Stroke unit treatment improves long-term quality of life: a randomized controlled trial

Integrated Care in Neurology: The Current Landscape and Future Directions

The rising burden of neurological disorders poses significant challenges to healthcare systems worldwide. There has been an increasing momentum to apply integrated approaches to the management of several chronic illnesses in order to address systemic healthcare challenges and improve the quality of care for patients. The aim of this paper is to provide a narrative review of the current landscape of integrated care in neurology. We identified a growing body of research from countries around the world applying a variety of integrated care models to the treatment of common neurological conditions. Based on our findings, we discuss opportunities for further study in this area. Finally, we discuss the future of integrated care in Canada, including unique geographic, historical, and economic considerations, and the role that integrated care may play in addressing challenges we face in our current healthcare system.

Effect of admission in the stroke care unit versus intensive care unit on in-hospital mortality in patients with acute ischemic stroke

BACKGROUND/OBJECTIVE

Few reports have directly compared the outcomes of patients with acute ischemic stroke (AIS) who are managed in a stroke care unit (SCU) with those who are managed in an intensive care units (ICU). This large database study in Japan aimed to compare in-hospital mortality between patients with AIS admitted into SCU and those admitted into ICU.

METHODS

Patients with AIS who were admitted between April 1, 2014, and March 31, 2019, were selected from the administrative database and divided into the SCU and ICU groups. We calculated the propensity score to match groups for which the admission unit assignment was independent of confounding factors, including the modified Rankin scale (mRS) score. The primary outcome was in-hospital mortality, and secondary outcomes were the mRS score at discharge, length of stay (LOS), and total hospitalization cost.

RESULTS

Overall, 8,683 patients were included, and 960 pairs were matched. After matching, the in-hospital mortality rates of the SCU and ICU groups were not significantly different (5.9% vs. 7.9%, P = 0.106). LOS was significantly shorter (SCU = 20.9 vs. ICU = 26.2 days, P < 0.001) and expenses were significantly lower in the SCU group than in the ICU group (SCU = 1,686,588 vs. ICU = 1,998,260 yen, P < 0.001). mRS scores (score of 1-3 or 4-6) at discharge were not significantly different after matching. Stratified analysis showed that the in-hospital mortality rate was lower in the ICU group than in the SCU group among patients who underwent thrombectomy.

CONCLUSIONS

In-hospital mortality was not significantly different between the ICU and SCU groups, with significantly lower costs and shorter LOS in the SCU group than in the ICU group.

Italian translation and cross-cultural validation of an assessment tool for participation in stroke survivors: the Frenchay Activities Index

PURPOSE

Participation needs to be assessed objectively, to state accurate rehabilitation objectives. The Frenchay Activities Index (FAI) is a widely used tool to measure participation in stroke patients. To date, no cross-culturally validated Italian version of FAI is available. This study provides a translation and cross-cultural adaptation of FAI into Italian, assessing its validity and reliability in sub-acute stroke patients.

METHODS

According to international guidelines, a multistep translation and cultural adaptation protocol of forward and backward translations was conducted by qualified linguists and independent native English translators and revised by a healthcare committee. Patients admitted to intensive inpatient rehabilitation after stroke were recruited. Structural validity, reliability (internal consistency, inter- and intra-rater reliability and measurement error), and construct validity were studied.

RESULTS

One hundred and seventy-three patients were included in this study. No significant observations in terms of comprehensibility and conceptual equivalence of the FAI Italian version emerged. The exploratory factorial analysis revealed the presence of two subscales (i.e., domestic chores and work/leisure). The internal consistency resulted good for the first and second subscale (α = 0.821 and 0.716, respectively). Intra- and inter-reliability showed an ICC > 0.90 for both subscales. SEM = 5.75% and 2.33% and MDC = 15.85% and 6.48% were found for the first and second subscale, respectively. Construct validity of first subscale was satisfactory, as 100.0% a priori hypotheses were met, while for the second subscale it was moderate, as 66.6% a priori hypotheses were respected.

CONCLUSION

FAI-I provides a tool for professionals to measure participation in Italian stroke patients in health and social care settings.

Stroke-unit care for stroke patients in China: the results from Bigdata Observatory platform for Stroke of China

BACKGROUND

To assess whether stroke patients admitted to stroke units (SU) have a better short-term outcome than those treated in conventional wards (CW).

METHODS

A total of 20 hospitals from 16 provinces in China were initially selected in this study. Finally, 24,090 consecutive admissions in 2013-2015 treated in CW and 21,332 consecutive entries in 2017-2019 treated in SU were included. The primary endpoint of this study was the all-cause death or dependency condition three months after admission.

RESULTS

Patients in the SU group were more likely receiving thrombolytic therapy (3.9 vs 2.1%) and intravascular treatment (1.2 and 0.7%). In-hospital death were lower in the SU group than the CW group (SU vs CW: 2.93 vs 4.58% [absolute difference, - 2.28% {95% CI, - 3.32% to - 0.93%}, odd ratio {OR}, 0.72{95% CI, 0.61 to 0.82}]. Death after discharge was also lower in the SU group than the CW (SU vs CW: 5.07 vs 6.72% [absolute difference, - 2.33% {95% CI, - 3.39% to - 0.90%}, odd ratio {OR}, 0.75{95% CI, 0.68 to 0.84}]. In addition, patients who received SU care were less likely to be dead or disabled than those patients who received CW care after adjusting for other variability (SU vs CW: 36.20 vs 44.33% [absolute difference, - 11.33% {95% CI, - 15.32% to - 7.14%}, odd ratio {OR}, 0.78{95% CI, 0.80 to 0.85}].

CONCLUSIONS

Among patients with stroke, admission to a designated SU was associated with modestly lower mortality at discharge, reduced probability of death, or being disabled at the end of follow-up.

A protocol for systematic review and meta-analysis on psychosocial factors related to rehabilitation motivation of stroke patients

BACKGROUND

Rehabilitation motivation is more important than any other factor in terms of treatment effects among stroke patients. The goal of this study is to explore the variables related to rehabilitation motivation that affect treatment effects and analyze their effect sizes, in order to manage the psychosocial interventions required by stroke patients.

METHODS

Thirteen electronic databases will be searched from November to December 2020. The search terms will be composed of the disease term part (eg, "stroke") and the intervention term part (eg, "rehabilitation motivation or rehabilitation factors related to motivation or self-efficacy or family support or rehabilitation adherence or achievement or psychosocial factors, including self-motivation, social support, psychological distress, rehabilitation adherence"). Selected studies the for systematic review and meta-analysis will include randomized, quasi-randomized, and nonrandomized controlled trials, and research programs on rehabilitation motivation; qualitative research and case studies will be excluded. The participants will be stroke patients. Two authors will independently assess each study for eligibility and risk of bias, and to extract data.

RESULTS

This study will comprehensively explore the psychosocial and physical behavioral variables related to the rehabilitation motivation of stroke patients and provide their priorities and effect sizes. In addition, we will report the magnitude of the correlation effect on the rehabilitation motivation of stroke patients according to each demographic variable.

CONCLUSIONS

The conclusions of our study will provide effective evidence of psychosocial variables that influence the treatment outcomes of stroke patients.

PROSPERO REGISTRATION NUMBER

CRD42020207467.

Pragmatic Solutions for Stroke Recovery and Improved Quality of Life in Low- and Middle-Income Countries-A Systematic Review

Background: Given the limited healthcare resources in low and middle income countries (LMICs), effective rehabilitation strategies that can be realistically adopted in such settings are required. Objective: A systematic review of literature was conducted to identify pragmatic solutions and outcomes capable of enhancing stroke recovery and quality of life of stroke survivors for low- and middle- income countries. Methods: PubMed, HINARI, and Directory of Open Access Journals databases were searched for published Randomized Controlled Trials (RCTs) till November 2018. Only completed trials published in English with non-pharmacological interventions on adult stroke survivors were included in the review while published protocols, pilot studies and feasibility analysis of trials were excluded. Obtained data were synthesized thematically and descriptively analyzed. Results: One thousand nine hundred and ninety six studies were identified while 347 (65.22% high quality) RCTs were found to be eligible for the review. The most commonly assessed variables (and outcome measure utility) were activities of daily living [75.79% of the studies, with Barthel Index (37.02%)], motor function [66.57%; with Fugl Meyer scale (71.88%)], and gait [31.12%; with 6 min walk test (38.67%)]. Majority of the innovatively high technology interventions such as robot therapy (95.24%), virtual reality (94.44%), transcranial direct current stimulation (78.95%), transcranial magnetic stimulation (88.0%) and functional electrical stimulation (85.00%) were conducted in high income countries. Several traditional and low-cost interventions such as constraint-induced movement therapy (CIMT), resistant and aerobic exercises (R&AE), task oriented therapy (TOT), body weight supported treadmill training (BWSTT) were reported to significantly contribute to the recovery of motor function, activity, participation, and improvement of quality of life after stroke. Conclusion: Several pragmatic, in terms of affordability, accessibility and utility, stroke rehabilitation solutions, and outcome measures that can be used in resource-limited settings were found to be effective in facilitating and enhancing post-stroke recovery and quality of life.

Organised inpatient (stroke unit) care for stroke: network meta-analysis

BACKGROUND

Organised inpatient (stroke unit) care is provided by multi-disciplinary teams that manage stroke patients. This can been provided in a ward dedicated to stroke patients (stroke ward), with a peripatetic stroke team (mobile stroke team), or within a generic disability service (mixed rehabilitation ward). Team members aim to provide co-ordinated multi-disciplinary care using standard approaches to manage common post-stroke problems.

OBJECTIVES

• To assess the effects of organised inpatient (stroke unit) care compared with an alternative service. • To use a network meta-analysis (NMA) approach to assess different types of organised inpatient (stroke unit) care for people admitted to hospital after a stroke (the standard comparator was care in a general ward). Originally, we conducted this systematic review to clarify: • The characteristic features of organised inpatient (stroke unit) care? • Whether organised inpatient (stroke unit) care provide better patient outcomes than alternative forms of care? • If benefits are apparent across a range of patient groups and across different approaches to delivering organised stroke unit care? Within the current version, we wished to establish whether previous conclusions were altered by the inclusion of new outcome data from recent trials and further analysis via NMA.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (2 April 2019); the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 4), in the Cochrane Library (searched 2 April 2019); MEDLINE Ovid (1946 to 1 April 2019); Embase Ovid (1974 to 1 April 2019); and the Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1982 to 2 April 2019). In an effort to identify further published, unpublished, and ongoing trials, we searched seven trial registries (2 April 2019). We also performed citation tracking of included studies, checked reference lists of relevant articles, and contacted trialists.

SELECTION CRITERIA

Randomised controlled clinical trials comparing organised inpatient stroke unit care with an alternative service (typically contemporary conventional care), including comparing different types of organised inpatient (stroke unit) care for people with stroke who are admitted to hospital.

DATA COLLECTION AND ANALYSIS

Two review authors assessed eligibility and trial quality. We checked descriptive details and trial data with co-ordinators of the original trials, assessed risk of bias, and applied GRADE. The primary outcome was poor outcome (death or dependency (Rankin score 3 to 5) or requiring institutional care) at the end of scheduled follow-up. Secondary outcomes included death, institutional care, dependency, subjective health status, satisfaction, and length of stay. We used direct (pairwise) comparisons to compare organised inpatient (stroke unit) care with an alternative service. We used an NMA to confirm the relative effects of different approaches.

MAIN RESULTS

We included 29 trials (5902 participants) that compared organised inpatient (stroke unit) care with an alternative service: 20 trials (4127 participants) compared organised (stroke unit) care with a general ward, six trials (982 participants) compared different forms of organised (stroke unit) care, and three trials (793 participants) incorporated more than one comparison. Compared with the alternative service, organised inpatient (stroke unit) care was associated with improved outcomes at the end of scheduled follow-up (median one year): poor outcome (odds ratio (OR) 0.77, 95% confidence interval (CI) 0.69 to 0.87; moderate-quality evidence), death (OR 0.76, 95% CI 0.66 to 0.88; moderate-quality evidence), death or institutional care (OR 0.76, 95% CI 0.67 to 0.85; moderate-quality evidence), and death or dependency (OR 0.75, 95% CI 0.66 to 0.85; moderate-quality evidence). Evidence was of very low quality for subjective health status and was not available for patient satisfaction. Analysis of length of stay was complicated by variations in definition and measurement plus substantial statistical heterogeneity (I² = 85%). There was no indication that organised stroke unit care resulted in a longer hospital stay. Sensitivity analyses indicated that observed benefits remained when the analysis was restricted to securely randomised trials that used unequivocally blinded outcome assessment with a fixed period of follow-up. Outcomes appeared to be independent of patient age, sex, initial stroke severity, stroke type, and duration of follow-up. When calculated as the absolute risk difference for every 100 participants receiving stroke unit care, this equates to two extra survivors, six more living at home, and six more living independently. The analysis of different types of organised (stroke unit) care used both direct pairwise comparisons and NMA. Direct comparison of stroke ward versus general ward: 15 trials (3523 participants) compared care in a stroke ward with care in general wards. Stroke ward care showed a reduction in the odds of a poor outcome at the end of follow-up (OR 0.78, 95% CI 0.68 to 0.91; moderate-quality evidence). Direct comparison of mobile stroke team versus general ward: two trials (438 participants) compared care from a mobile stroke team with care in general wards. Stroke team care may result in little difference in the odds of a poor outcome at the end of follow-up (OR 0.80, 95% CI 0.52 to 1.22; low-quality evidence). Direct comparison of mixed rehabilitation ward versus general ward: six trials (630 participants) compared care in a mixed rehabilitation ward with care in general wards. Mixed rehabilitation ward care showed a reduction in the odds of a poor outcome at the end of follow-up (OR 0.65, 95% CI 0.47 to 0.90; moderate-quality evidence). In a NMA using care in a general ward as the comparator, the odds of a poor outcome were as follows: stroke ward - OR 0.74, 95% CI 0.62 to 0.89, moderate-quality evidence; mobile stroke team - OR 0.88, 95% CI 0.58 to 1.34, low-quality evidence; mixed rehabilitation ward - OR 0.70, 95% CI 0.52 to 0.95, low-quality evidence.

AUTHORS' CONCLUSIONS

We found moderate-quality evidence that stroke patients who receive organised inpatient (stroke unit) care are more likely to be alive, independent, and living at home one year after the stroke. The apparent benefits were independent of patient age, sex, initial stroke severity, or stroke type, and were most obvious in units based in a discrete stroke ward. We observed no systematic increase in the length of inpatient stay, but these findings had considerable uncertainty.

Early mobilization and quality of life after stroke: Findings from AVERT

OBJECTIVE

To determine whether early and more frequent mobilization after stroke affects health-related quality of life.

METHODS

A Very Early Rehabilitation Trial (AVERT) was an international, multicenter (56 sites), phase 3 randomized controlled trial, spanning 2006-2015. People were included if they were aged ≥18 years, presented within 24 hours of a first or recurrent stroke (ischemic or hemorrhagic), and satisfied preordained physiologic criteria. Participants were randomized to usual care alone or very early and more frequent mobilization in addition to usual care. Quality of life at 12 months was a prespecified secondary outcome, evaluated using the Assessment of Quality of Life 4D (AQoL-4D). This utility-weighted scale has scores ranging from -0.04 (worse than death) to 1 (perfect health). Participants who died were assigned an AQoL-4D score of 0.

RESULTS

No significant difference in quality of life at 12 months between intervention (median 0.47, interquartile range [IQR] 0.07-0.81) and usual care (median 0.49, IQR 0.08-0.81) groups was identified (p = 0.86), nor were there any group differences across the 4 AQoL-4D domains. The same lack of group difference in quality of life was observed at 3 months. When cohort data were analyzed (both groups together), quality of life was strongly associated with acute length of stay, independence in activities of daily living, cognitive function, depressive symptoms, and anxiety symptoms (all p < 0.001). Quality of life in AVERT participants was substantially lower than population norms, and the gap increased with age.

CONCLUSIONS

Earlier and more frequent mobilization after stroke did not influence quality of life.

CLINICAL TRIAL REGISTRATION

anzctr.org.au; ACTRN12606000185561 CLASSIFICATION OF EVIDENCE: This study provides Class II evidence that for people with stroke, earlier and more frequent mobilization did not influence quality of life over the subsequent year.

Predictive accuracy of physicians' estimates of outcome after severe stroke

Introduction

End-of-life decisions after stroke should be guided by accurate estimates of the patient’s prognosis. We assessed the accuracy of physicians’ estimates regarding mortality, functional outcome, and quality of life in patients with severe stroke.

Methods

Treating physicians predicted mortality, functional outcome (modified Rankin scale (mRS)), and quality of life (visual analogue scale (VAS)) at six months in patients with major disabling stroke who had a Barthel Index ≤6 (of 20) at day four. Unfavorable functional outcome was defined as mRS >3, non-satisfactory quality of life as VAS <60. Patients were followed-up at six months after stroke. We compared physicians’ estimates with actual outcomes.

Results

Sixty patients were included, with a mean age of 72 years. Of fifteen patients who were predicted to die, one actually survived at six months (positive predictive value (PPV), 0.93; 95% CI, 0.66–0.99). Of thirty patients who survived, one was predicted to die (false positive rate (FPR), 0.03; 95%CI 0.00–0.20). Of forty-six patients who were predicted to have an unfavorable outcome, four had a favorable outcome (PPV, 0.93; 95% CI, 0.81–0.98; FPR, 0.30; 95% CI; 0.08–0.65). Prediction of non-satisfactory quality of life was less accurate (PPV, 0.63; 95% CI, 0.26–0.90; FPR, 0.18; 95% CI 0.05–0.44).

Conclusions

In patients with severe stroke, treating physicians’ estimation of the risk of mortality or unfavorable functional outcome at six months is relatively inaccurate. Prediction of quality of life is even more imprecise.

Treatment restrictions in patients with severe stroke are associated with an increased risk of death

Introduction

Treatment restrictions in the first 2 days after intracerebral haemorrhage have been independently associated with an increased risk of early death. It is unknown whether these restrictions also affect mortality if these are installed several days after stroke onset.

Patients and methods

Sixty patients with severe functional dependence at day 4 after ischaemic stroke or intracerebral haemorrhage were included in this prospective two-centre cohort study. The presence of treatment restrictions was assessed at the day of inclusion. Information about mortality, functional outcome (modified Rankin scale) score and quality of life (visual analogue scale) was recorded 6 months after stroke onset. Poor outcome was defined as modified Rankin scale >3. Satisfactory quality of life was defined as visual analogue scale ≥ 60.

Results

At 6 months, 30 patients had died, 19 survivors had a poor functional outcome and 9 patients had a poor quality of life. Treatment restrictions were independently associated with mortality at 6 months (adjusted relative risk, 1.30; 95% confidence interval, 1.06–1.59; p = 0.01), but not with functional outcome.

Discussion

Our findings were observed in 60 selected patients with severe stroke.

Conclusion

The instalment of treatment restrictions by itself may increase the risk of death after stroke, even if the first 4 days have passed. In future stroke studies, this potential confounder should be taken into account. Quality of life was satisfactory in the majority of the survivors, despite considerable disability.

Early interdisciplinary intensive rehabilitation significantly improves the quality of life of stroke survivors: a multi-center study

Background: Interdisciplinary and intensive stroke rehabilitation programs have been shown to be positively correlated with improved functional outcomes. However, data regarding their combined use on the quality of life (QOL) of stroke survivors appears scant.

Objective: To evaluate whether interdisciplinary intensive rehabilitation programs for stroke survivors can improve their health-related QOL (HRQOL) scores and whether the timing of the interdisciplinary intensive rehabilitation has a significant effect on HRQOL scores.

Materials and Methods: This was a multi-center, prospective study. Patients were retrospectively selected from the Thai Stroke Rehabilitation Registry database. Three hundred seventy-six stroke patients from nine main tertiary hospitals in Thailand who had received acute stroke rehabilitation were screened between March and December 2006. Two hundred seven patients completed World Health Organization Quality of Life scale abbreviated Thai version (WHOQOL-BREF-Thai) questionnaires and were divided into two groups based on the time after onset of stroke to start interdisciplinary intensive rehabilitation: sub-acute (<1 month) and chronic (≥1 month). WHOQOL-BREF-Thai questionnaires were composed of four domains (physical health, psychological well being, social relationships and environment satisfaction), which were administered to the patients before and after interdisciplinary intensive rehabilitation to assess QOL.

Results: After interdisciplinary intensive rehabilitation, patients from both groups showed significant improvement in their quality of life in all domains, sex life and family relationships. However, patients from the sub-acute group had more significant improvement in their environment domain, family relationships and overall WHOQOL scores than those in the chronic group.

Conclusion: Early interdisciplinary intensive stroke rehabilitation can significantly improve environment domain, family relationships and overall WHOQOL of stroke patients.

A study to assess the effect of nursing interventions at the weekend for people with stroke

Objective: To examine whether additional therapy provided by nurses at the weekend improved the physical outcome for people with stroke on a stroke rehabilitation unit.

Design: A single blind randomized controlled trial.

Setting: A 16-bed stroke rehabilitation unit in the north of England.

Subjects: Forty-one people with stroke were randomized by means of minimization to intervention and control groups.

Interventions: The intervention group received additional exercise at the weekend provided by the nursing staff and the control group received their usual care. Both groups received usual care during weekdays.

Main outcome measures: The Motor Assessment Scale (MAS), the Barthel Index (BI) and length of stay in hospital.

Results: No significant differences were found between the groups in terms of MAS and BI at discharge but there was a borderline significant difference between the groups on unconditional testing in terms of length of stay in hospital and on the stroke unit ( p = 0.05 and p = 0.07 respectively). However, these findings were in favour of the control group. On conditional testing (adjusting for BI on admission and age) these differences disappeared ( p = 0.14 and p = 0.15) for length of stay in hospital and on the stroke unit respectively.

Conclusions: The present study indicates that an increase in one-to-one input by nurses for people with stroke did not lead to a measurable difference in outcome in this small study.

Electroencephalographic markers of robot-aided therapy in stroke patients for the evaluation of upper limb rehabilitation

Stroke is the leading cause of permanent disability in developed countries; its effects may include sensory, motor, and cognitive impairment as well as a reduced ability to perform self-care and participate in social and community activities. A number of studies have shown that the use of robotic systems in upper limb motor rehabilitation programs provides safe and intensive treatment to patients with motor impairments because of a neurological injury. Furthermore, robot-aided therapy was shown to be well accepted and tolerated by all patients; however, it is not known whether a specific robot-aided rehabilitation can induce beneficial cortical plasticity in stroke patients. Here, we present a procedure to study neural underpinning of robot-aided upper limb rehabilitation in stroke patients. Neurophysiological recordings use the following: (a) 10-20 system electroencephalographic (EEG) electrode montage; (b) bipolar vertical and horizontal electrooculographies; and (c) bipolar electromyography from the operating upper limb. Behavior monitoring includes the following: (a) clinical data and (b) kinematic and dynamic of the operant upper limb movements. Experimental conditions include the following: (a) resting state eyes closed and eyes open, and (b) robotic rehabilitation task (maximum 80 s each block to reach 4-min EEG data; interblock pause of 1 min). The data collection is performed before and after a program of 30 daily rehabilitation sessions. EEG markers include the following: (a) EEG power density in the eyes-closed condition; (b) reactivity of EEG power density to eyes opening; and (c) reactivity of EEG power density to robotic rehabilitation task. The above procedure was tested on a subacute patient (29 poststroke days) and on a chronic patient (21 poststroke months). After the rehabilitation program, we observed (a) improved clinical condition; (b) improved performance during the robotic task; (c) reduced delta rhythms (1-4 Hz) and increased alpha rhythms (8-12 Hz) during the resting state eyes-closed condition; (d) increased alpha desynchronization to eyes opening; and (e) decreased alpha desynchronization during the robotic rehabilitation task. We conclude that the present procedure is suitable for evaluation of the neural underpinning of robot-aided upper limb rehabilitation.

Evidence-based guidelines for the management of large hemispheric infarction : a statement for health care professionals from the Neurocritical Care Society and the German Society for Neuro-intensive Care and Emergency Medicine

Large hemispheric infarction (LHI), also known as malignant middle cerebral infarction, is a devastating disease associated with significant disability and mortality. Clinicians and family members are often faced with a paucity of high quality clinical data as they attempt to determine the most appropriate course of treatment for patients with LHI, and current stroke guidelines do not provide a detailed approach regarding the day-to-day management of these complicated patients. To address this need, the Neurocritical Care Society organized an international multidisciplinary consensus conference on the critical care management of LHI. Experts from neurocritical care, neurosurgery, neurology, interventional neuroradiology, and neuroanesthesiology from Europe and North America were recruited based on their publications and expertise. The panel devised a series of clinical questions related to LHI, and assessed the quality of data related to these questions using the Grading of Recommendation Assessment, Development and Evaluation guideline system. They then developed recommendations (denoted as strong or weak) based on the quality of the evidence, as well as the balance of benefits and harms of the studied interventions, the values and preferences of patients, and resource considerations.

Determinants of geriatric patients' quality of life after stroke rehabilitation

OBJECTIVES

Geriatric patients' physical disabilities, dependency on care, and possible psychological ill-being may negatively affect both the patient's quality of life and the informal caregiver burden. Focusing on this interrelationship which can be particularly prominent in geriatric patients with stroke, the objective of this study was to identify determinants of patients' quality of life and informal caregiver burden.

METHOD

This is a prospective, multicentre, cohort study. Data were collected in 84 geriatric home-dwelling patients with stroke three months after their rehabilitation period in skilled nursing facilities (SNFs). We assessed patients' quality of life, depressive complaints, neuropsychiatric symptoms, balance, (instrumental) activities of daily living, and informal caregiver burden. Linear regression models were constructed to study the association between the variables.

RESULTS

For several domains, high quality of life of these geriatric patients was associated with high functional independence, less neuropsychiatric symptoms, and less depressive complaints. Informal caregiver burden was not associated with patients' quality of life, but patients' neuropsychiatric symptoms were a significant determinant of high informal caregiver burden.

CONCLUSION

The presence of neuropsychiatric symptoms (more specifically depressive complaints) negatively affects the quality of life of geriatric patients. Their neuropsychiatric symptoms also affect caregiver burden. Health care professionals in SNFs can play an important role in providing the necessary psychosocial support and aftercare.

Ottawa Panel Evidence-Based Clinical Practice Guidelines for Post-Stroke Rehabilitation

BACKGROUND AND PURPOSE

The purpose of this project was to create guidelines for 13 types of physical rehabilitation interventions used in the management of adult patients (>18 years of age) presenting with hemiplegia or hemiparesis following a single clinically identifiable ischemic or hemorrhagic cerebrovascular accident (CVA).

METHOD

Using Cochrane Collaboration methods, the Ottawa Methods Group identified and synthesized evidence from comparative controlled trials. The group then formed an expert panel, which developed a set of criteria for grading the strength of the evidence and the recommendation. Patient-important outcomes were determined through consensus, provided that these outcomes were assessed with a validated and reliable scale.

RESULTS

The Ottawa Panel developed 147 positive recommendations of clinical benefit concerning the use of different types of physical rehabilitation interventions involved in post-stroke rehabilitation.

DISCUSSION AND CONCLUSION

The Ottawa Panel recommends the use of therapeutic exercise, task-oriented training, biofeedback, gait training, balance training, constraint-induced movement therapy, treatment of shoulder subluxation, electrical stimulation, transcutaneous electrical nerve stimulation, therapeutic ultrasound, acupuncture, and intensity and organization of rehabilitation in the management of post stroke.

Training and Stimulation in Post Stroke Recovery Brain Reorganization

In both animal and clinical studies, training or rehabilitation increases cortical representation with subsequent functional recovery, whereas a lack of rehabilitation or training decreases cortical representation and delays recovery. Animals exposed to enriched environments post stroke have improved functional outcomes compared with animals exposed to nonenriched environments. In humans, stroke units may be the closest approximation there is to an enriched environment. However, studies indicate that patients spend the majority of time being inactive and alone while on a stroke unit. Given the animal evidence (which emphasizes increased stimulation and increased activity), there is clearly an opportunity for improving the stroke rehabilitation experience to maximize post stroke recovery.

Neurostimulant Medication Usage During Stroke Rehabilitation: The Post-Stroke Rehabilitation Outcomes Project (PSROP)

Motor recovery after a stroke depends upon many upon different modalities. Intensive therapy using compensatory and facilitatory techniques is the primary method to improve movement and function in affected extremities. However, medications used to modulate neurotransmitters may be useful in augmenting therapy approaches. The Post-Stroke Rehabilitation Outcomes Project (PSROP) database was used to describe the frequency of prescribing neurostimulant medications; the types of neurostimulant medications used; and how the use of neurostimulant medications affected rehabilitation length of stay, motor recovery, cognitive recovery, and discharge destination. Of the 1,161 patients in the PSROP database, 929 (80.0%) patients did not receive any treatment with methylphenidate, modafinil, levodopa, amantadine, or bromocriptine. Patients who received neurostimulant medications did not have any more significant changes in length of stay, motor recovery, cognitive recovery, or discharge destination than patients who did not receive neurostimulant medications. Much research needs to be completed before clinicians know precisely whether and how rehabilitation therapies and medications interact to assist in functional recovery.

Organised inpatient (stroke unit) care for stroke

BACKGROUND

Organised stroke unit care is provided by multidisciplinary teams that exclusively manage stroke patients in a ward dedicated to stroke patients, with a mobile stroke team or within a generic disability service (mixed rehabilitation ward).

OBJECTIVES

To assess the effect of stroke unit care compared with alternative forms of care for people following a stroke.

SEARCH METHODS

We searched the trials registers of the Cochrane Stroke Group (January 2013) and the Cochrane Effective Practice and Organisation of Care (EPOC) Group (January 2013), MEDLINE (2008 to September 2012), EMBASE (2008 to September 2012) and CINAHL (1982 to September 2012). In an effort to identify further published, unpublished and ongoing trials, we searched 17 trial registers (January 2013), performed citation tracking of included studies, checked reference lists of relevant articles and contacted trialists.

SELECTION CRITERIA

Randomised controlled clinical trials comparing organised inpatient stroke unit care with an alternative service. After formal risk of bias assessment, we have now excluded previously included quasi-randomised trials.

DATA COLLECTION AND ANALYSIS

Two review authors initially assessed eligibility and trial quality. We checked descriptive details and trial data with the co-ordinators of the original trials.

MAIN RESULTS

We included 28 trials, involving 5855 participants, comparing stroke unit care with an alternative service. More-organised care was consistently associated with improved outcomes. Twenty-one trials (3994 participants) compared stroke unit care with care provided in general wards. Stroke unit care showed reductions in the odds of death recorded at final (median one year) follow-up (odds ratio (OR) 0.87, 95% confidence interval (CI) 0.69 to 0.94; P = 0.005), the odds of death or institutionalised care (OR 0.78, 95% CI 0.68 to 0.89; P = 0.0003) and the odds of death or dependency (OR 0.79, 95% CI 0.68 to 0.90; P = 0.0007). Sensitivity analyses indicated that the observed benefits remained when the analysis was restricted to securely randomised trials that used unequivocally blinded outcome assessment with a fixed period of follow-up. Outcomes were independent of patient age, sex, initial stroke severity or stroke type, and appeared to be better in stroke units based in a discrete ward. There was no indication that organised stroke unit care resulted in a longer hospital stay.

AUTHORS' CONCLUSIONS

Stroke patients who receive organised inpatient care in a stroke unit are more likely to be alive, independent, and living at home one year after the stroke. The benefits were most apparent in units based in a discrete ward. We observed no systematic increase in the length of inpatient stay.

Impact of implementing evidence-based acute stroke interventions on survival: the South London Stroke Register

Background

Studies examining the impact of organised acute stroke care interventions on survival in subgroups of stroke patients remain limited.

Aims

This study examined the effects of a range of evidence-based interventions of acute stroke care on one year survival post-stroke and determined the size of the effect across different socio-demographic and clinical subgroups of patients.

Methods

Data on 4026 patients with a first-ever stroke recruited to the population-based South London Stroke Register between 1995 and 2010 were used. In uni-variable analyses, one year cumulative survival rates in socio-demographic groups and by care received was determined. Survival functions were compared using Log-rank tests. Multivariable Cox models were used to test for interactions between components of care and age group, sex, ethnic group, social class, stroke subtype and level of consciousness.

Results

1949 (56.4%) patients were admitted to a stroke unit. Patients managed on a stroke unit, those with deficits receiving specific rehabilitation therapies and those with ischaemic stroke subtype receiving aspirin in the acute phase had better one year survival compared to those who did not receive these interventions. The greatest reduction in the hazards of death among patients treated on a stroke unit were in the youngest patients aged <65 years, (HR 0.39; 95% CI: 0.25–0.62), and those with reduced levels of consciousness, GCS <9, (HR: 0.44; CI: 0.33–0.58).

Conclusions

There was evidence of better one year survival in patients receiving specific acute interventions after stroke with a significantly greater effect in stroke subgroups, suggesting the possibility of re-organising stroke services to ensure that the most appropriate care is made accessible to patients likely to derive the most benefits from such interventions.

Physiotherapy practice in stroke rehabilitation: a cross-sectional survey of physiotherapists in the state of Kerala, India

BACKGROUND

Physiotherapy, a major component of rehabilitation for stroke patients, has been shown to have a positive effect on outcome. However, there is debate over efficacy of different interventions related to stroke rehabilitation.

PURPOSE

The purpose of this study was to compare knowledge and attitudes of physiotherapists working with stroke patients in Kerala, India, with emphasis on demographics, approach to treatment, and beliefs about stroke rehabilitation.

METHODS

Two hundred one physiotherapists in Kerala were surveyed using questionnaires, which were sent by post. Questionnaires consisted of items related to stroke rehabilitation such as approaches to physiotherapy, use of walking aids, and discharge issues. Data analysis was done using percentage-wise comparisons.

RESULTS

Examination of results showed variation in the beliefs held by physiotherapists about treatment of stroke patients. Of the 201 respondents, 153 (76.1%) used a conventional treatment approach. There was a strong disparity among physiotherapists regarding use of walking aids by stroke patients: 119 (59.2%) agreed that tripods or quadripods should be given to patients, but 55 (27.4%) disagreed and 27 (13.4%) were unsure. In response to questions about discharge issues, 30 (14.9%) of the 118 respondents agreed that they were actively involved in discharge planning for stroke patients, and 158 (78.6%) agreed that skill of the physiotherapist influences outcomes.

CONCLUSION

A great deal of variation among physiotherapists in treatment approaches and beliefs was revealed in this study, which indicates the need for development and implementation of a standardized protocol for stroke rehabilitation in Kerala.

[Long-term course of patients in neurological rehabilitation Phase B. Results of the 6-year follow-up in a multicenter study]

BACKGROUND

After conclusion of emergency care for severe neurological diseases patients in Germany are admitted at an early stage to so-called Phase B rehabilitation. No studies have been carried out on the long-term course of these patients.

PATIENTS AND METHODS

In a prospective study in 2002 patients in Phase B from 9 centers were included and follow-up investigations were carried out after 5 and 6 years. Assessment instruments used were the Barthel index, the Rankin scale and the EQ-5D. Factors for the risk of a poor outcome and the chances for a good outcome were evaluated using multivariate logistic regression.

RESULTS

A total of 1,280 patients were included in the study. A high age increased the risk of dying with a hazard quotient (HQ) of 1.05 (95% CI: 1.04-1.06) and high point counts in the coma remission scale (HQ 0.93; 95% CI: 0.92-0.96) and Barthel index (HQ 0.97; 95% CI: 0.97-0.98) on discharge reduced the risk of dying after 5 years. The factors swallowing impairment (OR 3.1; 95% CI: 1.7-5.5) and obligatory surveillance at the end of rehabilitation (OR 3.2; 95% CI: 1.2-8.6) increased the risk of a poor result in the Rankin scale 2-4 and the factors communication disorder (OR 5.0; 95% CI: 2.0-12.8) and PEG (percutaneous endoscopic gastrostomy) (OR 19.7; 95% CI: 2.7-144.4) on discharge increased the risk of a reduced health-related quality of life (defined as EQ-5D VAS <70) after 6 years.

CONCLUSIONS

If support for bodily functions can be successfully reduced during Phase B rehabilitation, the patients will have a good outcome with respect to 5-year survival. If this is not successful the outcome is unfavorable with respect to survival and with respect to achieving self-sufficiency and health-related quality of life after 6 years.

Functional exercise and physical fitness post stroke: the importance of exercise maintenance for motor control and physical fitness after stroke

It is argued that all stroke patients, indifferent of disability, have the same possibility to improve with training. The aim of the study was to follow and register functional improvements in two groups with different functional capacities at baseline for a period of 36 months. Stroke patients were recruited and divided into groups related to their functional status at baseline. During the acute rehabilitation, both groups received functional task-oriented training, followed by regular self- or therapeutic driven training the first year after stroke and varied exercise patterns the following 24 months. The participants were tested on admission, and at three, six, twelve, and thirty-six months after the onset of stroke. Both groups improved functional activity up to six months which then stabilized up to twelve months to decline somewhat at thirty-six months after stroke. Change scores indicate a greater potential for rehabilitation in the MAS ≤35 in relation to group MAS >35 although the functional capacity was higher in the latter. This indicates the importance of maintaining exercise and training for all persons after stroke.

Rehabilitation outcomes of stroke patients treated with tissue plasminogen activator

OBJECTIVE

To investigate the influence of thrombolysis on functional outcomes after rehabilitation.

BACKGROUND

Systemic thrombolysis with tissue plasminogen activator (tPA) is considered the mainstay of acute stroke therapy and was found to improve short-term outcome.

DESIGN

Matched case-controlled design.

SETTING

Inpatient neurology and rehabilitation departments.

PARTICIPANTS

Thirty-seven patients given tPA and 37 control patients not treated with lytics because of protocol limits.

METHODS

We retrospectively analyzed data from a cohort of stroke patients who were treated with systemic tPA. The rehabilitation outcome of thrombolysis-treated patients was compared with that observed for tPA-ineligible and age- and stroke severity-matched patients treated at the same neurology and rehabilitation departments.

MAIN OUTCOME MEASURE

Neurological evaluation was assessed with the National Institutes of Health stroke scale (NIHSS). Activity of daily living was measured using the Functional Independence Measure (FIM) instrument. Functional outcome was measured using the modified Rankin scale (mRS).

RESULTS

The treatment group included 37 patients given tPA; 37 tPA-ineligible patients served as controls. On admission to rehabilitation, there were no significant differences in functional, neurological, and rehabilitation parameters between the groups. At the end of the rehabilitation period, NIHSS scores were significantly lower in the thrombolysis group (P = .036). More patients in the thrombolysis group reached functional independence defined as mRS < or =2 (20/37 versus 10/37; P = .03). At the end of rehabilitation, total FIM score (mean 102.8 versus 93.9; P = .039), total FIM gain (mean 27.8 versus 21.4; P = .09), and total FIM efficiency scores (0.8 versus 0.43; P = .013) were higher in the thrombolysis group and more patients in this group were discharged home.

CONCLUSIONS

Although the bulk of neurological improvement occurred before the inpatient rehabilitation, thrombolysis-treated patients continue to improve faster and to a larger extent during the rehabilitation period suggesting that the beneficial effects of thrombolysis continue beyond the acute phase.

What is the benefit of a high-intensive exercise program on health-related quality of life and depression after stroke? A randomized controlled trial

The aim of the study was to evaluate the impact of a high-intensive exercise program containing high-intensive functional exercises implemented to real-life situations together with group discussions on falls and security aspects in stroke subjects with risk of falls. This was a pre-specified secondary outcome for this study. For evaluation, Short Form-36 (SF-36) health-related quality of life (HRQoL) and the Geriatric Depression Scale-15 (GDS-15) were used. This was a single-center, single-blinded, randomized, controlled trial. Consecutive >55 years old stroke patients with risk of falls at 3-6 months after first or recurrent stroke were randomized to the intervention group (IG, n = 15) or to the control group (CG, n = 19) who received group discussion with focus on hidden dysfunctions but no physical fitness training. The 5-week high-intensive exercise program was related to an improvement in the CG in the SF-36 Mental Component Scale and the Mental Health subscale at 3 months follow-up compared with baseline values while no improvement was seen in the IG at this time. For the SF-36 Physical Component Scale, there was an improvement in the whole study group at 3 and 6 months follow-up compared with baseline values without any significant changes between the IG and CG. The GDS-15 was unchanged throughout the follow-up period for both groups. Based on these data, it is concluded that high-intensive functional exercises implemented in real-life situations should also include education on hidden dysfunctions after stroke instead of solely focus on falls and safety aspects to have a favorable impact on HRQoL.

Psychosocial consequences of stroke: A long-term population-based follow-up

PRIMARY OBJECTIVE

To investigate psychosocial status among nationally representative groups of stroke patients at long intervals post-stroke.

METHODS AND PROCEDURES

From a Danish national register of hospitalizations, three representative groups of surviving patients were selected who had suffered a stroke 5, 10 and 15 years previously. A follow-up postal questionnaire was sent to them comprising items concerning symptomatology, functioning and social conditions, together with the Nottingham Health Profile (NHP).

MAIN OUTCOMES AND RESULTS

Longer follow-up intervals were associated with younger age at stroke and better functioning at discharge. At follow-up, the majority of patients reported difficulties with attention, memory and emotional control, irrespective of follow-up interval. Return to employment, social relations and leisure activities were affected, but were comparatively better at longer follow-up intervals, as was self-rated functioning and several NHP symptom scales. However, multi-variate analyses suggest that these positive changes with time appear to be mediated by attrition related to age at stroke and discharge functioning rather than time since stroke itself.

CONCLUSIONS

Symptomatology, functioning and social conditions remain affected and perhaps stagnant in long-term survivors of stroke.

Change in positive emotion and recovery of functional status following stroke

OBJECTIVES

To investigate change in positive emotion over a 3-month follow-up period and determine whether this change is associated with recovery of functional status in persons with stroke.

DESIGN

A longitudinal study using information from the Stroke Recovery in Underserved Patients (SRUP) database. Positive emotion and functional status were assessed within 72 hours of discharge from an in-patient medical rehabilitation facility and at 3-month follow-up using established measurement instruments.

PARTICIPANTS

The study included 840 adults 55 years old or older with a first-time stroke and admitted to one of eleven in-patient medical rehabilitation facilities in the United States.

RESULTS

The mean age was 72.9 (SD = 9.52) years, 78.6% were non-Hispanic white and 51.7% were women. The average length of stay was 20.2 (SD =10.1) days and the most prevalent type of stroke was ischemic (75.0%). Positive emotion increased for 35.6% of the sample, decreased for 29.2%, and 35.2% reported no change. Increases in positive emotion change score compared to no change (b = -3.2, SE = 1.5, p = .032) or a decline (b = -8.9, SE = 1.4, p = or <.001) was significantly associated with improved functional status at the 3-month follow-up after adjusting for sociodemographic and clinical variables as well as depressive symptoms.

CONCLUSION

Positive emotion is a dynamic process and can change over time. In persons with stroke, increases in positive emotion over a 3-month period was significantly associated with an increasing likelihood of recovery of functional status compared to no change or a decline in positive emotion. Understanding factors that influence both increases and decreases in positive emotion has implications for stroke rehabilitation programming and quality of life post-hospital discharge.

The molecular basis of thrombolysis and its clinical application in stroke

The rationale for thrombolysis, the most promising pharmacological approach in acute ischaemic stroke, is centred on the principal cause of most ischaemic strokes: the thrombus that occludes the cerebral artery, and renders part of the brain ischaemic. The occluding thrombus is bound together within fibrin. Fibrinolysis acts by activation of plasminogen to plasmin; plasmin splits fibrinogen and fibrin and lyses the clot, which then allows reperfusion of the ischaemic brain. Thrombolytic agents include streptokinase (SK) and recombinant tissue-type plasminogen activator (rt-PA) amongst others under test or development. SK is nonfibrin-specific, has a longer half-life than tissue-type plasminogen activator (t-PA), prevents re-occlusion and is degraded enzymatically in the circulation. rt-PA is more fibrin-specific and clot-dissolving, and is metabolized during the first passage in the liver. In animal models of ischaemic stroke, the effects of rt-PA are remarkably consistent with the effects seen in human clinical trials. For clinical application, some outcome data from the Cochrane Database of Systematic Reviews which includes all randomized evidence available on thrombolysis in man were used. Trials included tested urokinase, SK, rt-PA, pro-urokinase, or desmoteplase. The chief immediate hazard of thrombolytic therapy is fatal intracranial bleeding. However, despite the risk, the human trial data suggest the immediate hazards and the apparent substantial scope for net benefit of thrombolytic therapy given up to 6 h of acute ischaemic stroke. So far the fibrin-specific rt-PA is the only agent to be approved for use in stroke. This may be due to its short half-life and its absence of any specific amount of circulating fibrinogen degradation products, thereby leaving platelet function intact. The short half-life does not leave rt-PA without danger for haemorrhage after the infusion. Due to its fibrin-specificity, it can persist within a fibrin-rich clot for one or more days. The molecular mechanisms with regards to fibrin-specificity in thrombolytic agents should, if further studied, be addressed in within-trial comparisons. rt-PA has antigenic properties and although their long-term clinical relevance is unclear there should be surveillance for allergic reactions in relation to treatment. Although rt-PA is approved for use in selected patients, there is scope for benefit in a much wider variety of patients. A number of trials are underway to assess which additional patients - beyond the age and time limits of the current approval - might benefit, and how best to identify them.

Stroke: acute stroke receiving facilities and management

PURPOSE OF REVIEW

Management of ischemic stroke is challenging. No prehospital treatment option exists, and the only approved pharmacologic therapy, that is, systemic thrombolysis, requires brain imaging and initiation of therapy within a narrow therapeutic window. This review provides an overview of recent efforts to optimize management of suspected stroke patients by reducing the interval from symptom onset to reperfusion therapy.

RECENT FINDINGS

There is clear evidence that stroke patients have a favorable outcome when treated with thrombolysis in specialized stroke centers. Data from the European Cooperative Acute Stroke Study-III trial, coupled with improved patient selection by advanced imaging technologies will expand future therapeutic options. However, major obstacles remain in consistently translating scientific advances into clinical practice with only a small percentage of potentially eligible patients receiving thrombolysis. Integrated systems of prehospital management and clinical pathways are necessary to reduce this treatment gap.

SUMMARY

The dogma 'time is brain' is as relevant now as it was at the inauguration of recombinant tissue plasminogen activator for acute stroke treatment in 1996. Knowledge of stroke symptoms and treatment options by the public and first responders, along with integrated stroke systems of care are crucial to ensure rapid access to stroke expertise and treatment.

Effectiveness of applying progressive muscle relaxation technique on quality of life of patients with multiple sclerosis

AIMS AND OBJECTIVES

To identify the effects of applying Progressive Muscle Relaxation Technique on Quality of Life of patients with multiple Sclerosis.

BACKGROUND

In view of the growing caring options in Multiple Sclerosis, improvement of quality of life has become increasingly relevant as a caring intervention. Complementary therapies are widely used by multiple sclerosis patients and Progressive Muscle Relaxation Technique is a form of complementary therapies.

DESIGN

Quasi-experimental study.

METHOD

Multiple Sclerosis patients (n = 66) were selected with no probability sampling then assigned to experimental and control groups (33 patients in each group). Means of data collection included: Individual Information Questionnaire, SF-8 Health Survey, Self-reported checklist. PMRT performed for 63 sessions by experimental group during two months but no intervention was done for control group. Statistical analysis was done by SPSS software.

RESULTS

Student t-test showed that there was no significant difference between two groups in mean scores of health-related quality of life before the study but this test showed a significant difference between two groups, one and two months after intervention (p < 0.05). anova test with repeated measurements showed that there is a significant difference in mean score of whole and dimensions of health-related quality of life between two groups in three times (p < 0.05).

CONCLUSIONS

Although this study provides modest support for the effectiveness of Progressive Muscle Relaxation Technique on quality of life of multiple sclerosis patients, further research is required to determine better methods to promote quality of life of patients suffer multiple sclerosis and other chronic disease.

RELEVANCE TO CLINICAL PRACTICE

Progressive Muscle Relaxation Technique is practically feasible and is associated with increase of life quality of multiple sclerosis patients; so that health professionals need to update their knowledge about complementary therapies.

Review: Toward Realizing the Potential of Diversity in Composition of Interprofessional Health Care Teams

Interprofessional approaches to health and social care have been linked to improved planning and policy development, more clinically effective services, and enhanced problem solving; however, there is evidence that professionals tend to operate in uniprofessional silos and that attempts to share knowledge across professional borders are often unsuccessful.

Predictive factors of functional gain in long-term stroke survivors admitted to a rehabilitation programme

PRIMARY OBJECTIVE

To assess factors that may influence functional gain of patients with chronic sequelae of stroke.

RESEARCH DESIGN

Prospective study of 290 stroke patients consecutively admitted to a rehabilitation setting.

METHODS AND PROCEDURES

Functional Independence Measure Scale (FIM) was used to assess functional capacity. Functional improvement registered during hospitalization (FIM-gain score) was compared to demographic data, stroke sub-type, vascular risk factors, motor deficit, visual hemineglect, aphasia, level of response and sphincter control. FIM-gain score was classified as high-gain (=22) and low-gain (<22).

MAIN OUTCOMES AND RESULTS

Two hundred and fifty-two patients who had no prior rehabilitation and were capable of completing the rehabilitation programme were studied (average age 58.4+/-13.9 years; 42.9% women). The mean time from stroke onset to admission was 271.5 days. Average FIM score at admission was 58.8 and at discharge was 81.6. Average FIM Gain was 23.6. The 38% patients admitted later than 6 months after stroke had an average FIM Gain of 19 vs 26 for patients admitted prior to 6 months. Significant predictors of functional improvement were time from stroke onset, age, sitting balance and level of responsiveness.

CONCLUSION

The functional improvement scores in persons with stroke beginning a rehabilitation programme at a later stage are 73% of the scores obtained by patients beginning treatment in the first 6 months. FIM score improvement can be predicted by time since stroke onset, age, sitting balance and level of responsiveness.

Recombinant factor VIIa plus surgery for intracerebral hemorrhage

BACKGROUND

Hyperacute surgical evacuation of intracerebral hemorrhage is associated with a high rebleeding rate. The peri-operative administration of rFVIIa to patients with intracerebral hemorrhage may decrease the frequency of post-operative hemorrhage, and improve outcome.

METHODS

Patients receiving recombinant activated factor VII (rFVIIA) therapy immediately prior to acute surgery were collected at two centres. The intracerebral hemorrhage (ICH) score and ICH Grading Scale were determined, as was long-term outcome using the modified Rankin Scale. Residual/recurrent clot was evaluated by comparing pre-operative to post-operative CT scans.

RESULTS

Fifteen patients with intracerebral hemorrhage received 40-90 microg/kg of rFVIIa and underwent surgical hematoma evacuation at a median time of five hours following symptom onset. Median pre-operative clot volume was 60 ml, decreasing to 2 ml post-operatively. There were no thromboembolic adverse events. Thirteen patients survived, 11 (73%) were independent, and two (13%) had a moderate to severe disability. These outcomes were significantly better than expected based on the median ICH score (40% mortality) and based on median ICH Grading Scale (18% good outcome).

CONCLUSIONS

The pre or perioperative administration of rFVIIa resulted in minimal residual or recurrent hematoma volume and may be an important adjunct to surgery in patients with intracerebral hemorrhage.