-oriented interventions, recommendations for daily nursing practice are lacking. DATA SOURCES A range of databases was searched to identify papers addressing task-oriented training in stroke rehabilitation, including Medline, CINAHL, Embase and the Cochrane Library of systematic reviews. Papers published in English between January 1996 and September 2007 were included. There were 42 papers in the final dataset, including nine systematic reviews. REVIEW METHODS The selected randomized controlled trials and systematic reviews were assessed for quality. Important characteristics and outcomes were extracted and summarized. RESULTS Studies of task-related training showed benefits for functional outcome compared with traditional therapies. Active use of task-oriented training with stroke survivors will lead to improvements in functional outcomes and overall health-related quality of life. CONCLUSION Generally, task-oriented rehabilitation proved to be more effective. Many interventions are feasible for nurses and can be performed in a ward or at home. Nurses can and should play an important role in creating opportunities to practise meaningful functional tasks outside of regular therapy sessions.
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Affiliation(s)
- Marijke Rensink
- Care for elderly and chronically ill, University of Applied Sciences, Utrecht, The Netherlands.
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Gupta A, O'Malley MK, Patoglu V, Burgar C. Design, Control and Performance of RiceWrist: A Force Feedback Wrist Exoskeleton for Rehabilitation and Training. Int J Rob Res 2008. [DOI: 10.1177/0278364907084261] [Citation(s) in RCA: 170] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This paper presents the design, control and performance of a high fidelity four degree-of-freedom wrist exoskeleton robot, RiceWrist, for training and rehabilitation. The RiceWrist is intended to provide kinesthetic feedback during the training of motor skills or rehabilitation of reaching movements. Motivation for such applications is based on findings that show robot-assisted physical therapy aids in the rehabilitation process following neurological injuries. The exoskeleton device accommodates forearm supination and pronation, wrist flexion and extension and radial and ulnar deviation in a compact parallel mechanism design with low friction, zero backlash and high stiffness. As compared to other exoskeleton devices, the RiceWrist allows easy measurement of human joint angles and independent kinesthetic feedback to individual human joints. In this paper, joint-space as well as task-space position controllers and an impedance-based force controller for the device are presented. The kinematic performance of the device is characterized in terms of its workspace, singularities, manipulability, backlash and backdrivability. The dynamic performance of RiceWrist is characterized in terms of motor torque output, joint friction, step responses, behavior under closed loop set-point and trajectory tracking control and display of virtual walls. The device is singularity-free, encompasses most of the natural workspace of the human joints and exhibits low friction, zero-backlash and high manipulability, which are kinematic properties that characterize a high-quality impedance display device. In addition, the device displays fast, accurate response under position control that matches human actuation bandwidth and the capability to display sufficiently hard contact with little coupling between controlled degrees-of-freedom.
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Affiliation(s)
- Abhishek Gupta
- Department of Mechanical Engineering and Materials Science Rice University, Houston, TX 77005, USA,
| | - Marcia K. O'Malley
- Department of Mechanical Engineering and Materials Science Rice University, Houston, TX 77005, USA,
| | - Volkan Patoglu
- Faculty of Engineering and Natural Sciences Sabanci University Tuzla, Istanbul 34956, Turkey,
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Saxena SK, Ng TP, Yong D, Fong NP, Koh G. Subthreshold depression and cognitive impairment but not demented in stroke patients during their rehabilitation. Acta Neurol Scand 2008; 117:133-40. [PMID: 18184349 DOI: 10.1111/j.1600-0404.2007.00922.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Subthreshold depression (sD) and cognitive impairment but not demented (CIND) in stroke patients are associated with poorer rehabilitative outcomes. Their diagnosis can easily be operationalized using validated scales. AIM The aim of the study was to ascertain the prevalence of depressive symptoms and cognitive impairment in stroke patients during three crucial stages of the rehabilitative process, viz. upon admission, upon planned discharges from rehabilitation hospitals and at 6 months post-stroke, using validated scales like the Geriatric Depression Scale and Abbreviated Mental Test (recommended by the British Geriatric Society). Their baseline risk factors were also ascertained. RESULTS On admission, the prevalence of depressive symptoms and cognitive impairment was 60% and 54% respectively. The prevalence upon planned discharges and 6 months post-stroke, respectively, of depressive symptoms was 38% and 34% and that of impaired cognition was 33% and 40%. Baseline independent correlates at 6 months post-stroke depressive symptoms were: recurrent stroke (OR 3.34); on admission cognitive impairment (OR 4.78) and ADL dependence (OR 5.28). And that of cognitive impairment were: increasing age (OR 8.07); post-stroke dysphagia (OR 4.58); on admission cognitive impairment (OR 23.95) and on admission depressive symptoms (OR 3.50). CONCLUSIONS Continuous screening and appropriate intervention, especially at baseline, would significantly decrease the burden posed by stroke patients with such psychological impairments in the community.
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Saxena SK, Ng TP, Koh G, Yong D, Fong NP. Is improvement in impaired cognition and depressive symptoms in post-stroke patients associated with recovery in activities of daily living? Acta Neurol Scand 2007; 115:339-46. [PMID: 17489945 DOI: 10.1111/j.1600-0404.2006.00751.x] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE Depression and cognitive impairment after stroke are associated with physical functional outcomes, but there are limited data on whether depressive symptoms and cognitive status and improvements independently influence functional status and recovery. METHODS In a 6-month prospective cohort study of 141 post-acute stroke patients, demographic and clinical data on admission, and neurological, cognitive, depressive symptoms and functional variables on admission and at 6 months after stroke were measured using the National Institute of Health Stroke Scale (NIHSS), Abbreviated Mental Test (AMT), Geriatric Depression Scale (GDS) and Barthel Index (BI). RESULTS On multivariate analysis, severe activities of daily living (ADL) dependence at 6 months was significantly less likely associated with higher baseline AMT score denoting better cognitive status (OR=0.68, 95% CI 0.48-0.97 per score point) and with greater AMT change score denoting greater cognitive improvement (OR=0.61, 95% CI 0.41-0.91 per change score point); it was also more likely with higher baseline NIHSS scores denoting severe neurological impairment, (OR=1.74, 95% CI 1.13-2.63 per point score), NIHSS change score [denoting lesser neurological improvement (OR = 1.83, 95% CI 1.13-2.93 per unit change score)], but was not associated with baseline or change scores of GDS. Greater magnitudes of functional recovery [BI change score (standardized beta)] were associated with better baseline depressive symptoms (-0.21) and improvement (-0.31), but not with cognitive status or improvement, in the presence of other significant variables, neurological status (-0.89) and improvement (-0.65), lower baseline physical functional status (-0.85) and younger age (-0.23). CONCLUSIONS These data suggest that improving depressive symptoms in stroke patients may accelerate functional recovery, but the level of physical functioning achieved post-stroke is determined by neurological and cognitive factors, consistent with the evidence that improvement of depressive symptoms through therapeutic intervention is limited by cognitive impairment.
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Affiliation(s)
- S K Saxena
- National Disease Registries Office, Health Promotion Board, Singapore.
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Cameron JI, Cheung AM, Streiner DL, Coyte PC, Stewart DE. Stroke Survivors’ Behavioral and Psychologic Symptoms Are Associated With Informal Caregivers’ Experiences of Depression. Arch Phys Med Rehabil 2006; 87:177-83. [PMID: 16442969 DOI: 10.1016/j.apmr.2005.10.012] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2005] [Revised: 09/01/2005] [Accepted: 10/16/2005] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To determine the impact of stroke survivors' behavioral and psychologic symptoms (BPS) on informal caregivers' experience of depression in the context of the caregiving situation. DESIGN Cross-sectional survey using a structured quantitative interview. SETTING Rehabilitation facility outpatient clinic, tertiary care facility outpatient clinic, and community care organizations. PARTICIPANTS Ninety-four informal caregivers to stroke survivors completed standardized measurement instruments. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Measurement instruments included the Center for Epidemiological Studies Depression Scale, Brain Impairment Behavior Inventory-Revised, Caregiver Assistance Scale, Caregiving Impact Scale, and Mastery scale. RESULTS A substantial percentage (44.7%) of caregivers were at risk of clinical depression. Caregivers experienced more depression symptoms when they cared for stroke survivors exhibiting more BPS of memory and comprehension difficulties, provided less assistance, experienced more lifestyle interference, and had lower mastery (F(5,85)=26.02, P<.001, adjusted R(2)=.58). CONCLUSIONS BPS exhibited by stroke survivors contribute to informal caregivers' experience of depression. These results can assist rehabilitation professionals to identify informal care providers who are at greater risk of experiencing emotional distress and, therefore, may benefit from intervention.
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Affiliation(s)
- Jill I Cameron
- Toronto Rehabilitation Institute, University of Toronto, ON, Canada
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Wells JL, Dumbrell AC. Nutrition and aging: assessment and treatment of compromised nutritional status in frail elderly patients. Clin Interv Aging 2006; 1:67-79. [PMID: 18047259 PMCID: PMC2682454 DOI: 10.2147/ciia.2006.1.1.67] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Nutrition is an important determinant of health in persons over the age of 65. Malnutrition in the elderly is often underdiagnosed. Careful nutritional assessment is necessary for both the successful diagnosis and development of comprehensive treatment plans for malnutrition in this population. The purpose of this article is to provide clinicians with an educational overview of this essential but often underecognized aspect of geriatric assessment. This article will review some common issues in nutrition for the elderly in both hospital and community settings. The complexity and impact of multiple comorbidities on the successful nutritional assessment of elderly patients is highlighted by using case scenarios to discuss nutritional issues common to elderly patients and nutritional assessment tools. Three case studies provide some context for an overview of these issues, which include the physiology of aging, weight loss, protein undernutrition, impaired cognition, malnutrition during hospitalization, screening procedures, and general dietary recommendations for patients 65 years of age and older.
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Affiliation(s)
- Jennie L Wells
- Division of Geriatric Medicine, Department of Medicine, University of Western Ontario, London, ON, Canada.
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Murray CD, Harrison B. The meaning and experience of being a stroke survivor: an interpretative phenomenological analysis. Disabil Rehabil 2004; 26:808-16. [PMID: 15371053 DOI: 10.1080/09638280410001696746] [Citation(s) in RCA: 86] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE To investigate the meaning and experience of being a stroke survivor. METHOD Qualitative in-depth semi-structured interviews were conducted with 10 stroke survivors (five face-to-face and five e-mail interviews). The interview data were transcribed verbatim (these were pre-transcribed in e-mail exchange) and analysed using Interpretative Phenomenological Analysis. RESULTS Four themes emerged from the analysis: Disrupted embodiment and the loss of self; Invisibility of emotional difficulties; Gender, romance and sexuality; and Social interaction. These themes, respectively, revealed that participants often had difficulties with psychological adaptation to the physically disabling aspects of their stroke; they experienced enduring and disabling emotional difficulties; they had a particular concern for the viability and maintenance of romantic and sexual relationships; and they often became socially withdrawn, resulting in an increased pressure on familial caregivers. CONCLUSION The findings of the present work suggest the need for post-stroke counselling regarding romantic and sexual relationships, as well as promoting acceptance of some of the physical disabilities that come with having a stroke and encouraging positive self-regard. There would also appear to be a need to address the issue of social withdrawal and familial relationships, perhaps when health professionals convey information regarding the person's stroke, and in counselling targeted specifically at family caregivers.
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Affiliation(s)
- C D Murray
- Department of Psychology, Liverpool Hope University College, UK.
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Weiss Z, Snir D, Klein B, Avraham I, Shani R, Zetler H, Eyal P, Dynia A, Eldar R. Effectiveness of home rehabilitation after stroke in Israel. Int J Rehabil Res 2004; 27:119-25. [PMID: 15167109 DOI: 10.1097/01.mrr.0000128059.54064.58] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
On discharge from an acute general hospital after a stroke, 191 patients were in need of, and were appropriate for, multidisciplinary rehabilitation. One-hundred-and-one patients (52.4%) received it in a rehabilitation institution as inpatients (the institutional rehabilitation group (IR) group) and 91 patients received it at home (the home rehabilitation (HR) group). Patients in the HR group had their mobility, activities of daily living (ADL), range of movements, tonus, coordination and sensation determined on admission to home rehabilitation and on discharge from it, 6 weeks to 2 months later. This group contained more women and more patients able to walk with devices and who were partially independent in ADL. The IR group consisted of more men and more patients with diabetes and marked difficulties in ADL and ambulation. In both groups the Barthel index and the Frenchay activities index were determined 1 year after the stroke by way of a telephone interview and no meaningful differences were found between the two groups. IR was considerably more expensive than HR. In Israel there exists a subpopulation of acute stroke survivors in need of, and appropriate for, multidisciplinary rehabilitation that can be provided at home; such rehabilitation was found to be effective in the short and long term, as well as cost effective.
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Affiliation(s)
- Zwi Weiss
- Ha'Emek Medical Centre, Israel Institute of Technology, Haifa, Israel
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Eijkenboom M, Gerlach I, Barker A, Luiten P, van der Staay FJ. Chronic cognitive effects of bilateral subdural haematomas in the rat. Neuroscience 2004; 124:523-33. [PMID: 14980724 DOI: 10.1016/j.neuroscience.2003.11.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2003] [Indexed: 11/26/2022]
Abstract
Humans suffering from subdural haematomas often show long-term cognitive dysfunctions. For identifying putative, recovery-enhancing therapeutics, animal models need to be developed in which recovery of function can be measured. For investigating whether and which type of recovery, i.e. spontaneous or training-induced recovery, or continuous partial retardation, is present in the rat model for bilateral subdural haematomas, spatial navigation abilities were assessed in the Morris water escape task in independent groups of rats at 1, 2, 4, 8, or 18 weeks after surgery. Complete spontaneous recovery seemed to occur at 8 weeks after injury. However, at 18 weeks after injury, the subdural haematoma caused a renewed deterioration of water maze performance, which was of a lesser degree than the impairments observed immediately after injury. This second phase performance deterioration was accompanied by an increase in generalised astrocyte reactivity. The rat subdural haematoma model provides an interesting tool for investigating spontaneous recovery processes of spatial navigation (8 weeks after injury), but also for progressive brain dysfunctions, considering the second phase of behavioural impairments seen at 18 weeks after injury.
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Affiliation(s)
- M Eijkenboom
- Central Nervous System Research, Bayer Healthcare, Aprather Weg 18a, 42906 Wuppertal, Germany.
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Aichner F, Adelwöhrer C, Haring HP. Rehabilitation approaches to stroke. JOURNAL OF NEURAL TRANSMISSION. SUPPLEMENTUM 2003:59-73. [PMID: 12597609 DOI: 10.1007/978-3-7091-6137-1_4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
This article describes the state of the science in stroke rehabilitation dealing with three main topics: (1) General approach to stroke rehabilitation (stroke services and stroke units), (2) Neurophysiological and pharmacological interventions (facilitation of brain repair mechanisms) and (3) Experimental approaches (neuronal transplantation). Stroke rehabilitation is an active process beginning during acute hospitalisation, progressing to a systematic program of rehabilitation services and continuing after the individual returns to the community. There is world-wide consensus that stroke patients should be treated at specialised stroke unit with specially trained medical and nursing staff, co-ordinated multidisciplinary rehabilitation and education programs for patients and their families. Stroke Unit has been shown to be associated with a long-term reduction of death and of the combined poor outcomes of death and dependency, independent of patients age, sex, or variations in stroke unit organisations. No study has clearly shown to what extent the beneficial effect is due to specific rehabilitation strategies. New imaging studies in stroke patients indicate altered post stroke activation patterns, which suggest some functional reorganisation. Reorganisation may be the principle process responsible for recovery after stroke. It is assumed that different post ischaemic interventions like physiotherapy, occupational therapy, speech therapy, electrical stimulation, etc. facilitates such changes. Scientific evidence demonstrating the values of specific rehabilitation interventions after stroke is limited. Comparisons between different methods in current use have so far mostly failed to show that any particular physiotherapy, occupational therapy, speech therapy or stroke rehabilitation strategy is superior to another. Clinical data are strongly in favour of early mobilisation and training. Pharmacological interventions in animals revealed that norepinephrine, amphetamine and other alpha-adrenergic stimulating drugs can enhance motor performance after unilateral ablation of the sensory motor cortex. The clinical data in humans are rather contradictory. Neural grafting and neurogenesis are new potential modes of stroke therapy. Neural grafting enhanced functional outcome and reduced thalamic atrophy in rats only when combined with housing in enriched environments. Recent studies have shown that stem cells can differentiate to neurons in the adult human dentate gyrus in vivo.
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Affiliation(s)
- F Aichner
- Department of Neurology, Wagner-Jauregg Hospital, Linz, Teaching Hospital, University Innsbruck, Linz, Austria.
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Abstract
This article discusses stroke, the third leading cause of death and number one cause of adult disability in the United States, inflicting a devastating physical, emotional, and financial toll on its victims and their families. The last decade has seen the emergence of new treatments for acute stroke, energizing stroke care providers and spreading a sense of optimism among them. Because effective stroke treatment is extremely time-dependent, it is paramount that emergency physicians understand and excel in their critical role at the forefront of stroke management. This article outlines the emergent evaluation and management of acute ischemic stroke, emphasizing the importance of the emergency physician in acute stroke treatment.
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Affiliation(s)
- R Jason Thurman
- Department of Emergency Medicine, University of Cincinnati, 231 Albert B. Sabin Way, Cincinnati, OH 45267-0769, USA.
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van der Smagt-Duijnstee M, Hamers JP, Abu-Saad HH. Relatives of stroke patients--their experiences and needs in hospital. Scand J Caring Sci 2002; 14:44-51. [PMID: 12035262 DOI: 10.1111/j.1471-6712.2000.tb00560.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
This study explores the experiences and needs of relatives of hospitalized stroke patients. In semi-structured interviews, 17 relatives of stroke patients were asked about their experiences during the hospitalization period. The interviews were analysed by thematic content analysis. The findings indicate that the experiences of the relatives change during the hospitalization period, and that they are influenced by four factors: the individual character of the relatives, the position of the patient, the people in the relatives' social environment and the hospital situation. Four categories of needs were also found: the need for information, communication, support and accessibility.
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Abstract
Despite continued advances in prevention and treatment, stroke remains the leading cause of neurologic disability. This article reviews the broad spectrum of palliative efforts underway to treat the impairment and disability that results from stroke. Emphasis is placed on the importance of symptom control, increasing compensation, and enhancing residual and recovering function in patients with stroke. New approaches to impairment reduction have produced encouraging results, but disability reduction remains the cornerstone of care.
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Affiliation(s)
- B T Volpe
- Department of Neurology and Neuroscience, Burke Medical Research Institute, Weill Medical College of Cornell University, White Plains, New York 10605, USA.
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Paolucci S, Grasso MG, Antonucci G, Bragoni M, Troisi E, Morelli D, Coiro P, De Angelis D, Rizzi F. Mobility status after inpatient stroke rehabilitation: 1-year follow-up and prognostic factors. Arch Phys Med Rehabil 2001; 82:2-8. [PMID: 11239278 DOI: 10.1053/apmr.2001.18585] [Citation(s) in RCA: 92] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To evaluate the stability of mobility status achieved by stroke patients during hospital rehabilitation treatment over time and to identify reliable prognostic factors associated with mobility changes. DESIGN Follow-up evaluation in consecutive first-ever stroke patients 1 year after hospital discharge. Multiple logistic regressions were used to analyze increases and decreases in Rivermead Mobility Index (RMI) scores (dependent variables) between discharge and follow-up. Independent variables were medical, demographic, and social factors. SETTING Rehabilitation hospital. PATIENTS A cohort of 155 patients with sequelae of first stroke, with a final sample of 141. MAIN OUTCOME MEASURES Mobility status at 1-year follow-up, as measured by the RMI, and odds ratios (OR) for improvement and decline in mobility. RESULTS Functionally, 19.9% improved the mobility levels achieved during the inpatient rehabilitation treatment; levels of 42.6% worsened. Patients with global aphasia (OR = 5.66; 95% confidence interval [CI], 1.50-21.33), unilateral neglect (OR = 3.01; 95% CI, 1.21-7.50), and age 75 years or older (OR = 5.77; 95% CI, 1.42-23.34) had a higher probability of mobility decline than the remaining patients. Postdischarge rehabilitation treatment (PDT), received by 52.5% of the final sample, was significantly and positively associated with mobility improvement (OR = 5.86; 95% CI, 2.02-17.00). Absence of PDT was associated with a decline in mobility (OR = 3.73; 95% CI, 1.73-8.04). CONCLUSIONS In most cases, mobility status had not yet stabilized at hospital discharge. PDT was useful in preventing a deterioration in mobility improvement achieved during inpatient treatment and in helping increase the likelihood of further mobility improvement.
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Affiliation(s)
- S Paolucci
- Fondazione IRCCS Santa Lucia, Rome, Italy.
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Affiliation(s)
- T Brott
- Department of Neurology, Mayo Clinic, Jacksonville, Fla 32224, USA.
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Paolucci S, Antonucci G, Grasso MG, Morelli D, Troisi E, Coiro P, Bragoni M. Early versus delayed inpatient stroke rehabilitation: a matched comparison conducted in Italy. Arch Phys Med Rehabil 2000; 81:695-700. [PMID: 10857508 DOI: 10.1016/s0003-9993(00)90095-9] [Citation(s) in RCA: 169] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To assess the specific influence of onset-admission interval (OAI) on rehabilitation results. DESIGN A case-control study in consecutive stroke inpatients, enrolled in homogeneous subgroups, matched for age (within 1 year) and Barthel Index (BI) score at admission, and different for OAI to the rehabilitation ward. The short OAI group began rehabilitation treatment within the first 20 days from stroke, medium OAI group between days 21 and 40, and long OAI between days 41 and 60. SETTING Rehabilitation hospital. PATIENTS One hundred forty-five patients with sequelae of first stroke. MAIN OUTCOME MEASURES Efficiency (average increase in BI per day), effectiveness (proportion of potential improvement achieved during rehabilitation) of treatment, and percentage of low- and high-response patients, calculated on BI, were evaluated. Odds ratios (ORs) of dropouts and of poor and excellent therapeutic response were also quantified. RESULTS The short OAI subgroup had significantly higher effectiveness of treatment than did the medium (p < .05) and the long OAI groups (p < .005). Beginning treatment within the first 20 days was associated with a significantly high probability of excellent therapeutic response (OR = 6.11; 95% confidence interval [CI], 2.03-18.36), and beginning later was associated with a similar risk of poor response (OR = 5.18; 95% CI, 1.07-25.00). On the other hand, early intervention was associated with a five times greater risk of dropout than that of patients with delayed start of treatment (OR = 4.99; 95% CI, 1.38-18.03). The three subgroups were significantly (p < .05) different regarding the percentage of low and high responders. CONCLUSION Our results showed a strong association between OAI and functional outcome.
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Farrell Z, O'Neill D. Towards better screening and assessment of oropharyngeal swallow disorders in the general hospital. Lancet 1999; 354:355-6. [PMID: 10437860 DOI: 10.1016/s0140-6736(98)90085-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Affiliation(s)
- Z Farrell
- Department of Speech and Language Therapy, Adelaide and Meath Hospital Dublin, Ireland
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