Reliability (inter-rater agreement) of the Barthel Index for assessment of stroke survivors: systematic review and meta-analysis

Mobility, functionality and functional mobility: A review and application for canine veterinary patients

Mobility is an essential aspect of a dog's daily life. It is defined as the ability to move freely and easily and deviations from an animals' normal mobility capabilities are often an indicator of disease, injury or pain. When a dog's mobility is compromised, often functionality (ability to perform activities of daily living [ADL]), is also impeded, which can diminish an animal's quality of life. Given this, it is necessary to understand the extent to which conditions impact a dog's physiological ability to move around their environment to carry out ADL, a concept termed functional mobility. In contrast to human medicine, validated measures of canine functional mobility are currently limited. The aim of this review is to summarise the extent to which canine mobility and functionality are associated with various diseases and how mobility and functional mobility are currently assessed within veterinary medicine. Future work should focus on developing a standardised method of assessing functional mobility in dogs, which can contextualise how a wide range of conditions impact a dog's daily life. However, for a true functional mobility assessment to be developed, a greater understanding of what activities dogs do on a daily basis and movements underpinning these activities must first be established.

Upper extremity training followed by lower extremity training with a brain-computer interface rehabilitation system

Introduction

Brain-computer interfaces (BCIs) based on functional electrical stimulation have been used for upper extremity motor rehabilitation after stroke. However, little is known about their efficacy for multiple BCI treatments. In this study, 19 stroke patients participated in 25 upper extremity followed by 25 lower extremity BCI training sessions.

Methods

Patients' functional state was assessed using two sets of clinical scales for the two BCI treatments. The Upper Extremity Fugl-Meyer Assessment (FMA-UE) and the 10-Meter Walk Test (10MWT) were the primary outcome measures for the upper and lower extremity BCI treatments, respectively.

Results

Patients' motor function as assessed by the FMA-UE improved by an average of 4.2 points (p < 0.001) following upper extremity BCI treatment. In addition, improvements in activities of daily living and clinically relevant improvements in hand and finger spasticity were observed. Patients showed further improvements after the lower extremity BCI treatment, with walking speed as measured by the 10MWT increasing by 0.15 m/s (p = 0.001), reflecting a substantial meaningful change. Furthermore, a clinically relevant improvement in ankle spasticity and balance and mobility were observed.

Discussion

The results of the current study provide evidence that both upper and lower extremity BCI treatments, as well as their combination, are effective in facilitating functional improvements after stroke. In addition, and most importantly improvements did not stop after the first 25 upper extremity BCI sessions.

Working-Age Caregivers of Stroke Survivors: Needs, Concerns, and Quality of Life

PURPOSE

The purpose of this study was to characterize the unmet needs and concerns of working-age caregivers of stroke survivors and to explore the relationships between these unmet needs and concerns and factors such as stroke survivor functional independence, caregiver strain, caregiver self-efficacy, caregiver perceived social support, and caregiver quality of life (QoL).

DESIGN

Cross-sectional descriptive design was used in this study.

METHODS

Participants ( N = 103) completed an online survey. Descriptive statistics, bivariate Pearson correlation, and linear regression analysis was performed.

RESULTS

Negative correlations were found between caregiver needs and concerns and both stroke survivor functional independence and caregiver self-efficacy. Positive correlations were identified between caregiver needs and concerns and caregiver strain. In multiple regression models, stroke survivor functional independence, caregiver self-efficacy, race, and gender were statistically significantly associated with caregiver QoL.

CLINICAL RELEVANCE TO THE PRACTICE OF REHABILITATION NURSING

Results of this study can inform nurses as they collaborate with informal caregivers and researchers in optimizing the rehabilitation and discharge process and aiding in the support of caregiver QoL.

CONCLUSION

Working-age caregivers of stroke survivors expressed many needs and concerns. These needs, along with other factors, can affect outcomes including QoL in caregivers and stroke survivors.

Psychometric properties of Fullerton Advanced Balance Scale in patients with stroke

BACKGROUND

Patients experience falls frequently after stroke. Preserved or acquired balance skills decrease fall risk and improve independence. Feasibility of Fullerton Advanced Balance Scale (FAB) has been shown in balance assessment in some neurological diseases except stroke.

OBJECTIVES

The purpose of this study was to investigate the reliability and validity of Turkish version of FAB (FAB-T) in patients with stroke (PwS).

METHODS

This cross-sectional study included 51 PwS (60.64 ± 7.66 years). Reliability analyses were conducted with Cronbach's alpha, intraclass correlation coefficient (ICC), and Spearman correlation analysis. Intra-rater and inter-rater reliability were assessed with three raters. FAB-T, Stroke Rehabilitation Assessment of Movement (STREAM), Brunnstrom Recovery Stages (BRS), Barthel Index (BI), and 36-Item Short Form Health Survey (SF-36) were used for convergent validity. Correlations of FAB-T with Berg Balance Scale (BBS) and Mini-Balance Evaluation Systems Test (Mini-BESTest) were measured for concurrent validity. Spearman correlation analysis was used for convergent and concurrent validity. For predictive validity patients' self-reports of falling were analyzed with ROC.

RESULTS

Intra-rater (ICC = 0.998) and inter-rater reliability (ICCs = 0.984; 0.984; 0.990), and internal consistency (Cronbach's alpha = 0.930) were excellent. FAB-T had good correlations with STREAM (ρ = 0.677) and BI (ρ = 0.628), moderate correlations with BRS (ρ = 0.504 and ρ = 0.579) and physical function of SF-36 (ρ = 0.436). FAB-T excellently correlated with Mini-BESTest and BBS (ρ = 0.928 and ρ = 0.942). The cutoff score of FAB-T was determined to be 21.5 points, with sensitivity of 84% and specificity of 61% (AUC = 0.749).

CONCLUSIONS

FAB-T is a reliable and valid balance assessment tool with an acceptable accuracy of fall prediction in PwS.

Comparative efficacy of non-invasive brain stimulation for post-stroke cognitive impairment: a network meta-analysis

BACKGROUND

Non-invasive brain stimulation (NIBS) is a burgeoning approach with the potential to significantly enhance cognition and functional abilities in individuals who have undergone a stroke. However, the current evidence lacks robust comparisons and rankings of various NIBS methods concerning the specific stimulation sites and parameters used. To address this knowledge gap, this systematic review and meta-analysis seek to offer conclusive evidence on the efficacy and safety of NIBS in treating post-stroke cognitive impairment.

METHODS

A systematic review of randomized control trials (RCT) was performed using Bayesian network meta-analysis. We searched RCT in the following databases until June 2022: Cochrane Central Register of Controlled Trials (CENTRAL), PUBMED, and EMBASE. We compared any active NIBS to control in terms of improving cognition function and activities of daily living (ADL) capacity following stroke.

RESULTS

After reviewing 1577 retrieved citations, a total of 26 RCTs were included. High-frequency (HF)-repetitive transcranial magnetic stimulation (rTMS) (mean difference 2.25 [95% credible interval 0.77, 3.66]) was identified as a recommended approach for alleviating the global severity of cognition. Dual-rTMS (27.61 [25.66, 29.57]) emerged as a favorable technique for enhancing ADL function. In terms of stimulation targets, the dorsolateral prefrontal cortex exhibited a higher ranking in relation to the global severity of cognition.

CONCLUSIONS

Among various NIBS techniques, HF-rTMS stands out as the most promising intervention for enhancing cognitive function. Meanwhile, Dual-rTMS is highly recommended for improving ADL capacity.

Perioperative disabilities in activities of daily living are associated with worse prognosis after hepatectomy for colorectal liver metastasis

BACKGROUND

The number of vulnerable patients with colorectal liver metastasis (CRLM) has increased. This study aimed to clarify the relationship between perioperative activities of daily living (ADL) and clinical outcomes after hepatectomy for CRLM.

METHODS

Consecutive patients undergoing resection of CRLM from 2004 to 2020 were included. Pre- or postoperative ADL was evaluated according to Barthel index (BI) scores, which range from 0 to 100. Higher scores represent greater level of independence in ADL. Pre- or postoperative BI scores of ≤85 were defined as perioperative disabilities in ADL. Multivariable Cox proportional hazard regression models were utilised to estimate adjusted hazard ratios (HRs) and confidence interval (CI).

RESULTS

A total of 218 patients were included, 16 (7.3%) revealed preoperative BI scores of ≤85, and 32 (15%) revealed postoperative BI scores of ≤85. In multivariate analyses, the perioperative disabilities in ADL were independently associated with shorter overall survival (HR, 1.96; 95% CI, 1.10-3.31; P = 0.023) and cancer-specific survival (HR, 2.31; 95% CI, 1.29-3.92; P = 0.006).

CONCLUSION

Perioperative disabilities in ADL were associated with poor prognosis following hepatectomy for CRLM. Improving preoperative vulnerability and preventing functional decline after surgery may provide a favourable prognosis for patients with CRLM.

Reliability of interview-based ADL ability measures in older adults obtained by occupational therapists, physical therapists, and nursing staff

Purpose: To examine the reliability of ADL interview (ADL-I) ability measures when administered by different health professionals (HPs).Materials and methods:Older adults with stable ADL ability were invited to participate in three ADL-I interviews, administered by occupational therapists (OTs), physical therapists (PTs), and nursing staff (NS), respectively. Methods based on classic and modern test theory were applied.Results:Overall, n = 36 older adults and n = 11 HPs participated. Intraclass Correlation Coefficients were acceptable for research purposes (> 0.7), but not for clinical use. Mean differences in ADL ability measures were significant when comparing measures based on interviews by OTs to measures based on interviews by PTs and NS. Further, in 25 to 47% of the individuals, ADL-I ability measures differed significantly across HPs. Limits of Agreement revealed that measures based on interviews by OTs were systematically lower compared to measures based on interviews by PTs and NS. Four ADL-I items displayed Differential Item Functioning based on HP.Conclusion:When using the ADL-I, it is recommended to only involve one profession, to increase the reliability of measures. Results highlight the importance of evaluating reliability of measures based on instruments administered across HPs before implementation in rehabilitation practice and research.

The muscle shortening maneuver in individuals with stroke: a consideration-of-concept randomized pilot trial

BACKGROUND AND PURPOSE

The Muscle Shortening Maneuver (MSM) is derived from Feldman's λ model of motor control, and seems to induce a more balanced agonist- antagonist-muscular action. The hypothesized mechanism of action is a modulation of the Tonic Stretch Reflex Threshold (TSRT). We designed a pilot, randomized trial aimed to explore the mechanisms of action of the technique. An ancillary objective was to research the implementation of the MSM as a stroke rehabilitation intervention.

METHODS

A sample of 10 participants with chronic stroke was enrolled and randomly assigned to MSM (n, 5) or conventional physical therapy (CPT) (n, 5) treatments. The TSRTs were assessed by the Montreal Spasticity Measure device. A selection of clinical and instrumental outcome measures was taken to investigate function and activity levels. Data were collected at baseline, end-of-treatment, and one month after the end-of-treatment.

RESULTS

No adverse events were observed. In both between- and within-group post-treatment assessments, in the affected ankle the MSM group showed decreased TSRTs of the plantar flexor, increased strength of the dorsiflexor and active range of motion; also, the time needed to perform the Timed Up and Go test decreased. No changes were evident across assessments in the CPT group.

DISCUSSION AND CONCLUSIONS

The MSM seems able to modulate the TSRTs in individuals with stroke. Although with the limitations due to the pilot design, the variation in participants' responses appear to be promising. Many methodological issues have to be clarified and specified conceiving the progression toward a confirmatory trial.

Post-stroke limitations in daily activities: experience from a tertiary care hospital in Ethiopia

BACKGROUND

The disability of stroke patients remains an important global health problem; yet information on the extent of restriction from basic and instrumental activities of daily living is limited, particularly in lower-and middle-income (LMIC) countries. Therefore, we examined the issue under the caption, since it is the first step in planning several rehabilitation services.

METHOD

A facility-based cross-sectional study was done to assess the magnitude and predictors of post-stroke limitations in basic activities of daily living (BADL) using the Barthel Index (BI) scale and instrumental activities of daily living (IADL) using the Frenchay Activities Index (FAI) scale among patients who visited Tikur Anbessa Specialized Hospital in Addis Ababa, Ethiopia, Neurology Clinic from April-October, 2022. All patients having a diagnosis of stroke for more than six months duration were enrolled. Descriptive and inferential statistical analyses were done, and measures of estimated crude and adjusted odds ratio with 95% CI were constructed and a p-value less than 0.05 was considered statistically significant. The results are presented in figures and tables.

RESULTS

A total of 150 stroke patients were enrolled in the present study. The mean age of participants was 53 (14.9) years with slight male preponderance (51.3%). Ischemic stroke was present in 106 (70.7%) of them, while 44 (29.3%) had hemorrhagic stroke. Of this, 57 (38%) and 115 (79.3%) of them had limitations in basic and instrumental ADL, respectively. Comorbid cardiac disease (AOR = 6.9; 95%CI = 1.3-37.5) and regular substance use (AOR = 11.1; 95%CI = 1.1-115) were associated with limitations in BADL, while an increase in age (AOR = 1.1; 95%CI = 1.04-1.15) was associated with severe limitations in BADL. Initial stroke severity (AOR = 7.3; 95%CI = 1.2-44.7) was associated with limitations in IADL, whereas depression (AOR = 5.1; 95%CI = 1.1-23.2) was identified as a predictor of severe limitation in IADL.

CONCLUSION

Limitation in activities of daily living (ADL) after stroke is common among Ethiopian patients. Therefore, screening for post-stroke limitations in daily activities is essential for further management and rehabilitative plans.

The Influence of Hemoglobin and Swallowing Ability on Daily Living Activities After Hospital Discharge in Taiwanese Stroke Patients: A Longitudinal Study

OBJECTIVE

This study aimed to examine the mediating effect of swallowing ability on hemoglobin levels and activities of daily living (ADL).

DESIGN

Prospective longitudinal study.

SETTING

Two rehabilitation wards in a national referral center for Northern Taiwan, followed by discharge.

PARTICIPANTS

101 participants were admitted for first or recurrent infarction or hemorrhagic stroke and transferred to the rehabilitation ward of a medical center (N=101).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Hemoglobin data were collected from medical records. Swallowing ability and ADL were measured using the Functional Oral Intake Scale and Barthel Index, respectively, with higher scores indicating better functioning.

RESULTS

Mediation analysis performed using path analysis illustrated that hemoglobin at the time of transfer to the rehabilitation ward had a direct and positive effect on swallowing ability at 1-3 days before discharge (path coefficient=0.21, 95% confidence interval [CI]: 0.04-0.35, P=.018), and swallowing ability at 1-3 days before discharge had a direct and positive effect on ADL at 1 month after discharge (path coefficient=0.36, 95% CI: 0.13-0.57, P=.002). Hemoglobin level at the time of transfer to the rehabilitation ward did not directly influence ADL 1 month after discharge (path coefficient=0.12, 95% CI: -0.05-0.28, P=.166). These results indicate that swallowing ability substantially mediates the relation between previous hemoglobin levels and subsequent ADL.

CONCLUSION

Low hemoglobin levels and poor swallowing ability should be concurrently addressed to improve ADL performance.

Tele-rehabilitation on independence in activities of daily living after stroke: A Matched Case-Control Study

OBJECTIVES

To compare independence in activities of daily living (ADLs) in post-acute patients with stroke following tele-rehabilitation and matched in-person controls.

MATERIALS AND METHODS

Matched case-control study. A total of 35 consecutive patients with stroke who followed tele-rehabilitation were compared to 35 historical in-person patients (controls) matched for age, functional independence at admission and time since injury to rehabilitation admission (<60 days). The tele-rehabilitation group was also compared to the complete cohort of historical controls (n=990). Independence in ADLs was assessed using the Functional Independence Measure (FIM) and the Barthel Index (BI). We formally compared FIM and BI gains calculated as discharge score - admission scores, efficiency measured as gains / length of stay and effectiveness defined as (discharge score-admission score)/ (maximum score-admission score). We analyzed the minimal clinically important difference (MCID) for FIM and BI.

RESULTS

The groups showed no significant differences in type of stroke (ischemic or hemorrhagic), location, severity, age at injury, length of stay, body mass index, diabetes, dyslipidemia, hypertension, aphasia, neglect, affected side of the body, dominance or educational level. The groups showed no significant differences in gains, efficiency nor effectiveness either using FIM or Barthel Index. We identified significant differences in two specific BI items (feeding and transfer) in favor of the in-person group. No differences were observed in the proportion of patients who achieved MCID.

CONCLUSIONS

No significant differences were seen between total ADL scores for tele-rehabilitation and in-person rehabilitation. Future research studies should analyze a combined rehabilitation approach that utilizes both models.

Morphological alterations of contralesional hemisphere relate to functional outcomes after stroke

The present study aimed to investigate poststroke morphological alterations contralesionally and correlations with functional outcomes. Structural magnetic resonance images were obtained from 27 poststroke patients (24 males, 50.21 ± 10.97 years) and 20 healthy controls (13 males, 46.63 ± 12.18 years). Voxel-based and surface-based morphometry analysis were conducted to detect alterations of contralesional grey matter volume (GMV), cortical thickness (CT), gyrification index (GI), sulcus depth (SD), and fractal dimension (FD) in poststroke patients. Partial correlation analysis was used to explore the relationship between regions with significant structural differences and scores of clinical assessments, including Modified Barthel Index (MBI), Berg Balance Scale (BBS), Fugl-Meyer Assessment of Upper Extremity (FMA-UE), Mini-Mental State Examination (MMSE), and Montreal Cognitive Assessment (MoCA). Correction for multiplicity was conducted within each parameter and for all tests. GMV significantly decreased in the contralesional motor-related, occipital and temporal cortex, limbic system, and cerebellum lobe (P < 0.01, family-wise error [FWE] correction). Lower CT was found in the contralesional precentral and lingual gyrus (P < 0.01, FWE correction), while lower GI found in the contralesional superior temporal gyrus and insula (P < 0.01, FWE correction). There were significant correlations between GMV of contralesional lingual gyrus and MBI (P = 0.031, r = 0.441), and BBS (P = 0.047, r = 0.409) scores, and GMV of contralesional hippocampus and FMA-UE scores (P = 0.048, r = 0.408). In conclusion, stroke patients exhibited wide grey matter loss and cortical morphological changes in the contralesional hemisphere, which correlated with sensorimotor functions and the ability of daily living.

Activities of daily living predict periprocedural myocardial infarction and injury following percutaneous coronary intervention: a cross-sectional study

BACKGROUND

In recent years, there has been growing interest in exploring the relationship between activities of daily living (ADL) and cardiovascular diseases. This retrospective cross-sectional study aimed to investigate the association of ADL measured by Barthel index (BI) with periprocedural myocardial infarction (PMI) and injury following percutaneous coronary intervention (PCI).

METHODS

Enrolled patients were stratified into impaired and unimpaired ADL groups according to their BI scores. Logistic regressions were conducted to explore the association of ADL on admission with periprocedural myocardial injury and infarction. Restricted cubic spline (RCS) curve and subgroup analysis were also performed.

RESULTS

Totally, 16.4% of patients suffered from PMI; the mean age was 65.8 ± 10.4 years old. RCS analysis showed that the morbidity of periprocedural myocardial infarction and injury showed a downward tendency with increasing BI scores. Multivariable logistic regression analysis demonstrated that impaired ADL was an independent risk factor for periprocedural myocardial infarction (OR = 1.190, 95% CI [1.041, 1.360], P = 0.011) and injury (OR = 1.131, 95% CI [1.017, 1.257], P = 0.023). Subgroup analysis showed that the association between ADL and PMI was founded in several subgroups, while the association between ADL and periprocedural myocardial injury was founded only in BMI ≥ 24 kg/m2 subgroup.

CONCLUSION

Impaired ADL at hospital admission was an independent risk factor for periprocedural myocardial infarction and injury among patients following PCI.

Comparison between the General Assessment of Hospitalised Patient Tool and the Barthel Index: A Retrospective Study

Among hospitalised patients, functional decline and increased dependence on others are common health problems. Identifying critical needs is an important starting point to empower patients to improve their own health and behaviour. Once these needs are determined, the most relevant goals for addressing patients' needs and health potential can be established. This study aimed to test a model for profiling patients using the General Assessment of Hospitalised Patients (ASGO) compared to the Barthel Index (BI) as the gold standard. A retrospective approach was conducted by reviewing administrative data recorded between 2017 and 2020 at the University of Padova, Italy. Data from patients (a) older than 18 years, (b) admitted to a local hospital, and (c) with a stay of at least three days were included in the study. The ASGO and the BI were both used on patients' admission and discharge from the ward. Data were analysed using STATA software (v.16) (StataCorp. 2019. Stata Statistical Software: Release 16. College Station, TX: StataCorp LLC). The database used for the analysis consisted of 842 patient records, with more than 50% over 75 years of age and consisting mainly of men. The results of the ASGO and the BI were more correlated at discharge (rho = -0.79) than at admission (rho = -0.59). Furthermore, sensitivity and specificity, calculated with reference to the optimal cut-off point (Youden index), demonstrated the highest reliability of the test at discharge (sensitivity: 0.87; specificity: 0.78) compared to admission (sensitivity: 0.77; specificity: 0.72). This result was confirmed by the analysis of the ROC curve: The area under the curve was greater at discharge (89%) than at admission (82%). Analysis of the results obtained from assessments created with the ASGO demonstrates the applicability of this model in the context of hospital care and how well it can represent functional dependence. This study was not registered.

Autonomic function may mediate the neuroprotection of remote ischemic postconditioning in stroke: A randomized controlled trial

OBJECTIVES

To evaluate the effect of remote ischemic postconditioning (RIPostC) on the prognosis of acute ischemic stroke(AIS) patients and investigate the mediating role of autonomic function in the neuroprotection of RIPostC.

MATERIALS AND METHODS

132 AIS patients were randomized into two groups. Patients received four cycles of 5-min inflation to a pressure of 200 mmHg(i.e., RIPostC) or patients' diastolic BP(i.e., shame), followed by 5 min of deflation on healthy upper limbs once a day for 30 days. The main outcome was neurological outcome including the National Institutes of Health Stroke Scale (NIHSS), modified Rankin Scale (mRS), and Barthel index(BI). The second outcome measure was autonomic function measured by heart rate variability(HRV).

RESULTS

Compared with the baseline, the post-intervention NIHSS score was significantly reduced in both groups (P<0.001). NIHSS score was significantly lower in the control group than intervention group at day 7.[RIPostC:3(1,5) versus shame:2(1,4); P=0.030]. mRS scored lower in the intervention group compared with the control group at day 90 follow-up(RIPostC:0.5±2.0 versus shame:1.0±2.0;P=0.016). The goodness-of-fit test revealed a significant difference between the generalized estimating equation model of mRS and BI scores of uncontrolled-HRV and controlled-HRV(P<0.05, both). The results of bootstrap revealed a complete mediation effect of HRV between group on mRS[indirect effect: -0.267 (LLCI = -0.549, ULCI = -0.048), the direct effect: -0.443 (LLCI = -0.831, ULCI = 0.118)].

CONCLUSION

This is the first human-based study providing evidence for a mediation role of autonomic function between RIpostC and prognosis in AIS patients. It indicated that RIPostC could improve the neurological outcome of AIS patients. Autonomic function may play a mediating role in this association.

TRIAL REGISTRATION

The clinical trials registration number for this study is NCT02777099 (ClinicalTrials.gov Identifier).

Application of action observation therapy in stroke rehabilitation: A systematic review

BACKGROUND

Numerous studies have described the positive effects of action observation therapy (AOT) on motor recovery among patients with stroke. However, there is no standardized procedure for when and how to intervene with AOT.

OBJECTIVES

Thus, we reviewed and analyzed previous studies to provide a guideline for the application of AOT in stroke rehabilitation.

METHOD

We searched PubMed, Cochrane Library, and EMBASE from inception to October 31 2022, using title and abstract search terms of "action observation" and "stroke" or "hemiplegia." Of 4108 potential articles, 29 articles (sample size = 429 in AOT groups; sample size = 423 in control groups) that met inclusion criteria were included in final analyses.

RESULTS

The results suggested starting adjuvant AOT > 23 days after stroke onset and conducting 30-40 min/session, 3-5 times/week for at least 4 weeks.

CONCLUSION

Based on our results, many factors will impact the effect of AOT on stroke rehabilitation, when to apply (timing) and how to apply (frequency, single, and total duration) should be fully considered when applying AOT as adjuvant therapy in stroke rehabilitation.

Using home monitoring technology to study the effects of traumatic brain injury on older multimorbid adults: protocol for a feasibility study

INTRODUCTION

The prevalence of traumatic brain injury (TBI) among older adults is increasing exponentially. The sequelae can be severe in older adults and interact with age-related conditions such as multimorbidity. Despite this, TBI research in older adults is sparse. Minder, an in-home monitoring system developed by the UK Dementia Research Institute Centre for Care Research and Technology, uses infrared sensors and a bed mat to passively collect sleep and activity data. Similar systems have been used to monitor the health of older adults living with dementia. We will assess the feasibility of using this system to study changes in the health status of older adults in the early period post-TBI.

METHODS AND ANALYSIS

The study will recruit 15 inpatients (>60 years) with a moderate-severe TBI, who will have their daily activity and sleep patterns monitored using passive and wearable sensors over 6 months. Participants will report on their health during weekly calls, which will be used to validate sensor data. Physical, functional and cognitive assessments will be conducted across the duration of the study. Activity levels and sleep patterns derived from sensor data will be calculated and visualised using activity maps. Within-participant analysis will be performed to determine if participants are deviating from their own routines. We will apply machine learning approaches to activity and sleep data to assess whether the changes in these data can predict clinical events. Qualitative analysis of interviews conducted with participants, carers and clinical staff will assess acceptability and utility of the system.

ETHICS AND DISSEMINATION

Ethical approval for this study has been granted by the London-Camberwell St Giles Research Ethics Committee (REC) (REC number: 17/LO/2066). Results will be submitted for publication in peer-reviewed journals, presented at conferences and inform the design of a larger trial assessing recovery after TBI.

Effects of transcutaneous electrical acupoint stimulation on upper-limb impairment after stroke: A randomized, controlled, single-blind trial

OBJECTIVE

To evaluate the effects of transcutaneous electrical acupoint stimulation (TEAS) on upper limb motor recovery during post-stroke rehabilitation.

DESIGN

Single-blind, randomized controlled trial.

SETTING

Four inpatient rehabilitation facilities.

SUBJECTS

A total of 204 stroke patients with unilateral upper limb motor impairment were randomly 1:1 allocated to TEAS or sham TEAS group. Baseline demographic and clinical characteristics were comparable between the two groups.

INTERVENTIONS

Both groups received conventional physical and occupational therapies. TEAS and sham TEAS therapy were administered to two acupoints (LI10 and TE5) with a pulse duration of 300 µs at 2 Hz on the affected forearm for 30 times over 6 weeks.

OUTCOME MEASURES

The upper-extremity Fugl-Meyer score (primary outcome), manual muscle testing, modified Ashworth scale, Lindmark hand function score, and Barthel index were evaluated by blinded assessors at baseline, 2, 4, 6, 10, and 18 weeks.

RESULTS

The number of patients who completed the treatment was 99 and 97 in the TEAS and the sham group. No significant between-group difference was found in the Upper-Extremity Fugl-Meyer score, Modified Ashworth Scale, Lindmark hand function score, and Barthel Index after intervention and during follow-up. However, the TEAS group exhibited 0.29 (95% CI 0.02 to 0.55) greater improvements in Manual Muscle Testing of wrist extension than the sham group (p  =  0.037) at 18 weeks.

CONCLUSIONS

Administration of TEAS therapy to hemiplegic forearm could not improve the upper extremity motor recovery. However, TEAS on the forearm might provide potential benefits for strength improvement of the wrist.

Is Intravenous Immunoglobulin Effective in Reducing the Risk of Mortality and Morbidity in Neuroinvasive West Nile Virus Infection?: A Critically Appraised Topic

BACKGROUND

The clinical benefit of intravenous immunoglobulin (IVIG) in adult individuals with neuroinvasive West Nile virus (niWNV) infection is not well substantiated. We sought to critically assess current evidence regarding the efficacy of IVIG in treating patients with niWNV.

METHODS

The objective was addressed through the development of a critically appraised topic that included a clinical scenario, structured question, literature search strategy, critical appraisal, assessment of results, evidence summary, commentary, and bottom-line conclusions. Participants included consultant and resident neurologists, a medical librarian, clinical epidemiologists, and a content expert in the field of neuro-infectious diseases.

RESULTS

The appraised study enrolled 62 participants with suspected niWNV, randomized into 3 different arms [37 participants in the Omr-IgG-am group, 12 in the Polygam group, and 13 in the normal saline (NS) group]. Omr-IgG-am and Polygam are different formulations of IVIG. IVIG safety, measured as rates of serious adverse events, was the primary study outcome while IVIG efficacy, measured as rates of unfavorable outcomes, was a secondary endpoint. The estimated rates of SAE were statistically similar in all groups (51.4% Omr-IgG-am, 58.3% Polygam, and 23.1% NS groups). Unfavorable outcomes also occurred at a similar rate between all the groups (51.5% Omr-IgG-am, 54.5% Polygam, and 27.3% NS).

CONCLUSIONS

The appraised trial showed that Omr-IgG-am and Polygam are as safe as NS. Data on efficacy from this trial were limited by a small sample size. Phase III clinical trials on IVIG efficacy in NiWNV infection are needed.

The effects of exercise intervention on cognition and motor function in stroke survivors: a systematic review and meta-analysis

BACKGROUND

Cognitive impairment was a common sequela among stroke survivors, and exercise intervention was a promising non-pharmacological treatment modality for it.

PURPOSE

To explore the effects of exercise intervention programs on cognitive and motor function in patients with cognitive impairment after stroke.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

Seven online databases (PubMed, Embase, Cochrane Library, Web of Science, Scopus, PsycInfo, and SPORTDiscus) were searched from their inception to 10 February 2022. Randomised controlled trials (RCTs) comparing the effects of exercise with non-exercise rehabilitation, using the Montreal Cognitive Assessment, Addenbrooke's Cognitive Examination, Mini-Mental State Examination, Trial Making Test, Upper and Lower Extremity Fugl-Meyer Assessment, Berg Balance Scale, and Barthel Index, were selected. Calculations for each assessment were performed for the overall effect and the therapy of interest, taking into account the effect of stroke severity or stimulus parameters.

RESULTS

Twelve RCTs involving 975 participants and investigating nine different types of exercise interventions were included. The results were not affected by participant characteristics or reactive balance outcomes. Our results emphasise the importance of lightweight and operable aerobic exercises. Exercise itself had a high potential to improve cognitive impairment and motor function after stroke.

CONCLUSIONS

Exercise had significant positive effects on alleviating cognitive and motor impairments after stroke.

Combination of the Barthel Index at Discharge with GRACE Leads to Improved One-Year Mortality Prediction in Older Patients with Acute Myocardial Infarction

Purpose

Many older patients with acute myocardial infarction (AMI) have impaired ability for activities of daily living (ADL). Impaired ADL leads to poor prognosis in elderly patients. The Global Registry of Acute Coronary Events (GRACE) score is widely used for risk stratification in AMI patients but does not consider physical performance, which is an important prognosis predictor for older adults. This study assessed whether the Barthel Index (BI) score combine the GRACE score would achieve improved one-year mortality prediction in older AMI patients.

Patients and Methods

This single-center retrospective study included 688 AMI patients aged ≥65 years who were divided into an impaired ADL group (BI ≤60, n = 102) and a normal ADL group (BI >60, n = 586) based on BI scores at discharge. The participants were followed up for one year. Cox survival models were constructed for BI score, GRACE score, and BI score combined GRACE score for one-year mortality prediction.

Results

Patients had a mean age of 76.29 ± 7.42 years, and 399 were men (58%). A lower BI score was associated with more years of hypertension and diabetes, less revascularization, longer hospital stays, and higher one-year mortality after discharge. Multivariable Cox regression analysis identified BI as a significant risk factor for one-year mortality in older AMI patients (HR 0.977, 95% CI, 0.963-0.992, P = 0.002). BI (0.774, 95% CI: 0.731-0.818) and GRACE (0.758, 95% CI: 0.704-0.812) scores had similar predictive power, but their combination outperformed either score alone (0.810, 95% CI: 0.770-0.851).

Conclusion

BI at discharge is a significant risk factor for one-year mortality in older AMI patients, which can be better predicted by the combination of BI and GRACE scores.

The effects of nurse driven mobility intervention (NDMI) on activities of daily living, mobility, fear of falling, and balance performance in hospitalized older patients: A pilot study

A decrease in mobilization during hospitalization leads to a decline in physical function for older patients, and nurses play a critical role in mobility promotion. The purpose of this pilot study was to examine the feasibility of Nurse Driven Mobility Intervention (NDMI) in improving activities of daily living, mobility, fear of falling, balance performance, and maladaptive fall risk appraisal using a one-group pretest-posttest design. NDMI incorporates a multidisciplinary care team, early assessment, timely and frequent mobilization, and constant encouragement. A post-intervention interview was also conducted to explore the barriers and facilitators for mobilization during hospitalization. The result shows a significant improvement in balance performance.

DIA-based technology explores hub pathways and biomarkers of neurological recovery in ischemic stroke after rehabilitation

Objective

Ischemic stroke (IS) is a common disease that causes severe and long-term neurological disability in people worldwide. Although rehabilitation is indispensable to promote neurological recovery in ischemic stroke, it is limited to providing a timely and efficient reference for developing and adjusting treatment strategies because neurological assessment after stroke treatment is mostly performed using scales and imaging. Therefore, there is an urgent need to find biomarkers that can help us evaluate and optimize the treatment plan.

Methods

We used data-independent acquisition (DIA) technology to screen differentially expressed proteins (DEPs) before and after ischemic stroke rehabilitation treatment, and then performed Gene Ontology (GO) and pathway enrichment analysis of DEPs using bioinformatics tools such as KEGG pathway and Reactome. In addition, the protein-protein interaction (PPI) network and modularity analysis of DEPs were integrated to identify the hub proteins (genes) and hub signaling pathways for neurological recovery in ischemic stroke. PRM-targeted proteomics was also used to validate some of the screened proteins of interest.

Results

Analyzing the serum protein expression profiles before and after rehabilitation, we identified 22 DEPs that were upregulated and downregulated each. Through GO and pathway enrichment analysis and subsequent PPI network analysis constructed using STRING data and subsequent Cytoscape MCODE analysis, we identified that complement-related pathways, lipoprotein-related functions and effects, thrombosis and hemostasis, coronavirus disease (COVID-19), and inflammatory and immune pathways are the major pathways involved in the improvement of neurological function after stroke rehabilitation.

Conclusion

Complement-related pathways, lipoprotein-related functions and effects, thrombosis and hemostasis, coronavirus disease (COVID-19), and inflammation and immunity pathways are not only key pathways in the pathogenesis of ischemic stroke but also the main pathways of action of rehabilitation therapy. In addition, IGHA1, LRG1, IGHV3-64D, and CP are upregulated in patients with ischemic stroke and downregulated after rehabilitation, which may be used as biomarkers to monitor neurological impairment and recovery after stroke.

Motor network reorganization after motor imagery training in stroke patients with moderate to severe upper limb impairment

BACKGROUND

Motor imagery training (MIT) has been widely used to improve hemiplegic upper limb function in stroke rehabilitation. The effectiveness of MIT is associated with the functional neuroplasticity of the motor network. Currently, brain activation and connectivity changes related to the motor recovery process after MIT are not well understood.

AIM

We aimed to investigate the neural mechanisms of MIT in stroke rehabilitation through a longitudinal intervention study design with task-based functional magnetic resonance imaging (fMRI) analysis.

METHODS

We recruited 39 stroke patients with moderate to severe upper limb motor impairment and randomly assigned them to either the MIT or control groups. Patients in the MIT group received 4 weeks of MIT therapy plus conventional rehabilitation, while the control group only received conventional rehabilitation. The assessment of Fugl-Meyer Upper Limb Scale (FM-UL) and Barthel Index (BI), and fMRI scanning using a passive hand movement task were conducted on all patients before and after treatment. The changes in brain activation and functional connectivity (FC) were analyzed. Pearson's correlation analysis was conducted to evaluate the association between neural functional changes and motor improvement.

RESULTS

The MIT group achieved higher improvements in FM-UL and BI relative to the control group after the treatment. Passive movement of the affected hand evoked an abnormal bilateral activation pattern in both groups before intervention. A significant Group × Time interaction was found in the contralesional S1 and ipsilesional M1, showing a decrease of activation after intervention specifically in the MIT group, which was negatively correlated with the FM-UL improvement. FC analysis of the ipsilesional M1 displayed the motor network reorganization within the ipsilesional hemisphere, which correlated with the motor score changes.

CONCLUSIONS

MIT could help decrease the compensatory activation at both hemispheres and reshape the FC within the ipsilesional hemisphere along with functional recovery in stroke patients.

A survey of caregiver burden for stroke survivors in non-teaching hospitals in Western China

The social factors that moderate stroke caregiver burden have been found to be culture- and gender-specific. We examined the factors that influence the social support and self-efficacy of caregivers of stroke survivors and the burden of caregiving in China. To determine the caregiver burden of stroke survivors, their social support, and their self-efficacy. A total of 328 stroke survivors and their caregivers were recruited from 4 tertiary medical centers to participate in this cross-sectional study. The sociodemographic and stroke-related characteristics of the participants were obtained. Perceived social support and self-efficacy were assessed using the Social Support Rating Scale and General Self-efficacy Scale, respectively. Caregiver burden was assessed using the Zarit Burden Interview Scale. Relationships between the variables were assessed using Pearson's correlation, the chi-square test, and a paired t test. A total of 27.4% of the caregivers reported receiving adequate social support, while 20.7% reported high levels of self-efficacy. A total of 67.1% of the caregivers experienced varying degrees of care burden, while the remaining 32.9% felt no burden. Participants' sociodemographic characteristics (age, daily care time, self-rated health, and financial situation) were significantly related to caregiver burden, social support, and self-efficacy (P < .001). The findings indicate an inverse relationship between caregiver burden, social support and self-efficacy. Adequate social support and self-efficacy can reduce stroke caregivers' burden. Hospital departments should provide assistance to stroke caregivers through educational programs and group training to increase their social support and self-efficacy, thereby alleviating their burden.

The Effect of Progressive Resistance Exercise Training on Cardiovascular Risk Factors in People with Intellectual Disabilities: A Study Protocol

Progressive resistance exercise training (PRET) reduces cardiovascular risk factors (CVRF) in the general population. It is unknown if PRET also reduces these risk factors in adults with intellectual disabilities (ID). The aim is to present the protocol of an intervention study that investigates the effect of PRET on CVRF in adults with ID. We will use a repeated time series design with one study group. Adults with mild-to-moderate ID and at least two CVRF are eligible (Netherlands Trial Register, NL8382). During a 12-week baseline period, measurements take place at a 6-week interval. After this, the PRET programme starts for 24 weeks, after which all measurements will be repeated. We will use hierarchical regression models, adjusted for sport activity and medication use, to estimate the effect of PRET. After the intervention, the participants will be followed-up for 12 weeks. We will evaluate factors for successful implementation of exercise in daily life. Primary outcomes are: hypertension, obesity, hypercholesterolemia, diabetes, metabolic syndrome. Secondary outcomes are: physical fitness, sarcopenia, physical activity, activities of daily living, falls, challenging behaviour. If our results show that the PRET programme is effective, it may be a promising non-pharmacological intervention to reduce CVRF in adults with ID.

Randomized Controlled Trial of Robot-Assisted Gait Training versus Therapist-Assisted Treadmill Gait Training as Add-on Therapy in Early Subacute Stroke Patients: The GAITFAST Study Protocol

The GAITFAST study (gait recovery in patients after acute ischemic stroke) aims to compare the effects of treadmill-based robot-assisted gait training (RTGT) and therapist-assisted treadmill gait training (TTGT) added to conventional physical therapy in first-ever ischemic stroke patients. GAITFAST (Clinicaltrials.gov identifier: NCT04824482) was designed as a single-blind single-center prospective randomized clinical trial with two parallel groups and a primary endpoint of gait speed recovery up to 6 months after ischemic stroke. A total of 120 eligible and enrolled participants will be randomly allocated (1:1) in TTGT or RTGT. All enrolled patients will undergo a 2-week intensive inpatient rehabilitation including TTGT or RTGT followed by four clinical assessments (at the beginning of inpatient rehabilitation 8-15 days after stroke onset, after 2 weeks, and 3 and 6 months after the first assessment). Every clinical assessment will include the assessment of gait speed and walking dependency, fMRI activation measures, neurological and sensorimotor impairments, and gait biomechanics. In a random selection (1:2) of the 120 enrolled patients, multimodal magnetic resonance imaging (MRI) data will be acquired and analyzed. This study will provide insight into the mechanisms behind poststroke gait behavioral changes resulting from intensive rehabilitation including assisted gait training (RTGT or TTGT) in early subacute IS patients.

Identity, social engagement and community participation impact physical activity levels of stroke survivors: A mixed-methods study

Objective

To explore how personal characteristics and social engagement impact the physical activity levels of chronic stroke survivors.

Design

A mixed-methods study comprising in-depth semi-structured interviews and objective 24-h physical activity monitoring. Interviews were thematically analysed, and activity diaries were compared to activity monitor data to attain a complete picture of physical activity. Triangulation explored the relationship between perceptions, beliefs, activity levels and social engagement.

Setting

Community.

Participants

Community-dwelling, independently mobile, adult stroke survivors (n = 19). The mean age was 74 (11 SD) years, 52% female, mean time post-stroke 41 (SD 61) months.

Main measures

Qualitative and quantitative measures including individual semi-structured interviews, accelerometry, activity diaries, self-efficacy, Frenchay Activities Index and Barthel Index.

Results

Individual identity had the greatest perceived influence on post-stroke physical activity. Pre-stroke identity, meaningful activities and family culture contributed to identity; while social and community activities, self-efficacy, co-morbidities, stroke symptoms and exercise, also impacted physical activity. Participants averaged 5365 (IQR 3378–7854) steps per day and reported a mean self-efficacy for exercise score of 51 (SD 20). Triangulation showed convergent relationships between post-stroke physical activity levels and participant motivation, comorbidities, level of social and community participation, self-efficacy and pre-stroke activity levels.

Conclusion

Personal identity, social engagement and community participation are important factors to consider when implementing a person-centred approach to increasing physical activity participation post-stroke.

Oral health knowledge, attitudes, and practices and oral health-related quality of life among stroke inpatients: a cross-sectional study

BACKGROUND

Stroke patients have poor oral hygiene, experience oral dysfunction due to disease factors, and have impaired oral health-related quality of life (OHRQoL). This study aimed to determine the oral health knowledge, attitudes, and practices of stroke inpatients, assess the OHRQoL of these patients, and identify their correlates.

METHODS

In this cross-sectional study, 281 stroke inpatients aged between 22 and 88 years (57.94 ± 10.94) were conveniently selected from three hospitals in Guangzhou, China. OHRQoL was measured among these stroke patients using a Chinese version of the Oral Health Impact Profile-14 (OHIP-14). SPSS 26.0 was used for statistical analysis. Mean scores, standard deviations, and frequency distributions were obtained. The Mann-Whitney U test, Kruskal‒Wallis H test, Spearman's correlation, and multiple linear regression were used in the analysis.

RESULTS

The mean score of the patients' OHRQoL was 8.37 ± 6.67, with the highest score in the pain or discomfort of the mouth dimension (3.11 ± 2.13) and pain being the most common negative effect (13.5%). In multiple linear regression analysis, significant differences were found between patients only in age (P = 0.008), toothache (P < 0.001), self-rated oral health (P < 0.001), time since last dentist visit (P = 0.037) and reason for not having visited a dentist in the past year (P < 0.001).

CONCLUSION

The OHRQoL of patients hospitalised with stroke was moderate, and oral conditions still need to be improved. Increasing age, toothache, a longer time since the last dental visit and the reason for not visiting a dentist in the past year had a negative effect on OHRQoL, and better self-rated oral health had a positive effect. Therefore, in clinical work, greater attention should be given to elderly stroke patients, patients with poor oral status and poor oral health behaviours, timely assessment of patients' swallowing function, nutritional function, and self-care ability, and early and targeted oral health interventions and guidance.

Effect of Grading Rehabilitation Nursing Mode on Limb Function, Speech Rehabilitation, and Quality of Life of Stroke Patients

Objective. The aim of this study is to investigate the influence of grading rehabilitation nursing mode on limb function, speech function, and QOL of stroke patients. Methods. From January 2018 to April 2019, the stroke patients who received treatment in our hospital were selected as the study participants. Based on the random number table, they were assigned to CG (n = 60) and OG (n = 60). The routine rehabilitation nursing mode was used in the CG, and the grading rehabilitation nursing mode was used in the OG. The limb function, speech function, QOL, and nursing satisfaction were evaluated in both the groups, and the survival curve was analyzed after 12 months of follow-up. Results. The motor function of upper and lower limbs in OG was significantly higher than that in CG, and the total effective rate of speech function recovery in OG was 95.00%, which was obviously higher than 81.67% in CG ( $P<0.05$ ); the total QOL score in OG was (80.72 ± 7.15), which was significantly higher than (69.53 ± 6.42) in CG. The nursing satisfaction of the OG was higher ( $P<0.05$ ). The Kaplan–Meier curve analysis revealed that the difference of 12-month survival rate between CG and OG was statistically significant (χ2 = 4.710, $P=0.030$ ). Conclusion. The application of grading rehabilitation nursing mode in stroke patients can effectively facilitate the recovery of extremity function and speech function, ameliorate the QOL and nursing satisfaction of patients, reduce the death and disability of patients, and prolong the survival time of patients.

Development and Validation of a Novel Robot-Based Assessment of Upper Limb Sensory Processing in Chronic Stroke

Upper limb sensory processing deficits are common in the chronic phase after stroke and are associated with decreased functional performance. Yet, current clinical assessments show suboptimal psychometric properties. Our aim was to develop and validate a novel robot-based assessment of sensory processing. We assessed 60 healthy participants and 20 participants with chronic stroke using existing clinical and robot-based assessments of sensorimotor function. In addition, sensory processing was evaluated with a new evaluation protocol, using a bimanual planar robot, through passive or active exploration, reproduction and identification of 15 geometrical shapes. The discriminative validity of this novel assessment was evaluated by comparing the performance between healthy participants and participants with stroke, and the convergent validity was evaluated by calculating the correlation coefficients with existing assessments for people with stroke. The results showed that participants with stroke showed a significantly worse sensory processing ability than healthy participants (passive condition: p = 0.028, Hedges’ g = 0.58; active condition: p = 0.012, Hedges’ g = 0.73), as shown by the less accurate reproduction and identification of shapes. The novel assessment showed moderate to high correlations with the tactile discrimination test: a sensitive clinical assessment of sensory processing (r = 0.52–0.71). We conclude that the novel robot-based sensory processing assessment shows good discriminant and convergent validity for use in participants with chronic stroke.

Personalized neurorehabilitative precision medicine: from data to therapies (MWKNeuroReha) - a multi-centre prospective observational clinical trial to predict long-term outcome of patients with acute motor stroke

BACKGROUND

Stroke is one of the most frequent diseases, and half of the stroke survivors are left with permanent impairment. Prediction of individual outcome is still difficult. Many but not all patients with stroke improve by approximately 1.7 times the initial impairment, that has been termed proportional recovery rule. The present study aims at identifying factors predicting motor outcome after stroke more accurately than before, and observe associations of rehabilitation treatment with outcome.

METHODS

The study is designed as a multi-centre prospective clinical observational trial. An extensive primary data set of clinical, neuroimaging, electrophysiological, and laboratory data will be collected within 96 h of stroke onset from patients with relevant upper extremity deficit, as indexed by a Fugl-Meyer-Upper Extremity (FM-UE) score ≤ 50. At least 200 patients will be recruited. Clinical scores will include the FM-UE score (range 0-66, unimpaired function is indicated by a score of 66), Action Research Arm Test, modified Rankin Scale, Barthel Index and Stroke-Specific Quality of Life Scale. Follow-up clinical scores and applied types and amount of rehabilitation treatment will be documented in the rehabilitation hospitals. Final follow-up clinical scoring will be performed 90 days after the stroke event. The primary endpoint is the change in FM-UE defined as 90 days FM-UE minus initial FM-UE, divided by initial FM-UE impairment. Changes in the other clinical scores serve as secondary endpoints. Machine learning methods will be employed to analyze the data and predict primary and secondary endpoints based on the primary data set and the different rehabilitation treatments.

DISCUSSION

If successful, outcome and relation to rehabilitation treatment in patients with acute motor stroke will be predictable more reliably than currently possible, leading to personalized neurorehabilitation. An important regulatory aspect of this trial is the first-time implementation of systematic patient data transfer between emergency and rehabilitation hospitals, which are divided institutions in Germany.

TRIAL REGISTRATION

This study was registered at ClinicalTrials.gov ( NCT04688970 ) on 30 December 2020.

Foot and ankle deformities in stroke: relationship with ambulation, balance, and daily living activities: a cross-sectional study

BACKGROUND

Ankle-foot deformities play a critical role in functional capacity and therefore activities of daily living in stroke patients.

AIM

This is the first study to evaluate all foot deformities in stroke patients together. The primary aim of this study is to determine the frequency of ankle-foot deformities in stroke patients. The secondary aim is to investigate the relationships between ankle-foot deformities and ambulation, postural control, balance, spasticity, and activities of daily living.

MATERIAL AND METHODS

The Functional Ambulation Classification was used to assess ambulation status, Postural Assessment Scale for Stroke Patients was used to assess postural control and balance. Lower extremity spasticity was evaluated with Modified Ashworth Scale. Activities of daily living were evaluated with Barthel Index.

RESULTS

Ankle-foot deformity was detected in 77 (42%) of 184 cases. The incidence of pes equinovarus was 48%, pes equinus was seen in 22%, claw toe in 19.5%, and pes varus in 10.4%. Pes equinovarus and claw toe were seen together in 8 cases. In the group with ankle-foot deformity, the disease duration was longer and the rate of spasticity in the lower extremity was statistically higher (p = 0.29, p = 0.023). There was no difference in Functional Ambulation Classification, Barthel Index, and Postural Assessment Scale for Stroke Patients scores between patients with or without ankle-foot deformity (p = 0.811, 0.321, 0.385).

CONCLUSION

It is important to detect ankle-foot deformities in stroke patients. Ankle-foot deformities are associated with spasticity in patients with stroke and are an important factor to be considered when determining the rehabilitation program.

Modulation of Brain Rhythm Oscillations by Xingnao Kaiqiao Acupuncture Correlates with Stroke Recovery: A Randomized Control Trial

Objectives: In China, Xingnao Kaiqiao (XNKQ) acupuncture has been widely used for stroke treatment. However, its electrophysiological mechanism remains unclear. Hence, this study aims to study how XNKQ acupuncture modulates brain rhythm oscillations of stroke patients, and investigate its correlation with stroke recovery. Design: Randomized control trial. Subjects: Twenty (sub)acute ischemic stroke patients were enrolled and randomly assigned to two groups (an acupuncture group [AG] [n = 10] and a control group [CG] [n = 10]), and four patients (two patients in each group) dropped out of the study. Interventions: All patients received conventional treatments, and the patients in AG received additional XNKQ acupuncture treatment once a day for 10 consecutive days. Outcome measures: Before treatment, 14 days after, and 30 days after treatment onset, their movement impairments and neurologic deficits were measured using the National Institute of Health Stroke Scale (NIHSS), the Fugl-Meyer (FM) Scale, the Modified Rankin Scale (mRS), and the Modified Barthel Index (MBI), and their electroencephalogram data were recorded. Results: Compared with the CG, the AG showed more improvement in FM scores (p = 0.02), as well as decreased relative delta power and increased relative alpha power after 2 weeks' treatment. The decrease of the relative delta power and the increase of the relative alpha power in the ipsilesional frontal area were significantly correlated with the FM improvement (F5, F7, FC1, and Fz electrodes, all |r| > 0.517, p < 0.040). Conclusions: The curative effect of XNKQ acupuncture related to its electrophysiological modulation. This study was registered at the Chinese Clinical Trial Registry (ChiCTR2000038560).

Synergy-Based Motor Therapy Inducing Favorable Changes in Motor Function Components among Poststroke Subjects: A Single-Group Study

Background  Synergy is an outcome of multiple muscles acting in a synchronized pattern, controlled by the central nervous system. After brain insult, a set of deviated movement pattern emerges in the affected limb. The methods to train synchronization of muscles may diminish the deviated movement augmenting neuromotor control. The purpose of this investigation was to develop a synergy-based motor therapy (SBMT) protocol for the paretic upper limb in poststroke subjects. Further, the feasibility and effectiveness of the program was evaluated. .

Methods  The design was Pretest–posttest single-group assessor-blinded trial. Department of occupational therapy of a national institute for persons with physical disabilities was the study site. There were 40 study subjects (23 men, ranging from 40 to 60 years, 18 subjects with hemorrhagic cerebrovascular accident, and > 6 months after the accident) exhibiting motor paresis of half side of the body. SBMT is a stage-specific regime based on the linkage between the deviated and usual muscle action. SBMT items were selected considering the strength and magnitude of the deviated motor components. The movement linkages were utilized to dissociate strong coupled components; for instance, forearm pronation-supination with elbow 90-degree flexion. Fugl-Meyer Assessment (upper extremity) (FMA-UE), Wolf Motor Function Test (WMFT), and Barthel Index (BI) were applied to quantify the motor status, motor functional ability of the upper extremity, and self-care activities, respectively.

Results  All the enrolled subjects could perform their corresponding SBMT sessions. Posttreatment, FMA-UE improved significantly ( p  < 0.001) from mean of 26.30 (standard deviation [SD] 15.02) to 35.20 (SD 17.64). Similarly, the WMFT both time (in seconds) and quality also positively improved significantly ( p  < .001) from mean of 76.77 (SD 54.73) to 64.07 (SD 56.99) and 1.34 (SD 1.06) to 1.87 (SD 1.34), respectively. BI improved from 79.88 (SD 17.07) to 92.62 (SD 21.2) after the intervention ( p  < 0.001).

Conclusion  SBMT protocol was a feasible and effective intervention to facilitate motor function components in chronic hemiparetic subjects. The regime could be considered as a potential intervention for stroke rehabilitation. Further trials and use of sophisticated measures are recommended to authenticate the outcome of this investigation.

Clinical Trial Registration  Clinical Trial Registry of India as CTRI/2017/10/010162 on October 23, 2017 (retrospectively).

Development of Deep Learning Models for Predicting In-Hospital Mortality Using an Administrative Claims Database: Retrospective Cohort Study

BACKGROUND

Administrative claims databases have been used widely in studies because they have large sample sizes and are easily available. However, studies using administrative databases lack information on disease severity, so a risk adjustment method needs to be developed.

OBJECTIVE

We aimed to develop and validate deep learning-based prediction models for in-hospital mortality of acute care patients.

METHODS

The main model was developed using only administrative claims data (age, sex, diagnoses, and procedures on the day of admission). We also constructed disease-specific models for acute myocardial infarction, heart failure, stroke, and pneumonia using common severity indices for these diseases. Using the Japanese Diagnosis Procedure Combination data from July 2010 to March 2017, we identified 46,665,933 inpatients and divided them into derivation and validation cohorts in a ratio of 95:5. The main model was developed using a 9-layer deep neural network with 4 hidden dense layers that had 1000 nodes and were fully connected to adjacent layers. We evaluated model discrimination ability by an area under the receiver operating characteristic curve (AUC) and calibration ability by calibration plot.

RESULTS

Among the eligible patients, 2,005,035 (4.3%) died. Discrimination and calibration of the models were satisfactory. The AUC of the main model in the validation cohort was 0.954 (95% CI 0.954-0.955). The main model had higher discrimination ability than the disease-specific models.

CONCLUSIONS

Our deep learning-based model using diagnoses and procedures produced valid predictions of in-hospital mortality.

Depression, Adherence, and Functionality in Patients Undergoing Hemodialysis

Background 

Patients undergoing hemodialysis face multiple problems such as difficulties in performing daily activities, low functional capacity, non-adherence to the hemodialysis regimen, and depressive symptoms that lead to poor health outcomes. The present study aimed to assess the levels of depression, adherence, and functionality in patients undergoing hemodialysis, as well as the association between the above variables.

Materials and methods

In this cross-sectional study, 100 patients undergoing hemodialysis from a private hospital in Athens participated. Data were collected via the Zung Self-Rating Depression Scale, the Barthel Scale/Index, and the Greek Simplified Medication Adherence Questionnaire-Hemodialysis for the evaluation of patients’ depression, functionality, and adherence to hemodialysis regimen, respectively. In addition, sociodemographic and clinical characteristics were recorded. The study was conducted during the period of December 2020 to February 2021. IBM SPSS Statistics for Windows, Version 25.0 (Released 2017. IBM Corp., Armonk, New York) was used for the statistical analysis of the data. The statistical significance level was set up at 0.05.

Results

Of the patients, 50% scored < 38 (possible range 20-80) in the scale pof depression, and 25% of patients scored < 34. Regarding adherence, the median value was 7 (IQR: 7-7) while 77% scored 7 (possible range of 0-8). Regarding functionality, mild dependence (score 91-99) was referred by 77% of the participants, moderate dependence (score 61-90) by 17%, and severe dependence (score 21-60) was referred by 6% of the patients. A statistically significant negative association emerged between depression and functionality (r= -0.342, p=0.001) while no significant association arised between depression and adherence (r= 0.021,p=0.836) as well as between adherence and functionality (r = 0.078, p = 0.439). Statistical significantly higher scores of depression were seen in women (β = 3.65, p = 0.001) and elderly >70 years old (β = 3.51, CI=0.09-6.93, p = 0.044). Statistically significantly lower functionality were referred by patients >70 years old (β = -13.58, CI: -21.68-5.49, p = 0.001) and by patients with high depression score (β= -0.62, 95% CI: -1.06-0.20, p = 0.005).

Conclusion

Patients experienced moderate to low levels of depression and high levels of adherence and functionality. The higher the functionality scores, the lower the depression scores. Demographic characteristics, such as age and gender, seem to be significant predictors of depression and functionality.

An Empirical Comparative Assessment of Inter-Rater Agreement of Binary Outcomes and Multiple Raters

Background: Many methods under the umbrella of inter-rater agreement (IRA) have been proposed to evaluate how well two or more medical experts agree on a set of outcomes. The objective of this work was to assess key IRA statistics in the context of multiple raters with binary outcomes. Methods: We simulated the responses of several raters (2–5) with 20, 50, 300, and 500 observations. For each combination of raters and observations, we estimated the expected value and variance of four commonly used inter-rater agreement statistics (Fleiss’ Kappa, Light’s Kappa, Conger’s Kappa, and Gwet’s AC1). Results: In the case of equal outcome prevalence (symmetric), the estimated expected values of all four statistics were equal. In the asymmetric case, only the estimated expected values of the three Kappa statistics were equal. In the symmetric case, Fleiss’ Kappa yielded a higher estimated variance than the other three statistics. In the asymmetric case, Gwet’s AC1 yielded a lower estimated variance than the three Kappa statistics for each scenario. Conclusion: Since the population-level prevalence of a set of outcomes may not be known a priori, Gwet’s AC1 statistic should be favored over the three Kappa statistics. For meaningful direct comparisons between IRA measures, transformations between statistics should be conducted.

Determining the inter-rater reliability of the SOFMER Activity Score (version 2) for subjects in rehabilitation centers

OBJECTIVES

To assess the inter-rater reliability of the SOFMER Activity Score (SAS, version 2, an 8-item -4 motor and 4 cognitive- and 5-level scale) and improve its scoring system before conducting further validation steps.

DESIGN

Cross-sectional, prospective, observational, non-interventional, and multicentric study.

SETTING

The study was conducted between November 2018 and September 2019 in four French rehabilitation centers (two public university hospitals for adults and two private not-for-profit rehabilitation centers for children).

PARTICIPANTS

The study included 101 subjects (mean age: 44.5 years; SD: 25.4; 28.7% under 18 and 18.8% over 65). The female/male sex ratio was 0.6. The causes for admission to the center were mainly neurological (65%) or orthopedic (24%).

INTERVENTIONS

None.

MAIN OUTCOME MEASURE

Activity limitation was rated with the SOFMER Activity Score the same day by two independent multidisciplinary teams. The inter-rater reliabilities of the Score items were assessed using weighted kappa coefficients.

RESULTS

All weighted kappa coefficients ranged between 0.83 and 0.92 indicating 'good' to 'excellent' inter-rater reliability. Inter-team score disagreements occurred in 227 scores out of 808 (28%). The reason for most disagreements was unnoticed human or material aid during the observation period.

CONCLUSION

The results demonstrate the high inter-rater reliability of the SASv2 and allow carrying out further validation steps after minor changes to item scoring instructions and clearer definitions of some items that help improving scoring standardization. The SASv2 may then become a consistent measure of activity level for clinical research or burden of care investigations.

The German version of the Stroke Upper Limb Capacity Scale: Translation, cross-cultural adaption and evaluation of its psychometric properties

OBJECTIVE

To investigate the psychometric properties of a newly developed German version of the Stroke Upper Limb Capacity Scale (SULCS).

DESIGN

Prospective cohort study.

SETTING

Neurorehabilitation clinic.

SUBJECTS

Patients after stroke (n = 50) with moderate to severe upper limb hemiparesis undergoing inpatient rehabilitation.

INTERVENTION

Not applicable.

MAIN MEASURES

The SULCS was administered twice by two different raters on the first day of assessments and another time the day after. Additionally the Fugl-Meyer-Assessment, Action Research Arm Test and the Box and Block Test were conducted. Three and six weeks later, the SULCS, Fugl-Meyer-Assessment and Box and Block Test were repeated. Floor and ceiling effects were analyzed.

RESULTS

Reliability was demonstrated to be excellent as displayed by weighted kappa of 0.960 (95%-confidence interval: CIκw = 0.808-1.112) for the intra-rater reliability and 0.936 (CIκw = 0.749-1.123) for the inter-rater reliability. High correlations of the SULCS with the Fugl-Meyer-Assessment (ρ = 0.889), Action Research Arm Test (ρ = 0.872), and Box and Block Test (ρ = 0.845; all P < 0.001) confirmed a high convergent validity. The longitudinal validity was determined by a moderate to high correlation of the SULCS and Box and Block Test changes (ρ ⩾ 0.695, P ⩽ 0.001). Although floor effects were observed for the SULCS (16%), they were more substantial for the Action Research Arm Test and the Box and Block Test (>38%).

CONCLUSION

Due to the good to excellent psychometric properties and the low level of floor effects of the German version of the SULCS, the usage for clinical and scientific purposes can be recommended.

Cerebellar Intermittent Theta-Burst Stimulation Reduces Upper Limb Spasticity After Subacute Stroke: A Randomized Controlled Trial

Objective: This study aims to explore the efficacy of cerebellar intermittent theta-burst stimulation (iTBS) on upper limb spasticity in subacute stroke patients.

Methods: A total of 32 patients with upper limb spasticity were enrolled and randomly assigned to treatment with cerebellar iTBS or sham stimulation before conventional physical therapy daily for 2 weeks. The primary outcomes included the modified Ashworth scale (MAS), the modified Tardieu scale (MTS), and the shear wave velocity (SWV). The secondary outcomes were the H-maximum wave/M-maximum wave amplitude ratio (H_max/M_max ratio), motor-evoked potential (MEP) latency and amplitude, central motor conduction time (CMCT), and the Barthel Index (BI). All outcomes were evaluated at baseline and after 10 sessions of intervention.

Results: After the intervention, both groups showed significant improvements in the MAS, MTS, SWV, and BI. In addition, patients treated with cerebellar iTBS had a significant increase in MEP amplitude, and patients treated with sham stimulation had a significant decrease in H_max/M_max ratio. Compared with the sham stimulation group, the MAS, MTS, and SWV decreased more in the cerebellar iTBS group.

Conclusion: Cerebellar iTBS is a promising adjuvant tool to reinforce the therapeutic effect of conventional physical therapy in upper limb spasticity management after subacute stroke (Chinese Clinical Trial Registry: ChiCTR1900026516).

Characterizing non-critically ill COVID-19 survivors with and without in-hospital rehabilitation

This study investigated pre-COVID-19 admission dependency, discharge assistive equipment, discharge medical follow-up recommendation, and functional status at hospital discharge of non-critically ill COVID-19 survivors, stratified by those with (N = 155) and without (N = 162) in-hospital rehabilitation. “Mental Status”, intensive-care-unit (ICU) Mobility, and modified Barthel Index scores were assessed at hospital discharge. Relative to the non-rehabilitation patients, rehabilitation patients were older, had more comorbidities, worse pre-admission dependency, were discharged with more assistive equipment and supplemental oxygen, spent more days in the hospital, and had more hospital-acquired acute kidney injury, acute respiratory failure, and more follow-up referrals (p < 0.05 for all). Cardiology, vascular medicine, urology, and endocrinology were amongst the top referrals. Functional scores of many non-critically ill COVID-19 survivors were abnormal at discharge (p < 0.05) and were associated with pre-admission dependency (p < 0.05). Some functional scores were negatively correlated with age, hypertension, coronary artery disease, chronic kidney disease, psychiatric disease, anemia, and neurological disorders (p < 0.05). In-hospital rehabilitation providing restorative therapies and assisting discharge planning were challenging in COVID-19 circumstances. Knowledge of the functional status, discharge assistive equipment, and follow-up medical recommendations at discharge could enable appropriate and timely post-discharge care. Follow-up studies of COVID-19 survivors are warranted as many will likely have significant post-acute COVID-19 sequela.

Influencing factors of Barthel index scores among the community-dwelling elderly in Hong Kong: a random intercept model

Background

Barthel Index (BI) is one of the most widely utilized tools for assessing functional independence in activities of daily living. Most existing BI studies used populations with specific diseases (e.g., Alzheimer’s and stroke) to test prognostic factors of BI scores; however, the generalization of these findings was limited when the target populations varied.

Objectives

The aim of the present study was to utilize electronic health records (EHRs) and data mining techniques to develop a generic procedure for identifying prognostic factors that influence BI score changes among community-dwelling elderly.

Methods

Longitudinal data were collected from 113 older adults (81 females; mean age = 84 years, SD = 6.9 years) in Hong Kong elderly care centers. Visualization technologies were used to align annual BI scores with individual EHRs chronologically. Linear mixed-effects (LME) regression was conducted to model longitudinal BI scores based on socio-demographics, disease conditions, and features extracted from EHRs.

Results

The visualization presented a decline in BI scores changed by time and health history events. The LME model yielded a conditional R² of 84%, a marginal R² of 75%, and a Cohen’s f² of 0.68 in the design of random intercepts for individual heterogeneity. Changes in BI scores were significantly influenced by a set of socio-demographics (i.e., sex, education, living arrangement, and hobbies), disease conditions (i.e., dementia and diabetes mellitus), and EHRs features (i.e., event counts in allergies, diagnoses, accidents, wounds, hospital admissions, injections, etc.).

Conclusions

The proposed visualization approach and the LME model estimation can help to trace older adults’ BI score changes and identify the influencing factors. The constructed long-term surveillance system provides reference data in clinical practice and help healthcare providers manage the time, cost, data and human resources in community-dwelling settings.

Predictors of nasogastric tube removal in patients with stroke and dysphagia

Dysphagia is present in 25-50% of patients with stroke. Therefore, studying the probability of nasogastric tube removal in such patients before discharge from the rehabilitation ward is crucial. In this study, we developed a model to predict the outcome of dysphagia in patients with stroke. A retrospective study was performed from May 2015 to December 2018. We reviewed the medical charts of all patients with a diagnosis of stroke receiving nasogastric tube feeding. Patients were divided into weaned and nonweaned groups to compare baseline characteristics and functional status. The weaned and nonweaned groups comprised 55 and 65 patients, respectively. In the final logistic regression analysis model, the Barthel index at admission, lip closing status, ability to answer simple questions and functional independence before stroke were used to develop a predictive model (Logit = 0.8942 × functional independence before this stroke + 1.1279 × ability to answer simple question + 0.5345 × lip-close status + 0.0546 × Barthel index at admission - 2.2805). The optimal cutoff point based on Youden's index was more than -0.8403 with a sensitivity and specificity of 85.45 and 73.85%, respectively. The positive predicted value was 73.44%. In patients with stroke and dysphagia, a high Barthel index, intact lip closing status, ability to answer simple questions and better functional status before stroke appeared to affect nasogastric tube removal before discharge from the rehabilitation ward. Based on the final regression model, the proposed equation will help physicians and speech pathologists in planning patient care.

Effectiveness of autogenic relaxation training in addition to usual physiotherapy on emotional state and functional independence of stroke survivors

INTRODUCTION

The occurrence of post-stroke emotional problems is significant during the early post-stroke stage and affects the recovery of functionality among the survivors. Because stroke survivors require active engagement in rehabilitation to optimize the process of neuroplasticity in the initial stage of stroke, there is a need to integrate an intervention, preferably therapists-mediated during rehabilitation, which reduce emotional problems thus improve motivation level among the survivors. One such technique is autogenic relaxation training (ART). ART has been found to reduce anxiety and depression among patients with several medical conditions. However, its usage in stroke survivors during rehabilitation has been limited to date. Therefore, this study is intended to evaluate the effectiveness of ART in addition to usual physiotherapy in improving emotional state and functional level of stroke survivors during rehabilitation.

METHODS

This is an assessor blinded randomized controlled trial comparing 2 intervention approaches namely ART-added physiotherapy (experimental group) and usual physiotherapy (control group). A total of 70 post-stroke patients will be recruited and allocated into either the ART-added physiotherapy or the usual physiotherapy group. The ART-added physiotherapy group will undergo a 20-minute ART session followed by 40 minutes of usual physiotherapy. While the usual physiotherapy group will receive usual physiotherapy alone for 60 minutes. All participants will be treated once a week and are required to carry out a set of home exercises for 2 times per week during the 12-week intervention. Assessment of emotional status and functional independence will be carried out at pre-intervention and week 13 of the intervention with the use of Hospital anxiety and depression scale, Barthel index, and EuroQol-5 dimensions-5 levels. All data will be analyzed using descriptive and inferential statistics.

DISCUSSION

The expected main study outcome is an enhanced evidence-based physiotherapy program that may be used by physiotherapists in the rehabilitation of stroke patients with emotional disturbances.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry, ACTRN12619001664134 (last updated on 28/11/2019).

Translation and validation of the stroke impact scale 3.0 into urdu for Pakistan

BACKGROUND

The Stroke Impact Scale version 3.0 (SIS 3.0) is a self-reported outcome measure designed to assess quality of life (QoL) following a stroke. Although the psychometric properties of the SIS 3.0 are identified as superior to the generic QoL scales, it has not been translated and tested in Pakistan.

OBJECTIVE

To validate the Urdu version of the SIS 3.0 (USIS 3.0) for Pakistan.

METHODS

A prospective cohort of 116 patients with mild to moderate stroke reported their recovery using the USIS 3.0. The patients were concurrently assessed on the established tools to assess the validity and were re-evaluated to determine the test-retest reliability, precision, minimal detectable change (MDC), and minimal clinically important difference (MCID).

RESULTS

The reliability and internal consistency of USIS were satisfactory except for the emotion domain. The correlations of USIS with the established tools were strong. The discriminant validity was also significant across the levels of the modified Rankin scale (MRS). Only hand function and communication domains exhibited significant floor and ceiling effects, respectively. Regarding weighted K, values ranged from 0.53 to 0.88.

CONCLUSIONS

The USIS 3.0 has satisfactory psychometric properties and can be used in clinical and research settings for stroke survivors.

Investigating novel biomarkers of immune activation and modulation in the context of sedentary behaviour: a multicentre prospective ischemic stroke cohort study

Background

Sedentary behaviour is associated with disease, but the molecular mechanisms are not understood. Valid biomarkers with predictive and explanatory properties are required. Therefore, we have investigated traditional and novel biomarkers of inflammation and immune modulation and their association to objectively measured sedentary behaviour in an ischemic stroke population.

Methods

Patients admitted to hospital with acute ischemic stroke were included in the multicentre Norwegian Cognitive Impairment After Stroke (Nor-COAST) study (n = 815). For this sub-study (n = 257), sedentary behaviour was registered 3 months after stroke using position transition data from the body-worn sensor, ActivPal®. Blood samples were analysed for high sensitive C-reactive protein (hsCRP), the cytokines interleukin-6 (IL-6) and 10 (IL-10), neopterin, tryptophan (Trp), kynurenine (kyn), kynurenic acid (KA), and three B6 vitamers, pyridoxal 5′-phosphate (PLP), pyridoxal (PL), and pyridoxic acid (PA). The kynurenine/tryptophan ratio (KTR) and the pyridoxic acid ratio index (PAr = PA: PL + PLP) were calculated.

Results

Of the 815 patients included in the main study, 700 attended the three-month follow-up, and 257 fulfilled the inclusion criteria for this study. Sedentary time was significantly associated with levels of hsCRP, IL-6, neopterin, PAr-index, and KA adjusted for age, sex, waist circumference, and creatinine. In a fully adjusted model including all the significant biomarkers except hsCRP (because of missing values), sedentary time was independently positively associated with the PAr-index and negatively with KA. We did not find an association between sedentary behaviour, IL-10, and KTR.

Conclusions

The PAr-index is known to capture several modes of inflammation and has previously shown predictive abilities for future stroke. This novel result indicates that the PAr-index could be a useful biomarker in future studies on sedentary behaviour and disease progression. KA is an important modulator of inflammation, and this finding opens new and exciting pathways to understand the hazards of sedentary behaviour.

Trial registration

The study was registered at Clinicaltrials.gov (NCT02650531). First posted 08/01/2016.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-021-02343-0.

Sex differences in independence in activities of daily living early in stroke rehabilitation

BACKGROUND

Current stroke research suggests that there are differences between females and males regarding incidence, stroke risk factors, stroke severity, outcome, and mortality. The few studies that have investigated sex differences in rehabilitation 8-12 months poststroke found that males are more independent, compared to females.

OBJECTIVES

To investigate if there is a difference in the improvement of independence in activities of daily living (ADL) between females and males in the acute phase (first 2 weeks) of stroke rehabilitation in a Danish population.

METHODS

A prospective cohort study enrolling patients admitted to the hospital's rehabilitation ward with a stroke diagnosis from January 1, 2016, to March 17, 2017. Baseline and follow-up data regarding the primary outcome, Barthel-100 index, were analyzed using an adjusted linear mixed model.

RESULTS

The study included 206 patients (83 females). Females were older at admission and more males lived with a partner. No differences in stroke severity or any of the risk factors were found. There were no differences between female and male scores at baseline. In the adjusted linear mixed model, quantifying the difference between follow-up and baseline Barthel-100 score, females increased their Barthel-100 score by 20.8 points (95% confidence interval (CI) 15.4-26.3) and males with 29.0 points (95% CI 24.6-33.4).

CONCLUSION

In a homogeneous sample of stroke survivors undergoing specialized 24-h stroke rehabilitation for 11-14 days, females were more dependent in ADL than males.

Healthcare utilization associated with adherence to antibiotics for abdominal surgeries in Japan: cross-sectional analysis of administrative database

BACKGROUND

Since patients receiving surgery may experience surgical site infections, therapeutic guidelines for reducing hospitalization time and cost include appropriate antibiotic use. However, the association between adherence to therapeutic guidelines and healthcare utilization is currently unclear.

OBJECTIVES

This study aimed to confirm the positive association between the adherence to guidelines of antibiotic therapy and a reduction in the length of stay and cost of hospitalization, especially considering the high infection rates in abdominal surgery.

METHODS

This cross-sectional study used administrative data (diagnosis procedure combination data) collected using the case-mix system implemented in acute-care hospitals in Japan. We assessed the length of hospital stay and cost of hospitalization for patients who received prophylactic antibiotic for abdominal surgeries consistent with therapeutic guidelines. The data of patients aged 15 years or older who received appendectomy, laparoscopic cholecystectomy or inguinal hernia repair were extracted. The appropriateness of antibiotic prophylaxis was evaluated in terms of the Japanese guidelines for antibiotic selection and treatment duration. To assess the mean difference in antibiotic costs and length of stay, we performed the propensity score matching by confounding factors. Furthermore, we assessed the progress in healthcare utilization of this therapy over a decade.

RESULTS

Of the 302 233 patients who received single general surgery from April 2014 to March 2016, 198 885 were eligible for analysis after applying the exclusion criteria (143 975 in the adherence and 54 910 in the non-adherence group). Each group comprised 48 439 patients after propensity score matching. Inappropriate antibiotic selection and duration were observed in 9294 (9.8%) and 687 (0.7%) of inguinal hernia repairs, 6431 (25.3%) and 311 (1.2%) of appendectomies and 38 134 (48.5%) and 391 (0.5%) of laparoscopic cholecystectomy cases, respectively. After propensity score matching by operation type, average hospitalization length (6.5 [SD 3.8] and 7.3 [SD 4.8] days) and costs (536 000 [SD 167 000] JPY and 573 000 [SD 213 000] JPY) differed significantly between adherence and non-adherence groups.

CONCLUSION

The results revealed that unnecessary healthcare utilization was associated with failure to adhere to therapeutic guidelines for prophylactic antibiotic therapy in elective general surgeries. We concluded that the progress of reduction in length of hospitalization over the decade was successful. Notably, adherence to treatment duration was better than that was 10 years ago. In this decade, administrators in hospitals have attempted to reduce the duration of hospitalization by developing various clinical pathways for surgical procedures and quality indicators. However, 15 877 patients (8.7%) were prescribed oral antibiotics the day after surgery. These observations should be evaluated further.