Age-based prediction of incidence of complications during inpatient stroke rehabilitation: a retrospective longitudinal cohort study

Effects of physical therapy modalities for motor function, functional recovery, and post-stroke complications in patients with severe stroke: a systematic review update

BACKGROUND

Physical therapy interventions play a crucial role in the daily care of patients recovering from severe stroke. However, the efficacy of these interventions and associated modalities, including duration, intensity, and frequency, have not been fully elucidated. In 2020, a systematic review reported the beneficial effects of physical therapy for patients with severe stroke but did not assess therapeutic modalities. We aim to update the current evidence on the effects of physical therapy interventions and their modalities in relation to the recovery phase in people with severe stroke in a hospital or inpatient rehabilitation facility.

METHODS

We searched CENTRAL, MEDLINE, Web of Science, and three other relevant databases between December 2018 and March 2021 and updated the search between April 2021 and March 2023.

CLINICALTRIALS

gov and ICTRP for searching trial registries helped to identify ongoing RCTs since 2023. We included individual and cluster randomized controlled trials in the English and German languages that compared physical therapy interventions to similar or other interventions, usual care, or no intervention in a hospital or rehabilitation inpatient setting. We screened the studies from this recent review for eligibility criteria, especially according to the setting. Critical appraisal was performed according to the Cochrane risk-of-bias tool 2.0. The data were synthesized narratively.

RESULTS

The update identified 15 new studies, cumulating in a total of 30 studies (n = 2545 participants) meeting the eligibility criteria. These studies reported 54 outcomes and 20 physical therapy interventions. Two studies included participants during the hyperacute phase, 4 during the acute phase,18 during the early subacute phase, and 3 in the late subacute phase. Three studies started in the chronic phase. Summarised evidence has revealed an uncertain effect of physical therapy on patient outcomes (with moderate to low-quality evidence). Most studies showed a high risk of bias and did not reach the optimal sample size. Little was stated about the standard care and their therapy modalities.

DISCUSSION

There is conflicting evidence for the effectiveness of physical therapy interventions in patients with severe stroke. There is a need for additional high-quality studies that also systematically report therapeutic modalities from a multidimensional perspective in motor stroke recovery. Due to the high risk of bias and the generally small sample size of the included studies, the generalizability of the findings to large and heterogeneous volumes of outcome data is limited.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42021244285.

Gastrointestinal Dysfunction in Stroke

Gastrointestinal (GI) complications are seen in over 50% of ischemic stroke survivors; the most common complications are dysphagia, constipation, and GI bleeding. The bidirectional relationship of the gut-brain axis and stroke has recently gained traction, wherein stroke contributes to gut dysbiosis (alterations in the normal host intestinal microbiome) and gut dysbiosis perpetuates poor functional neurologic outcomes in stroke. It is postulated that the propagation of proinflammatory cells and gut metabolites (including trimethylamine N-oxide and short-chain fatty acids) from the GI tract to the central nervous system play a central role in gut-brain axis dysfunction. In this review, we discuss the known GI complications in acute ischemic stroke, our current knowledge from experimental stroke models for gut-brain axis dysfunction in stroke, and emerging therapeutics that target the gut-brain axis.

Frequency and Characteristics of Medical Complications in Rehabilitation Settings: A Scoping Review

OBJECTIVE

To synthesize the available evidence on medical complications occurring in adult patients in subacute inpatient rehabilitation, and to describe the impact on subacute length of stay and readmission to acute care.

DESIGN

Scoping review.

SUBJECTS

Adult patients, within the inpatient rehabilitation environment, who experienced medical complications, clinical deterioration and/or the requirement of transfer to acute care.

METHODS

A systematic search of MEDLINE and CINAHL electronic databases was undertaken to identify primary research studies published in English and French during the period 2000-2021. Study reporting followed the standards indicated by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews checklist (PRISMA-ScR).

RESULTS

A total of 47 studies were identified for inclusion. Key results included differences in the type and frequency of complications according to admission type, the proportion of patients experiencing at least 1 complication, and complications associated with transfer to acute care.

CONCLUSION

Patients admitted for inpatient rehabilitation are at high risk of medical complications and may not be medically stable during their admission, requiring care by clinicians with expertise in functional rehabilitation, and ongoing management by members of the multidisciplinary team with expertise in acute general medicine, infectious diseases and recognition and response to clinical deterioration.

Young individuals with stroke in rehabilitation: a cohort study

Stroke in younger populations is a public health crisis and the prevalence is rising. Little is known about the progress of younger individuals with stroke in rehabilitation. Characterization of the course and speed of recovery is needed so that rehabilitation professionals can set goals and make decisions. This was a cohort study with data extracted from electronic medical records. Participants were 408 individuals diagnosed with stroke who participated in inpatient rehabilitation in an urban, academic medical center in the USA. The main predictor was age which was categorized as (18-44, 45-64, 65-74 and 75+). Outcomes included baseline-adjusted discharge functional independence measure (FIM) scores and FIM efficiency. In linear regression models for FIM scores, the reference category was the youngest age group. The oldest group was discharged with significantly lower FIM total (B = -8.84), mobility (B = -4.13), self-care (B = -4.07) and cognitive (B = -1.57) scores than the youngest group after controlling for covariates. The 45-64 group also finished with significantly lower FIM total (B = -6.17), mobility (B = -2.61) and self-care (B = -3.01) scores than youngest group. FIM efficiencies were similar for all ages in each of the FIM scales. Younger individuals with stroke make slightly greater functional gains compared to older individuals with stroke, but other factors, such as admission scores, are more important and the rates of recovery may be similar.

Age-Related Disparities in the Quality of Stroke Care and Outcomes in Rehabilitation Hospitals: The Australian National Audit

INTRODUCTION

Stroke affects all ages. Despite increased incidence in those <65 years, little is known about age-based differences in inpatient rehabilitation management and outcomes.

OBJECTIVES

To investigate management and outcomes, comparing younger (<65 years) and older (≥65 years) patients with stroke, who received inpatient rehabilitation.

METHODS

Multicentre, cross-sectional study using data from Australian hospitals who participated in the Stroke Foundation national stroke rehabilitation audit (2016-2018). Chi-square tests compared characteristics and care by age. Multivariable regression models were used to compare outcomes by age (e.g. length of stay). Models were adjusted for sex, stroke type and severity factors.

RESULTS

7,165 audited cases from 127 hospitals; 23% <65 years (66% male; 72% ischaemic stroke). When compared to older patients, younger patients were more likely male (66% vs 52%); identify as Aboriginal or Torres Strait Islander (6% vs 1%); be less disabled on admission; receive psychology (46% vs 34%) input, and community reintegration support, including return to work (OR 1.47, 95% CI 1.03, 2.11), sexuality (OR 1.60, 95% CI 1.39, 1.84) and self-management (OR 1.39, 95% CI 1.23, 1.57) advice. Following adjustment, younger patients had longer lengths of stay (coeff 3.54, 95% CI 2.27, 4.81); were more likely to be independent on discharge (aOR 1.96, 95% CI 1.68, 2.28); be discharged to previous residences (aOR 1.64, 95% CI 1.41, 1.91) and receive community rehabilitation (aOR: 2.27, 95% CI 1.91, 2.70).

CONCLUSIONS

Age-related differences exist in characteristics, management and outcomes for inpatients with stroke accessing rehabilitation in Australia.

Clinical Correlation Analysis of Complications in Elderly Patients with Sequelae of Stroke with Different Barthel Index in Tianjin Emergency Department

OBJECTIVE

The Barthel index (BI) is the most commonly used measure of poststroke disability. The purpose of this article is to explore the different complications and severity of the sequelae of elderly stroke patients with different BI in the emergency department, so as to provide a theoretical basis for strengthening the treatment of elderly patients with stroke sequelae.

METHODS

A retrospective study was adopted, and 1896 patients were divided into two groups according to the BI: 823 patients in the bedridden group (BI ≤ 40 points) and 1073 patients in the nonbedridden group (BI > 40 points). The type and number of complications and APACHE II score were compared between the two groups.

RESULTS

Compared with the two groups, pneumonia, renal insufficiency, respiratory failure, and decubitus ulcer in the bedridden group had a higher incidence, but the incidence of upper gastrointestinal bleeding and fractures in the nonbedridden group was significantly higher (P < 0.05). The APACHE II score of the patients in the bedridden group was higher than that of the nonbedridden group, and they were critical (P < 0.001). And the number of complications was higher than that in the nonbedridden group. Moreover, the BI was negatively correlated with the APACHE-II score and the number of complications, and the APACHE II score was positively correlated with the number of complications (P < 0.001).

CONCLUSION

Different complications and severity of illness occur in elderly patients with sequelae of stroke after different BI in the emergency department.

Incidence, Prevalence, and Risk Factors of Hemiplegic Shoulder Pain: A Systematic Review

The current systematic review aimed to investigate the incidence, prevalence, and risk factors causing hemiplegic shoulder pain (HSP) after stroke. Two independent authors screened titles and abstracts for the eligibility of the included studies in the electronic databases PubMed and Web of Science. Studies which reported the incidence, prevalence, and risk factors of HSP following stroke were included. The included studies were assessed using the Newcastle–Ottawa Scale for evaluating the quality of nonrandomized studies in meta-analyses. Eighteen studies were included in the final synthesis. In all studies, the number of patients ranged between 58 and 608, with the mean age ranging from 58.7 to 76 years. Seven included studies were rated as “good “quality, while one study rated “fair” and 10 studies rated “poor” quality. Eight studies reported incidence rate while 11 studies reported the prevalence of HSP following a stroke. The incidence of HSP was ranging from 10 to 22% in the metanalysis of the included studies. The prevalence of HSP was ranging from 22 to 47% in the metanalysis of the included studies. The most significant predictors of HSP were age, female gender, increased tone, sensory impairment, left-sided hemiparesis, hemorrhagic stroke, hemispatial neglect, positive past medical history, and poor National Institutes of Health Stroke Scale score. The incidence and prevalence of HSP after stroke vary considerably due to various factors. Knowledge of predictors is important to minimize the risk of developing HSP following a stroke.

A 2 DS 2 Score to Predict the Risk of Stroke-Associated Pneumonia in Acute Stroke: An Indian Perspective

Background  Stroke-associated pneumonia (SAP) is an important cause of poststroke morbidity and mortality. Several clinical risk scores predict the risk of SAP. In this study, we used the A ² DS ² score (age, atrial fibrillation, dysphagia, sex, and stroke severity) to assess the risk of SAP in patients admitted with acute stroke. Methods  A high (5-10) and a low (0-4) A ² DS ² score was assigned to patients with acute stroke admitted to the neurology ward. Univariate binary logistic regression analysis was performed to find the strength of association of SAP and A ² DS ² score. Results  There were 250 patients with acute stroke of which 46 developed SAP. Forty-four patients developed SAP in high score as against 2 in low-score group (odds ratio [OR] = 0.03, 95% confidence interval [CI] = 0.01-0.15, p = 0.0001). A ² DS ² score >5 had sensitivity of 82.6% and specificity of 65.1% to predict SAP. The mean A ² DS ² score in patients with pneumonia was 7.02 ± 1.40 compared to 4.75 ± 1.92 in patients without pneumonia ( p = 0.0001). Conclusions  A ² DS ² score has a high sensitivity of 82% in predicting the risk of SAP and is a useful tool to monitor patients after acute stroke. A ² DS ² score can help in timely detection and prevention of SAP and reduction in caregiver's burden.

Management of Acute Stroke in the Older Person

The majority of people who suffer a stroke are older adults. The last two decades have brought major progress in the diagnosis and management of stroke, which has led to significant reductions in mortality, long-term disability, and the need for institutional care. However, acute, interventional and preventative treatments have mostly been trialled in younger age groups. In this article we will provide an overview of the evidence for acute stroke treatments in relation to age, discuss special considerations in the older person, and contemplate patient choice, quality of life, and end-of-life-decisions.

Incidence of constipation in stroke patients: A systematic review and meta-analysis

There is growing awareness of a link between the gut and cardiovascular disease. Constipation is common among individuals who have had a stroke, and it negatively affects social functioning and quality of life. However, no systematic study on the incidence of constipation in stroke patients has been reported.We selected studies included in Medline, Embase, Cochrane database, and Web of Science. Studies were included if they reported the incidence in stroke patients. Two authors selected the studies, extracted the data independently, and assessed these. Subgroup analyses were conducted according to the stroke subtype and stage of stroke.After detailed evaluations, 8 studies (n  =  1385 participants) were found that contained data that were suitable for meta-analytic synthesis. A forest plot showed that the incidence of constipation was 48% (95% confidence interval [CI]  =  33%-63%). In the analysis of the type of stroke subgroup, the incidence of constipation in patients who had had a hemorrhagic stroke (66% [95% CI  =  40-91%]) was higher than that in patients who had experienced an ischemic stroke (51% [95% CI  =  27%-75%]). The incidence in the acute stage (45% [95% CI  =  36%-54%]) was lower than that in the rehabilitation stage (48% [95% CI  =  23%-73%]).Constipation after a stroke event occurs frequently. This finding may raise awareness about bowel complications to allow correct evaluation and proper management.

Stroke-Associated Pneumonia Risk Score: Validity in a French Stroke Unit

BACKGROUND

Stroke-associated pneumonia is a leading cause of in-hospital death and post-stroke outcome. Screening patients at high risk is one of the main challenges in acute stroke units. Several screening tests have been developed, but their feasibility and validity still remain unclear.

OBJECTIVE

The aim of our study was to evaluate the validity of four risk scores (Pneumonia score, A2DS2, ISAN score, and AIS-APS) in a population of ischemic stroke patients admitted in a French stroke unit.

METHODS

Consecutive ischemic stroke patients admitted to a stroke unit were retrospectively analyzed. Data that allowed to retrospectively calculate the different pneumonia risk scores were recorded. Sensitivity and specificity of each score were assessed for in-hospital stroke-associated pneumonia and mortality. The qualitative and quantitative accuracy and utility of each diagnostic screening test were assessed by measuring the Youden Index and the Clinical Utility Index.

RESULTS

Complete data were available for only 1960 patients. Pneumonia was observed in 8.6% of patients. Sensitivity and specificity were, respectively, .583 and .907 for Pneumonia score, .744 and .796 for A2DS2, and .696 and .812 for ISAN score. Data were insufficient to test AIS-APS. Stroke-associated pneumonia risk scores had an excellent negative Clinical Utility Index (.77-.87) to screen for in-hospital risk of pneumonia after acute ischemic stroke.

CONCLUSION

All scores might be useful and applied to screen stroke-associated pneumonia in stroke patients treated in French comprehensive stroke units.

The impact of lower extremity pain conditions on clinical variables and health-related quality of life in patients with stroke

BACKGROUND

The presence of lower extremity pain may be associated with poorer motor recovery, impaired activities of daily living (ADL), reduced quality of life, and disability in patients with stroke.

OBJECTIVE

The aims of the study were to describe the characteristics of lower extremity pain conditions and to evaluate the impact of lower extremity pain on clinical variables, and health-related quality of life in patients with stroke.

METHODS

One hundred and eighty-five patients with stroke who have self-reported pain in the lower extremity were included in the study. Lower extremity pain characteristics of stroke survivors including etiology, intensity, onset time, frequency, aggravating factors, relieving factors, site, and location of pain were evaluated and recorded. The Brunnstrom motor recovery scale, the functional ambulation category, the mini-mental state examination, the star cancellation test, the beck depression inventory, the Barthel Index, and the Short Form-36 Questionnaire (SF-36) were used.

RESULTS

The causes of lower extremity pain were diagnosed as osteoarthritis (51.1%), central neuropathic pain (28.7%), mixed pain (10.3%), low back pain associated with leg pain (8.6%), greater trochanteric pain syndrome (5.2%), prior hip fracture (2.4%), heterotopic ossification (2%), developmental hip luxation (1%), hallux valgus (0.5%), and malignancy (0.5%). The intensity of lower extremity pain was a significant predictor of cognitive functions, ADL, depression, and all SF-36 subscales except emotional role and vitality. The duration of lower extremity pain was a significant predictor of depression and lower extremity spasticity.

CONCLUSIONS

Since lower extremity pain conditions have a significant important influence on clinical variables and health-related quality of life in stroke survivors, early identification and appropriate treatment of the lower extremity pain conditions should be carried out in order to reduce the level of disability in stroke patients.

The role of age in intracerebral hemorrhages

We aimed to identify the role of age in intracerebral hemorrhage (ICH), as well as characterize the most commonly used age cut off points in the literature, with the hope of understanding and guiding treatment. Strokes are one of the leading causes of death in the USA, and ICH is the deadliest type. Age is a strong risk factor, but it also affects the body in numerous ways, including changes to the cardiovascular and central nervous systems that interplay with the multiple risk factors for ICH. Understanding the role of age in risk and outcomes of ICH can guide treatment and future clinical trials. A current review of the literature suggests that the age cut offs for increased rates of mortality and morbidity vary from 60-80 years of age, with the most common age cut offs being at 65 or 70 years of age. In addition to age as a determinant of ICH outcomes, age has its own effects on the maturing body in terms of changes in physiology, while also increasing the risk of multiple chronic health conditions and comorbidities, including hypertension, diabetes, and anticoagulant treatment for atrial fibrillation, all of which contribute to the pathology of ICH. The interaction of these chronic conditions, changes in physiology, age, and ICH is evident. However, the exact mechanism and extent of the impacts remains unclear. The ambiguity of these connections may be further obscured by individual patient preferences, and there are limitations in the literature which guides the current recommendations for aging patients.

Predictors for total medical costs for acute hemorrhagic stroke patients transferred to the rehabilitation ward at a regional hospital in Taiwan

BACKGROUND

One-third of the acute stroke patients in Taiwan receive rehabilitation. It is imperative for clinicians who care for acute stroke patients undergoing inpatient rehabilitation to identify which medical factors could be the predictors of the total medical costs.

OBJECTIVES

The aim of this study was to identify the most important predictors of the total medical costs for first-time hemorrhagic stroke patients transferred to inpatient rehabilitation using a retrospective design.

METHODS

All data were retrospectively collected from July 2002 to June 2012 from a regional hospital in Taiwan. A stepwise multivariate linear regression analysis was used to identify the most important predictors for the total medical costs.

RESULTS

The medical records of 237 patients (137 males and 100 females) were reviewed. The mean total medical cost per patient was United States dollar (USD) 5939.5 ± 3578.5.The following were the significant predictors for the total medical costs: impaired consciousness [coefficient (B), 1075.7; 95% confidence interval (CI) = 138.5-2012.9], dysphagia [coefficient (B), 1025.8; 95% CI = 193.9-1857.8], number of surgeries [coefficient (B), 796.4; 95% CI = 316.0-1276.7], pneumonia in the neurosurgery ward [coefficient (B), 2330.1; 95% CI = 1339.5-3320.7], symptomatic urinary tract infection (UTI) in the rehabilitation ward [coefficient (B), 1138.7; 95% CI = 221.6-2055.7], and rehabilitation ward stay [coefficient (B), 64.9; 95% CI = 31.2-98.7] (R(2) = 0.387).

CONCLUSIONS

Our findings could help clinicians to understand that cost reduction may be achieved by minimizing complications (pneumonia and UTI) in these patients.