Quality of life in patients with TIA and minor ischemic stroke

The Role of Atrial Fibrillation and Oral Anticoagulation Status in Health-Related Quality of Life 12 Months After Ischemic Stroke or TIA

AIMS

Atrial fibrillation (AF) accounts for about 20% of all ischemic strokes worldwide. It is known that AF impairs health-related quality of life (HRQOL) in the general population, but data on HRQOL in stroke patients with newly diagnosed AF are sparse.

METHODS

Post hoc analysis of the prospective, investigator-initiated, multicenter MonDAFIS study (NCT02204267) to analyze whether AF-related oral anticoagulation (OAC), and/or AF-symptom severity are associated with HRQOL after ischemic stroke or transient ischemic attack (TIA). HRQOL was measured using the EQ-5D-3L-questionnaire (including EQ-index/EQ-VAS) at baseline and after 12 months using multivariable linear mixed models. AF symptom severity was assessed using the European Heart Rhythm Association classification and symptom severity score (EHRA score) categorizing patients with no/mild/severe/disabling AF-related symptoms.

RESULTS

A first episode of AF was detected in 261/2927 (8.9%) patients within 12 months after the index stroke and 227/2920 (7.8%) patients had AF and were anticoagulated at 12 months. HRQOL (measured by EQ-index, n = 2495 patients) was higher in AF patients on OAC compared to AF patients without OAC at 12 months after stroke (mean difference: MD: -16.8, 95% CI: 5.6 to 28.0), and similar in AF patients under OAC compared with patients without AF (MD: 2.0, 95% CI: -2.2 to 6.3). AF-related symptoms were negatively associated with HRQOL (measured by EQ-index) indicating that stroke patients with AF-related symptoms had a lower HRQOL compared to asymptomatic AF patients (mild vs. asymptomatic: MD: -9.0, 95% CI: -17.7 to -0.3; severe/disabling vs. asymptomatic: MD: -19.1, 95% CI: -34.7 to -3.4).

DISCUSSION

Stroke patients with newly diagnosed AF are at risk of lower quality of life at 12 months, depending on OAC status and AF symptom severity.

Risk of ischemic stroke in patients with pulmonary embolism and patent foramen ovale: A systematic review and meta-analysis

OBJECTIVE

Patients with acute pulmonary hypertension during an acute pulmonary embolism (PE) can develop stroke due to paradoxical embolism in the presence of a patent foramen ovale (PFO). We evaluated the current evidence regarding the risk of ischemic stroke and mortality in patients with PE and a PFO.

METHODS

We performed a systematic review and meta-analysis of studies found on PubMed, the Cochrane Library, Embase, SCOPUS, and the BVS portal. We included full-length reports, prospective observational cohorts, and clinical trials of adult patients (aged ≥18 years) diagnosed with PE and investigating the presence of PFO and new ischemic brain injuries. This study is registered with PROSPERO (CRD42023467133).

RESULTS

The initial search identified 1398 articles. After applying exclusion criteria, only 8 articles remained, including a total of 1197 individuals with PE, among whom PFO was identified in 318 patients. Ischemic stroke occurred in 62/318 (19.5 %) individuals in the PFO group and in 40/879 (4.5 %) individuals in the non-PFO group. The prevalence of ischemic stroke in the PFO group was higher than in the non-PFO group in all eight studies. The meta-analysis showed that PFO was significantly associated with ischemic stroke in patients with PE compared to those without PFO (odds ratio 5.36, 95 % CI 3.20-8.99, p < 0.00001; I² = 0 %). Three studies also reported higher mortality in the PFO group.

CONCLUSION

Patent foramen ovale is a common condition in patients with acute PE and is associated with a higher incidence of ischemic stroke and increased mortality.

Sensor-Acquired Reachable Workspace (RWS) Correlates with Activities of Daily Living (ADL) Function in Stroke as Measured by Functional Independence Measure (FIM) Self-Care

Optimal upper extremity motor control and range of motion are necessary to achieve even the basic activities of daily living (ADL) function. Stroke, with resulting hemiparesis, can significantly and negatively impact an individual's ADL function. Functional Independence Measure (FIM) self-care score can provide an assessment of what aspects and to what degree ADL functions are impaired. FIM self-care assessment can also track changes in ADL function during stroke recovery and rehabilitation. Recently, the sensor-acquired 3D motion analysis of stroke patients' upper extremity has shown promise as a potential alternative to assess ADL function. This observational study evaluates whether the sensor-acquired upper extremity reachable workspace (RWS) measure correlates with clinician-evaluated FIM self-care score in stroke patients. Seventeen patients with stroke were enrolled in the study. FIM self-care, NeuroQoL upper extremity, and reachable workspace outcome measures (relative surface area, RSA) were collected upon rehabilitation hospital admission, at discharge, and at the 3-month visit. Pearson and Spearman's rank correlation coefficients as well as multiple linear regression analyses were used to determine the relationships between FIM self-care, NeuroQoL, and reachable workspace RSAs. Moderately strong correlation between total reachable workspace RSA and total FIM self-care score at discharge and at 3 months were noted (r = 0.619, r = 0.661, p < 0.05), and similarly strong correlation was also noted with the upper extremity NeuroQoL total score (r = 0.690, r = 0.815, p < 0.05). Multiple linear regression analyses revealed a change in average bilateral total RSA of 0.1 unit from admission to the 3-month follow-up correlated with a respective change in the FIM self-care score of 2.011 points (95%CI: 0.663-3.360). Longitudinal improvement in ADL function during stroke rehabilitation and recovery process is correlated with improvement in reachable workspace.

Effect of Pre-Hospitalization Fall History on Physical Activity and Sedentary Behavior After the Implementation of a Behavioral Change Approach in Patients with Minor Ischemic Stroke: A Secondary Analysis of a Randomized Controlled Trial

BACKGROUND

We aimed to determine whether a history of falls before admission affected physical activity levels and sedentary behavior negatively after implementing a behavior modification approach in patients with minor ischemic stroke.

METHODS

This study constituted a secondary analysis of an intervention trial. In the intervention study, patients with minor ischemic stroke were randomly assigned to two groups: intervention and control groups. The intervention group was encouraged to reduce sedentary behavior during hospitalization and after discharge, while the control group was encouraged to increase physical activity levels solely during hospitalization. The study included 52 patients who completed the intervention trial. The exposure factor examined was a history of falls. Upon admission, patients were queried about any falls experienced in the year preceding admission and subsequently classified into fall and non-fall groups based on their responses. The primary outcome of interest focused on changes in physical activity levels (step count, light-intensity physical activity, and moderate-to-vigorous-intensity physical activity) and sedentary behavior. Measurements were obtained at two time points: before the intervention, during hospitalization (baseline), and 3 months after discharge (post-intervention).

RESULTS

Only a significantly lower change in the number of steps taken in the fall group than in the non-fall group was found.

CONCLUSION

Those with a history of falls showed a lesser change in the number of steps taken before and after implementing a behavior change approach compared with those without a history of falls. Those with a history of falls may have engaged in activities other than walking.

Post-discharge sedentary behavior and light-intensity physical activity-associated stroke recurrence in patients with minor ischemic stroke: A preliminary retrospective observational study

BACKGROUND AND PURPOSE

Evidence regarding whether reducing sedentary behavior and increasing physical activity levels to prevent stroke recurrence is insufficient. Therefore, this study preliminarily investigated whether post-discharge sedentary behavior and physical activity levels in patients with minor ischemic stroke were associated with stroke recurrence.

METHODS

This retrospective observational study included 73 patients (aged 72.0 years) with minor ischemic stroke from a previous study. The outcome was recurrent stroke 2 years after stroke onset, assessed using medical records. Exposure factors including sedentary behavior and physical activity levels 6 months post-discharge were measured using accelerometers; patients were classified into the recurrence or non-recurrence groups. Logistic regression analyses were then conducted to determine whether sedentary behavior and physical activity 6 months after discharge were associated with stroke recurrence.

RESULTS

Six patients experienced stroke recurrence (recurrence rate, 8.2%). The recurrence group showed greater sedentary behavior (recurrence group 68.0%, non-recurrence group 52.0%, p = 0.007) and less light-intensity physical activity (LPA) (recurrence group 21.0%, non-recurrence group 37.0%, p = 0.002) than in the non-recurrence group. Logistic regression analysis showed that sedentary behavior (odds ratio = 1.083, 95% confidence interval = 1.007-1.165, p = 0.032) and LPA (odds ratio = 0.874, 95% confidence interval = 0.785-0.975, p = 0.015) were independent factors for recurrence of stroke.

DISCUSSION

Post-discharge sedentary behavior and LPA in patients with minor ischemic stroke were associated with stroke recurrence. Results suggest that reducing post-discharge sedentary behavior and increasing LPA may be crucial for reducing the risk of stroke recurrence in patients with minor ischemic stroke.

What follow-up interventions, programmes and pathways exist for minor stroke survivors after discharge from the acute setting? A scoping review

OBJECTIVE

To identify the breadth and range of follow-up interventions currently provided to people after minor stroke with a focus on the definitions used for minor stroke, intervention components, intervention theory and outcomes used. These findings will inform the development and feasibility testing of a pathway of care.

DESIGN

Scoping review.

SEARCH STRATEGY

The final search was run in January 2022. Five databases were searched-EMBASE, MEDLINE, CINAHL, British Nursing Index and PsycINFO. Grey literature was also searched. Title and abstract screening and full-text reviews were conducted by two researchers and a third was involved when differences of opinion existed. A bespoke data extraction template was created, refined and then completed. The Template for Intervention Description and Replication (TIDieR) checklist was used to describe interventions.

RESULTS

Twenty-five studies, using a range of research methodologies were included in the review. A range of definitions were used for minor stroke. Interventions focused largely on secondary prevention and management of increased risk of further stroke. Fewer focused on the management of hidden impairments experienced after minor stroke. Limited family involvement was reported and collaboration between secondary and primary care was seldom described. The intervention components, content, duration and delivery were varied as were the outcome measures used.

CONCLUSION

There is an increasing volume of research exploring how best to provide follow-up care to people after minor stroke. Personalised, holistic and theory-informed interdisciplinary follow-up is needed that balances education and support needs with adjustment to life after stroke.

Effects on sedentary behaviour of an approach to reduce sedentary behaviour in patients with minor ischaemic stroke: A randomised controlled trial

OBJECTIVES

To determine the effects on sedentary behaviour of an approach that promotes reduction in sedentary behaviour in patients with minor ischaemic stroke after intervention and at follow-up.

DESIGN

A randomised controlled trial.

SETTING

During hospitalisation and after hospital discharge.

SUBJECTS

In total, 86 patients with minor ischaemic stroke admitted to an acute care hospital were assigned to the intervention (n = 43) and control (n = 43) groups.

INTERVENTION

An intervention group that received an approach to reduce sedentary behaviour upon hospital admission until 3 months after discharge (education, self-monitoring, phone calls, etc.) and a control group that received the usual care during hospitalisation. From 3 to 6 months after discharge, no group received any intervention.

MAIN OUTCOME

The primary outcome was the change (%) in sedentary behaviour from baseline to post-intervention (3 months after discharge) and follow-up (6 months after discharge). Sedentary behaviour was measured at baseline (upon hospital admission), post-intervention, and at follow-up using accelerometers.

RESULTS

At the post-intervention stage, the intervention group showed a significantly greater change in sedentary behaviour from baseline than that shown by the control group (sedentary behaviour: intervention group, -22.7%; control group, -14.9%; P = 0.013; effect size = 0.58). At follow-up too, the intervention group showed a significantly greater change in sedentary behaviour from baseline than that shown by the control group (sedentary behaviour: intervention group, -20.4%; control group, -13.6%; P = 0.025; effect size = 0.54).

CONCLUSIONS

An approach to reduce sedentary behaviour in patients with minor ischaemic stroke effectively reduces sedentary behaviour, which is sustained up to follow-up.

TRIAL REGISTRATION

This study is registered at www.umin.ac.jp/ctr/index/htm UMIN000038616.

Rehabilitation Therapy Doses Are Low After Stroke and Predicted by Clinical Factors

BACKGROUND

Stroke is a leading cause of long-term disability. Greater rehabilitation therapy after stroke is known to improve functional outcomes. This study examined therapy doses during the first year of stroke recovery and identified factors that predict rehabilitation therapy dose.

METHODS

Adults with new radiologically confirmed stroke were enrolled 2 to 10 days after stroke onset at 28 acute care hospitals across the United States. Following an initial assessment during acute hospitalization, the number of physical therapy, occupational therapy, and speech therapy sessions were determined at visits occurring 3, 6, and 12 months following stroke. Negative binomial regression examined whether clinical and demographic factors were associated with therapy counts. False discovery rate was used to correct for multiple comparisons.

RESULTS

Of 763 patients enrolled during acute stroke admission, 510 were available for follow-up. Therapy counts were low overall, with most therapy delivered within the first 3 months; 35.0% of patients received no physical therapy; 48.8%, no occupational therapy, and 61.7%, no speech therapy. Discharge destination was significantly related to cumulative therapy; the percentage of patients discharged to an inpatient rehabilitation facility varied across sites, from 0% to 71%. Most demographic factors did not predict therapy dose, although Hispanic patients received a lower cumulative amount of physical therapy and occupational therapy. Acutely, the severity of clinical factors (grip strength and National Institutes of Health Stroke Scale score, as well as National Institutes of Health Stroke Scale subscores for aphasia and neglect) predicted higher subsequent therapy doses. Measures of impairment and function (Fugl-Meyer, modified Rankin Scale, and Stroke Impact Scale Activities of Daily Living) assessed 3 months after stroke also predicted subsequent cumulative therapy doses.

CONCLUSIONS

Rehabilitative therapy doses during the first year poststroke are low in the United States. This is the first US-wide study to demonstrate that behavioral deficits predict therapy dose, with patients having more severe deficits receiving higher doses. Findings suggest directions for identifying groups at risk of receiving disproportionately low rehabilitation doses.

Higher comorbidity burden is associated with lower self-reported quality of life after stroke

Introduction

This study assesses the association of comorbidity burden and polypharmacy with self-reported quality of life after stroke.

Patients and methods

We performed a post-hoc analysis of a prospective, single-center, observational study of outcome evaluation by patient-reported outcome measures in stroke clinical practice. Consecutive patients with acute ischemic stroke (AIS) were enrolled and self-reported health-related quality of life (HrQoL) was assessed 90 days after acute stroke using the Patient-reported Outcomes Measurement Information System 10-Question Short-Form (PROMIS-10). Comorbidities at baseline were assessed by the Charlson Comorbidity Index (CCI). Polypharmacy was defined as medication intake of ≥5 at baseline. We used linear regression analysis to study the association of CCI, polypharmacy and other clinical covariates with HrQoL after stroke.

Results

Of 781 patients (median age 76 years, 48.4% female) enrolled, 30.2% had a CCI Score ≥2, and 31.5% presented with polypharmacy. At follow up, 71 (9.1%) had died. In 409 (52.4%) reached for outcome evaluation, Global Physical Health T-Score was 43.8 ± 10 and Global Mental Health T-Score was 43.5 ± 8.76, indicating lower HrQoL than the average population. A CCI Score ≥2, higher NIHSS Score, female sex, dependency on others for dressing, toileting and mobility before index stroke, atrial fibrillation and hypertension were independent predictors of worse physical and mental health outcomes, while polypharmacy was not.

Conclusion

In patients with AIS, high comorbidity burden and polypharmacy are frequent. Comorbidity burden at admission is independently associated with worse self-reported physical and mental health three months after stroke.

ABCD2, ABCD2-I, and OTTAWA scores for stroke risk assessment: a direct retrospective comparison

Transient ischemic attack (TIA) is a neurologic emergency characterized by cerebral ischemia eliciting a temporary focal neurological deficit. Many clinical prediction scores have been proposed to assess the risk of stroke after TIA; however, studies on their clinical validity and comparisons among them are scarce. The objective is to compare the accuracy of ABCD², ABCD²-I, and OTTAWA scores in the prediction of a stroke at 7, 90 days, and 1 year in patients presenting with TIA. Single-centre, retrospective study including patients with TIA admitted to the Emergency Department of our third-level, University Hospital, between 2018 and 2019. Five hundred three patients were included. Thirty-nine (7.7%) had a stroke within 1 year from the TIA: 9 (1.7%) and 24 (4.7%) within 7 and 90 days, respectively. ABCD², ABCD²-I, and OTTAWA scores were significantly higher in patients who developed a stroke. AUROCs ranged from 0.66 to 0.75, without statistically significant differences at each time-point. Considering the best cut-off of each score, only ABCD² > 3 showed a sensitivity of 100% only in the prediction of stroke within 7 days. Among clinical items of each score, duration of symptoms, previous TIA, hemiparesis, speech disturbance, gait disturbance, previous cerebral ischemic lesions, and known carotid artery disease were independent predictors of stroke. Clinical scores have moderate prognostic accuracy for stroke after TIA. Considering the independent predictors for stroke, our study indicates the need to continue research and prompts the development of new tools on predictive scores for TIA.

Outcomes of Mild Stroke and High-Risk Transient Ischemic Attack in Current Clinical Practice

INTRODUCTION

Early assessment and management of patients with mild stroke and transient ischemic attack (TIA) by specialists were recommended. This study aimed to evaluate the outcomes of these patients and identify the predictive factors of clinical progression, unfavorable outcomes, and recurrent stroke.

METHODS

Patients with mild ischemic stroke (NIHSS ≤5) and high-risk TIA were studied. All patients were managed by stroke specialists within 24 h of stroke onset. The outcomes of the patients at 3 months and final follow-up were studied. Predictive factors of clinical progression, unfavorable outcomes, and recurrent stroke were analyzed.

RESULTS

254 patients were studied. Thirty-eight patients (15%) had clinical progression during admission. Large artery atherosclerosis (OR 2.49, 95% CI: 1.06-5.81), cardioembolism (OR 3.34, 95% CI: 1.26-8.87), and brainstem stroke (OR 2.78, 95% CI: 1.28-6.01) were associated with clinical progression. At the final follow-up, median 22 months, 81 patients (32%) had unfavorable outcomes. Previous disability (OR 1.81, 95% CI: 3.31-100), moderate to severe white matter lesions (OR 2.90, 95% CI: 1.44-5.84), clinical progression (OR 12.5, 95% CI: 5.08-31.25), and recurrent stroke (OR 8.47, 95% CI: 3.21-22.72) were related to unfavorable outcomes. Eleven patients (4%) had recurrent stroke within 3 months and 31 patients (12%) at the final follow-up. Older age (OR 6.68, 95% CI: 2.35-19.02), diabetes mellitus (OR 2.59, 95% CI: 1.07-6.27), and smoking (OR 4.26, 95% CI: 1.52-11.95) were related to recurrent stroke.

CONCLUSION

Implementation of the up-to-date standard care in clinical practice would bring good clinical outcomes to the patients with mild stroke and high-risk TIA.

Association between physical activity levels and depressive symptoms in patients with minor ischemic stroke

OBJECTIVE

Post-stroke depression is associated with stroke recurrence and it is necessary to identify its influencing factors. The study aims to determine whether physical activity during hospitalization, as measured by accelerometer, was associated with depression after discharge in patients with minor ischemic stroke.

MATERIALS AND METHODS

This prospective observational study assessed 76 patients with minor ischemic stroke (aged 71.2 years) admitted to an acute care hospital. Depressive symptoms 3 months after discharge from the hospital was assessed using a questionnaire sent by mail. Baseline was set during hospitalization, and accelerometers were used to measure sedentary behavior, light and moderate-to-vigorous physical activities during hospitalization.

RESULTS

Three months after hospital discharge, 14 patients (18.4%) were placed in the depressive symptom group, with significantly more sedentary behavior (p = 0.021), less light physical activity (p = 0.016) and more depressive symptoms during hospitalization (p = 0.005) than in the non-depressive symptom group. Logistic regression analysis showed that sedentary behavior (odds ratio = 1.130, 95% confidence interval = 1.013‒1.281, p = 0.028) and light-intensity physical activity (odds ratio = 0.853, 95% confidence interval = 0.746‒0.976, p = 0.021) were independent factors for depressive symptoms at three months after discharge. Moderate to vigorous physical activity was not an independent factor.

CONCLUSIONS

Sedentary behavior and light-intensity physical activity during hospitalization were associated with depressive symptoms in patients with minor ischemic stroke after discharge. Reducing sedentary behavior and increasing light-intensity physical activity as part of inpatient rehabilitation may help prevent post-stroke depression.

Evaluation of an Australian neurological nurse-led model of postdischarge care

Neurological disorders are a leading cause of disease burden worldwide, placing a heavy demand on health systems. This study evaluated the impacts and cost savings of a community-based nursing service providing supported discharge for neurological patients deemed high-risk for unplanned emergency department presentations and/or hospital readmissions. It focused on adult patients with stroke, epilepsy, migraine/headache or functional neurological disorders discharged from a Western Australian tertiary hospital. An observational design was used comprising prospective enrolment of patients receiving nurse-led supported discharge and follow-up (Neurocare), 21 August 2018 to 6 December 2019 (N = 81), and hospital administrative data, 1 February 2016 to 31 January 2018, for patients in previous care model (N = 740). Healthcare utilisation and annualised cost savings from reduced rehospitalisation and/or emergency department presentations within 28 days post discharge were compared. Neurocare patients' postdischarge functional and health-related quality of life outcomes, and perceived involvement in self-management and integrated care were surveyed. The hospital's total cost savings are A$101,639 per annum and A$275/patient/year with a return on investment of 2.01. There was no significant difference in hospital length of stay (LOS) between models, but older age was associated with longer length of hospital stay and a predictor for non-neurological readmissions. Neurocare patients showed improved functional status, less equipment and/or service needs, improved health-related quality of life. They felt involved in self-managing their condition with well-integrated postdischarge care. This nurse-led model of transitional care for neurology patients discharged from hospital produced cost savings and a positive return on investment compared with usual care. With service maturity, earlier supported hospital discharge and reduced LOS may follow. Patients' reduced service needs and improved functional status and health-related quality of life may positively impact healthcare utilisation. Future research should include larger patient samples and multiple sites.

Optimal Methods for Reducing Proxy-Introduced Bias on Patient-Reported Outcome Measurements for Group-Level Analyses

BACKGROUND

Caregivers, or proxies, often complete patient-reported outcomes (PROs) on behalf of patients; yet, research has demonstrated proxies rate patient outcomes worse than patients rate their own outcomes. To improve interpretability of PROs in group-level analyses, our study aimed to identify optimal approaches for reducing proxy-introduced bias in the analysis of PROs.

METHODS

Data were simulated based on 200 patients with stroke and their proxies who both completed 9 PROMIS domains as part of a cross-sectional study. The sample size was varied as 50, 100, 200, and 500, and the proportion of patients with proxy-respondents was varied as 10%, 20%, and 50%. Six methods for handling proxy-completions were investigated: (1) complete case analysis; (2) proxy substitution; (3) Method 2 plus proxy adjustment; (4) Method 3 including inverse-probability of treatment weighting; (5) multiple imputation; (6) linear equating. These methods were evaluated by comparing average bias in PROMIS T-scores (estimated versus observed patient-only responses), as well as by comparing estimated regression coefficients to models using patient-only responses.

RESULTS

Overall mean T-score differences ranged from 0 to 1.75. The range of mean differences varied by the 6 methods with methods 1 and 5 providing estimates closest to the observed mean. In regression models, all but inverse-probability of treatment weighting resulted in low bias when proxy-completions were 10% to 20%. With 50% proxy-completions, method 5 resulted in less accurate estimations while methods 1 to 3 provided less proxy-introduced bias. Bias remained low across domain and varying sample sizes but increased with larger percentages of proxy-respondents.

CONCLUSIONS

Our study found modest proxy-introduced bias when estimating PRO scores or regression estimates across multiple domains of health. This bias remained low, even when sample size was 50 and there were large proportions of proxy-completions. While many of these methods can be chosen for including proxies in stroke PRO research with <20% proxy-respondents, proxy substitution with adjustment resulted in low bias with 50% proxy-respondents.

Approaches to Promote Reduction in Sedentary Behavior in Patients With Minor Ischemic Stroke: A Randomized Controlled Trial

OBJECTIVE

The purpose of this study was to determine whether an approach that promotes reduction in sedentary behavior (SB) during hospitalization and after hospital discharge reduces SB in patients with minor ischemic stroke (MIS) compared with an approach that promotes an increase in physical activity levels.

DESIGN

Randomized controlled trial design.

SETTING

During hospitalization and after hospital discharge.

PARTICIPANTS

We randomly assigned patients (N=61) with MIS (average age, 71.3±8.3y; 65.6% men) admitted to an acute hospital to either the intervention group (reduced SB, n=31) or the control group (increased physical activity levels, n=30).

INTERVENTIONS

During hospitalization, the intervention group received education on reducing SB, goal setting for SB after hospital discharge, and self-monitoring of SB and step count. In contrast, the control group received education on increasing physical activity levels and self-monitoring of step count. Patients in both groups wore an accelerometer during hospitalization until 3 months after hospital discharge. The intervention group received self-monitoring of SB and step count, stickers including information about reducing their SB, and phone calls once every 2 weeks for encouragement and feedback. The control group only wore the accelerometer.

MAIN OUTCOME MEASURES

The primary outcome was SB (in percentage) at 3 months after hospital discharge.

RESULTS

There was an interaction between the 2 groups for SB. Compared with the control group, the intervention group showed a significantly reduced SB (intervention group: baseline, 70.5%; 3 months after hospital discharge, 48.6%; control group: baseline, 71.5%; 3 months after hospital discharge, 57.5%; F value=5.981; P=.018).

CONCLUSIONS

The results suggested that an approach that promotes SB reduction during hospitalization and after hospital discharge is effective in reducing SB in patients with MIS 3 months after hospital discharge.

Predictive Model for Quality of Life in Patients 1 Year After First Stroke

BACKGROUND

Because the recurrence rate of stroke increases 1 year after its initial occurrence, it is important to predict quality of life at this stage, although most functions are likely recovered.

OBJECTIVES

We aimed to construct and verify a model of quality of life in patients 1 year post stroke by considering their characteristics at the time of the stroke based on the Wilson and Cleary model and previous literature.

METHODS

Participants comprised 288 patients who had experienced their first ischemic stroke and were enrolled in 3 regional stroke centers in South Korea. Data were analyzed using path analysis to identify a model of patients' quality of life 1 year post stroke.

RESULTS

Age, National Institutes of Health Stroke Scale score, the modified Rankin Scale score, and anxiety had a direct effect on quality of life, whereas type D personality and social support had an indirect effect. Type D personality, age, National Institutes of Health Stroke Scale score, social support, the modified Rankin Scale score, and anxiety explained 32.9% of the total variance in quality of life.

CONCLUSIONS

When predicting quality of life in a patient 1 year after a stroke, it is important to consider variables such as type D personality, age, National Institutes of Health Stroke Scale score, social support, the modified Rankin Scale score, and anxiety at the time of the first stroke. Interventions to improve the quality of life of patients with stroke should consider these factors.

Quantifying changes over 1 year in motor and cognitive skill after transient ischemic attack (TIA) using robotics

Recent work has highlighted that people who have had TIA may have abnormal motor and cognitive function. We aimed to quantify deficits in a cohort of individuals who had TIA and measured changes in their abilities to perform behavioural tasks over 1 year of follow-up using the Kinarm Exoskeleton robot. We additionally considered performance and change over time in an active control cohort of migraineurs. Individuals who had TIA or migraine completed 8 behavioural tasks that assessed cognition as well as motor and sensory functionality in the arm. Participants in the TIA cohort were assessed at 2, 6, 12, and 52 weeks after symptom resolution. Migraineurs were assessed at 2 and 52 weeks after symptom resolution. We measured overall performance on each task using an aggregate metric called Task Score and quantified any significant change in performance including the potential influence of learning. We recruited 48 individuals to the TIA cohort and 28 individuals to the migraine cohort. Individuals in both groups displayed impairments on robotic tasks within 2 weeks of symptom cessation and also at approximately 1 year after symptom cessation, most commonly in tests of cognitive-motor integration. Up to 51.3% of people in the TIA cohort demonstrated an impairment on a given task within 2-weeks of symptom resolution, and up to 27.3% had an impairment after 1 year. In the migraine group, these numbers were 37.5% and 31.6%, respectively. We identified that up to 18% of participants in the TIA group, and up to 10% in the migraine group, displayed impairments that persisted for up to 1 year after symptom resolution. Finally, we determined that a subset of both cohorts (25-30%) experienced statistically significant deteriorations in performance after 1 year. People who have experienced transient neurological symptoms, such as those that arise from TIA or migraine, may continue to experience lasting neurological impairments. Most individuals had relatively stable task performance over time, with some impairments persisting for up to 1 year. However, some individuals demonstrated substantial changes in performance, which highlights the heterogeneity of these neurological disorders. These findings demonstrate the need to consider factors that contribute to lasting neurological impairment, approaches that could be developed to alleviate the lasting effects of TIA or migraine, and the need to consider individual neurological status, even following transient neurological symptoms.

Effects of Chronic Care Model-based interventions on self-management, quality of life and patient satisfaction in patients with ischemic stroke: A single-blinded randomized controlled trial

AIM

This study was designed to evaluate the effect of Chronic Care Model (CCM)-based interventions on primary outcomes (self-efficacy, quality of life/QoL, patient satisfaction) and secondary outcomes (activities of daily living/ADL, metabolic control variables, stroke knowledge level, healthy eating habits, physical activity, taking regular medication, measuring blood pressure regularly, living in harmony with the disease, outcomes regarding telephone interviews) in patients with ischemic stroke.

METHOD

The intervention group (IG) received a 12-week StrokeCARE intervention protocol based on the four components of the CCM. The control group (CG) received only routine patient care. Changes between scores at two time points regarding self-efficacy, QoL, ADL, and metabolic control variables were calculated for each group, and then the mean changes were compared between the two groups.

RESULTS

The mean ages of the patients were 55.9 ± 11.44 and 58.9 ± 13.82 years (respectively IG; CG), and 64.7% of the patients were male in both groups. Most patients had other chronic diseases accompanying ischemic stroke. No significant differences were found between the two groups with respect to self-efficacy and QoL. Patient satisfaction was significantly higher in the IG. Positive feedback percentages of the patients in the IG regarding stroke knowledge level and consuming whole-grain food at the end of the 12 weeks increased significantly. This protocol had no significant effects on the secondary outcomes.

CONCLUSION

The CCM-based interventions may increase the satisfaction level of the patients and help to raise awareness of the risk of a secondary stroke. More studies are needed to examine the effects of these interventions (ClinicalTrials.gov-Identifier Number:NCT04161820).

Changes in Health-Related Quality of Life After Transient Ischemic Attack

IMPORTANCE

Numerous studies have found that patients diagnosed with TIA have decreased health-related quality of life, which has been interpreted as suggesting that patients with TIA have residual symptoms after the event. Studies assessing health status in the same patients before and after an event are lacking but may allow a direct determination of the association of TIA with postevent health status.

OBJECTIVE

To examine patient-reported health before transient ischemic attack (TIA) among individuals diagnosed with this event and evaluate change in patient-reported health after the event overall and by TIA characterization subgroups.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study was conducted among 236 patients with a clinical diagnosis of TIA from October 2015 to December 2017 in a large US health system that collects a patient-reported outcome measure in ambulatory setting as part of routine care. Included patients had patient-reported global health scale assessments completed as part of routine care before and after a TIA event. Data were analyzed from March through July 2020.

MAIN OUTCOMES AND MEASURES

The main outcome was Patient-Reported Outcome Measurement Information System Global Health (PROMIS GH) scale score before and after TIA. A change of 5 or more points in this score is considered clinically relevant. The secondary outcomes included change in patient-reported global health by clinical impression of the probability of a TIA event, pattern of neurological deficits, and short-term risk of stroke, as assessed by the ABCD2 score.

RESULTS

Among 263 patients who experienced TIA, mean (SD) age was 67.9 (13.4) years and 138 (52.5%) were women. The median (interquartile range) time between patient-reported global health scores was 152 (94-284) days. Mean (SD) baseline patient-reported global physical health and mental health scale summary scores were 43.4 (8.2) and 47.7 (9.7), respectively, and were statistically significantly decreased compared with the general population mean (SD) scores of 50 (10; P < .001) for physical and mental health. The difference between physical health summary score among study participants and the general population was clinically relevant. Mean (SD) summary scores were not statistically significantly different after the event compared with before the event overall (physical health: 44.1 [8.2], for a mean [SE] improvement of 0.65 [0.38] points; P = .09; mental health: 47.4 [9.1], for a mean [SE] worsening of 0.25 [0.38] points; P = .51) or within subgroups.

CONCLUSIONS AND RELEVANCE

These findings suggest that impaired health status among patients diagnosed with TIA reflect, at least in part, an impaired premorbid state of health. This study did not find that TIA events were associated with worsening of health status overall or within subgroups.

Factors associated with met and unmet rehabilitation needs after stroke: A multicentre cohort study in Denmark and Norway

OBJECTIVES

To examine patient-reported needs for care and rehabilitation in a cohort following different subacute pathways of rehabilitation, and to explore factors underpinning met and unmet needs.

DESIGN

Observational multicentre cohort study.

PATIENTS AND METHODS

A total of 318 Norwegian and 155 Danish patients with first-ever stroke were included. Participants answered questions from the Norwegian Stroke Registry about perceived met, unmet or lack of need for help and training during the first 3 months post stroke. The term "training" in this context was used for all rehabilitative therapy offered by physiotherapists, occupational or speech therapists. The term "help" was used for care provided by health professionals.

RESULTS

Need for training: 15% reported unmet need, 52% reported met need, and 33% reported no need. Need for help: 10% reported unmet need, 58% reported met, and 31% reported no need. Participants from both Norway and Denmark had similar patterns of unmet/met need for help or training. Unmet need for training was associated with lower functioning, (odds ratio (OR) = 0.32, p < 0.05) and more anxiety (OR = 0.36, p < 0.05). Patients reporting unmet needs for help more often lived alone (OR = 0.40, p < 0.05) and were more often depressed (OR = 0.31, p < 0.05).

CONCLUSION

Similar levels of met and unmet needs for training and help at 3 months after stroke were reported despite differences in the organization of the rehabilitation services. Functioning and psychological factors were associated with unmet rehabilitation needs.

Nonleisure-Time Physical Activity Guidance Following Minor Ischemic Stroke: A Randomized Clinical Trial

The purpose of this single-masked randomized clinical trial was to examine whether nonleisure-time physical activity guidance (NLTPAG) improves physical activity levels in patients after minor ischemic stroke. Patients who had been hospitalized for minor ischemic stroke in an acute care hospital (National Health Institute Stroke Scale ≤ 5) were randomized to either an NLTPAG group (n = 17) or a leisure-time physical activity guidance group (n = 16). NLTPAG focused on reducing sedentary behavior and increasing the frequency of walking for shopping and household activities to improve physical activity levels in daily life. Physical activity levels significantly improved only in participants in the NLTPAG group (initial assessment: metabolic equivalents of task = 12.6; final assessment: metabolic equivalents of task = 14.8; p = .035, r = .51). These results suggest that NLTPAG may be effective for improving physical activity levels in patients after minor ischemic stroke.

Influence of Type D Personality on Health Promoting Behaviours and Quality of Life in Stroke Patients: A Cross-Sectional Study in South Korea

OBJECTIVES

Type D personality is vulnerable to stress and is associated with high symptom severity, unhealthy behaviors, and low quality of life (QoL) in patients with chronic diseases. This study aimed to identify the influence of type D personality on health promoting behaviors and QoL in patients with ischemic stroke in South Korea.

MATERIALS AND METHODS

A descriptive, cross-sectional design was used. This study collected data from a convenience sample of 170 patients with ischemic stroke. Demographic and clinical characteristics, health promoting behaviors, and QoL were compared between the type D personality group and the non-type D group. Stepwise multiple regression analysis was performed to identify factors influencing patients' QoL.

RESULTS

Of the 170 subjects, 39 (22.9%) were classified as having type D personality. Type D personality was associated with higher National Institutes of Health Stroke Scale scores at admission and discharge, higher modified Rankin Scale (mRS) scores at 3 months after stroke, lower scores for health promoting behaviors, and lower QoL. Regression analysis showed that mRS score 3 months after stroke was the most significant factor influencing QoL, followed by health promoting behaviors, type D personality, speech deficits, and family income.

CONCLUSIONS

Type D personality should be considered together with health promoting behaviors and QoL in patients with ischemic stroke. Interventions considering type D personality may be helpful in improving health promoting behavior and QoL for the stroke patients.

Health-related quality of life, anxiety and depression up to 12 months post-stroke: Influence of sex, age, stroke severity and atrial fibrillation - A longitudinal subanalysis of the Find-AFRANDOMISED trial

BACKGROUND

Stroke can negatively impact the health-related quality of life (HRQoL). Anxiety or depression after stroke have been associated with poorer HRQoL, higher mortality and greater dependence in activities of daily living. We aimed to analyze HRQoL, anxiety and depressive symptoms in patients with and without atrial fibrillation (AF) up to 12 months post-stroke.

METHODS

Find-AF_RANDOMISED was a prospective, randomized multicenter study, which included 398 patients ≥60 years with acute cerebral ischemia. HRQoL data were collected using the 3-level EuroQol-5D (EQ-5D-3L) and Stroke Impact Scale (SIS-16). Anxiety and depressive symptoms were measured using the Hospital Anxiety and Depression Scale (HADS). The severity of stroke was measured using the modified Rankin Scale (mRS).

RESULTS

In this study (mean age 72.7 ± 7.5 years, 40.2% females), there was a significant improvement in HRQoL using EQ-5D-3L after 3 months (β = 0.37, p < .01), 6 months (β = 0.43, p < .01) and 12 months (β = 0.44, p < .01) post-stroke compared to baseline. HADS anxiety scores after 3 months (β = -0.22, p < .01) and 12 months (β = -0.28, p < .01) were significantly reduced. Older patients reported reduced HRQoL and more depressive symptoms. Females indicated lower HRQoL and more anxiety. mRS score at baseline was an independent predictor for HRQoL. There was a significant but small effect of AF on EQ-5D-3L and on HADS anxiety.

CONCLUSIONS

Patients showed significant improvement in HRQoL and reduced anxiety after 3 and 12 months after stroke. We could demonstrate that the severity of stroke as well as sex and age impact long-term post-stroke HRQoL.

CLINICAL TRIAL REGISTRATION

Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT01855035.

Early Seizures Are Predictive of Worse Health-Related Quality of Life at Follow-Up After Intracerebral Hemorrhage

OBJECTIVES

Early seizures are a common complication of intracerebral hemorrhage, occurring in ~10% of patients. However, the independent effect of early seizures on patient outcomes, particularly health-related quality of life, is unclear. Without a potential benefit to patient outcomes, the widespread use (~40%) of prophylactic seizure medications has no reasonable chance of improving patient outcomes. We tested the hypothesis that health-related quality of life at follow-up is different between patients with and without early seizures (and secondarily, with nonconvulsive status epilepticus) after intracerebral hemorrhage.

DESIGN

Patients with intracerebral hemorrhage were enrolled in an observational cohort study that prospectively collected clinical data and health-related quality of life at follow-up.

SETTING

Academic medical center.

PATIENTS

One-hundred thirty-three patients whose health-related quality of life was assessed 3 months after intracerebral hemorrhage onset.

MEASUREMENTS AND MAIN RESULTS

Health-related quality of life was obtained at 3 months after intracerebral hemorrhage onset. T Scores of health-related quality of life were modeled with multivariable linear models accounting for severity with the intracerebral hemorrhage Score and hematoma location. Health-related quality of life was measured with National Institutes of Health Patient Reported Outcomes Measurement Information System/Neuroquality of life, expressed in T Scores (U.S. normal 50 ± 10). The modified Rankin Scale (a global measure) was a secondary outcome. There were 12 patients (9%) with early seizures. T Scores of health-related quality of life at follow-up were lower (worse) in patients with early seizure compared with patients without an early seizure (44 [32.75-51.85] vs 30.25 [18.9-39.15]; p = 0.04); results for other domains of health-related quality of life were similar. The association persisted in multivariable models. There was no association between early seizures and prophylactic seizure medications (p = 0.4). Results for patients with nonconvulsive status epilepticus were similar. There was no association between early seizures and the modified Rankin Scale at 3 months.

CONCLUSIONS

Early seizures and nonconvulsive status epilepticus were associated with lower health-related quality of life at follow-up in survivors of intracerebral hemorrhage.

Comparison between EQ-5D-5L and PROMIS-10 to evaluate health-related quality of life 3 months after stroke: a cross-sectional multicenter study

BACKGROUND

Although the use of patient-reported outcome measures to assess Health-Related Quality of Life (HRQoL) has been advocated, it is still open to debate which patient-reported outcome measure should be preferred to evaluate HRQoL after stroke.

AIM

To compare the measurement properties (including concurrent validity and discriminant ability) between the 5-dimensional 5-level EuroQol (EQ-5D-5L) and the Patient-Reported Outcomes Measurement Information System 10-Question Global Health Short Form (PROMIS-10) to evaluate HRQoL 3 months after stroke.

DESIGN

Cross-sectional study.

SETTING

Neurology outpatient clinics in 6 Dutch hospitals.

POPULATION

The participants 360 consecutive individuals with stroke. Their median age was 71 years, 143 (39.7%) were female and 335 (93.0%) had suffered an ischemic stroke.

METHODS

The EQ-5D-5L, PROMIS-10, modified Rankin Scale and two items on experienced decrease in health and activities post-stroke were administered by a stroke nurse or nurse practitioner through a telephone interview 3 months after stroke. The internal consistency, distribution, floor/ceiling effects, inter-correlations and discriminant ability (using the modified Rankin Scale and experienced decrease in health and in activities post-stroke as external anchors) were calculated for both the EQ-5D-5L and PROMIS-10.

RESULTS

Ninety-six percent of the participants were living at home and 50.9% experienced minimal or no disabilities (modified Rankin Scale 0-1) 3 months after stroke. A ceiling effect and a non-normal left skewed distribution were observed in the EQ-5D-5L. The PROMIS-10 showed higher internal consistency (α=0.90) compared to the EQ-5D-5L (α=0.75). Both the EQ-5D-5L and the PROMIS-10 were strongly correlated with the modified Rankin Scale (r=0.62 and 0.60 respectively). The PROMIS-10 showed better discriminant ability in less affected individuals with stroke, whereas the EQ-5D-5L showed slightly better discriminant ability in more affected individuals with stroke.

CONCLUSIONS

Both EQ-5D-5L and PROMIS-10 prove to be useful instruments to evaluate HRQoL in patients who are living at home 3 months after stroke.

CLINICAL REHABILITATION IMPACT

The clinical rehabilitation impact depended on the setting and underlying goal which patient-reported outcome measure is preferred to evaluate HRQoL 3 months after stroke. The PROMIS-10 should be preferred to detect differences in less affected stroke patients, whereas the EQ-5D-5L provides slightly more information in more affected stroke patients.

Trade-Offs in Quality-of-Life Assessment Between the Modified Rankin Scale and Neuro-QoL Measures

INTRODUCTION

We aimed to describe the physical and cognitive health of patients with differing levels of post-stroke disability, as defined by modified Rankin Scale (mRS) scores. We also compared cross-sectional correlations between the mRS and the Quality of Life in Neurological Disorders (Neuro-QoL) T-scores to longitudinal correlations of change estimates from each measure.

METHODS

Mean Neuro-QoL T-scores representing mobility, dexterity, executive function, and cognitive concerns were compared among mRS subgroups. Fixed-effects regression models with robust standard errors estimated correlations among mRS and Neuro-QoL domain scores and correlations among longitudinal change estimates. These change estimates were then compared to distribution-based estimates of minimal clinically important differences.

RESULTS

Seven hundred forty-five patients with ischemic stroke (79%) or transient ischemic attack (21%) were enrolled in this longitudinal observational study of post-stroke outcomes. Larger differences in cognitive function were observed in the severe mRS groups (ie, 4-5) while larger differences in physical function were observed in the mild-moderate mRS groups (ie, 0-2). Cross-sectional correlations among mRS and Neuro-QoL T-scores were high (r = 0.61-0.83), but correlations among longitudinal change estimates were weak (r = 0.14-0.44).

CONCLUSIONS

Findings from this study undermine the validity and utility of the mRS as an outcome measure in longitudinal studies in ischemic stroke patients. Nevertheless, strong correlations indicate that the mRS score, obtained with a single interview, is efficient at capturing important differences in patient-reported quality of life, and is useful for identifying meaningful cross-sectional differences among clinical subgroups.

The association of stroke severity with health-related quality of life in survivors of acute cerebrovascular disease and their informal caregivers during the first year post stroke: a survey study

PURPOSE

To describe the health-related quality of life (HRQoL) of caregivers and survivors of transient ischaemic attack (TIA) and stroke during one year post discharge in comparison to age- and sex-matched population norms; and to analyse the association of initial stroke severity, measured by a routinely used stroke-specific scale, on subsequent HRQoL of caregivers and survivors.

METHODS

Cohort of hospitalized patients with TIA and stroke discharged alive from a large university hospital in Norway, and their informal caregivers. Questionnaires at 3 and 12 months post discharge were filled out by caregivers (n = 320 and n = 326, respectively) and survivors (n = 368 and n = 383, respectively). Multivariable linear regression analyses tested associations between initial stroke severity (National Institutes of Health Stroke Scale, NIHSS) and HRQoL (EQ-5D-3L) in caregivers and survivors.

RESULTS

Caregivers of survivors with TIA or stroke did not report lower HRQoL than matched norms. There was some evidence of an association of the NIHSS with caregiver HRQoL at 3 months only (age-sex-adjusted coefficient - 0.01, p = 0.008), however, this was attenuated after additional adjustments. Survivors with stroke, but not TIA, reported lower HRQoL than population norms at both time points. There was a negative association between higher NIHSS scores and survivors' HRQoL; fully adjusted coefficient - 0.01 at both time points (p = 0.001).

CONCLUSION

The informal caregivers and survivors with TIA did not report lower than expected HRQoL. Increasing stroke severity was associated with decreasing HRQoL among survivors, but had limited predictive value among caregivers. Other factors may therefore be better indicators of 'at risk' caregivers.

Clinical Symptom Profiles After Mild-Moderate Stroke

Background

There is heterogeneity in the severity of domains affected in patients with stroke, resulting in differences in health‐related quality of life (hrQoL). Identifying different clinical profiles of stroke patients may provide a means for selecting patients for tailored interventions to improve hrQoL.

Methods and Results

This was an observational study of 496 patients with ischemic stroke or intracerebral hemorrhage seen in a cerebrovascular clinic from October 12, 2015, through June 11, 2018, who completed patient‐reported outcome measures using Patient‐Reported Outcome Measurement Information System (PROMIS) tools within 1 month of stroke. Latent profile analysis identified groups based on PROMIS domain scores—pain, depression, cognitive function, fatigue, social role satisfaction, and physical function—as well as clinician‐reported modified Rankin Scale (mRS). Five distinct profiles were identified. Group 1 (“excellent hrQoL,” n=106) had fewer symptoms in all domains than the general population. Group 2 (“disabled with mixed hrQoL,” n=17) had fewer symptoms than the general population in all domains except social role satisfaction and physical function, despite having moderate disability (median mRS score: 3). Group 3 (“mild limitations with average hrQoL,” n=189) had scores similar to the general population for all domains and minimal disability (median mRS score: 1). Group 4 (“mild limitations with poor hrQoL,” n=152) also had a median mRS score of 1 but had worse scores than group 3 on all domains. Group 5 (“disabled with poor hrQoL,” n=32) had worse symptoms than patients in the other profiles and a median mRS score of 3.

Conclusions

Patients with recent stroke have distinct clinical symptom profiles, even with similar levels of clinician‐reported disability. Symptom profiles provide a means of understanding patterns of outcomes in patients with stroke.

Brain Imaging Signs and Health-Related Quality of Life after Acute Ischemic Stroke: Analysis of ENCHANTED Alteplase Dose Arm

BACKGROUND AND PURPOSE

The influence of specific brain lesions on health-related quality of life (HRQoL) after acute ischemic stroke (AIS) is uncertain. We aimed to identify imaging predictors of poor HRQoL in alteplase-treated participants of the alteplase dose arm of the Enhanced Control of Hypertension and Thrombolysis Stroke Study (ENCHANTED).

METHODS

ENCHANTED was an international trial of low- versus standard-dose intravenous alteplase in AIS patients, with functional outcome (modified Rankin scale [mRS]) and HRQoL on the 5-dimension European Quality of Life Scale (EQ-5D) assessed at 90 days post-randomization. Brain images were analyzed centrally by trained assessors. Multivariable logistic regression was undertaken in the study population randomly divided (2:1) into training (development) and validation (performance) groups, with age (per 10-year increase), ethnicity, baseline National Institutes of Health Stroke Scale (NIHSS) score, diabetes mellitus, premorbid function (mRS score 0 or 1), and proxy respondent, forced into all models. Data are presented with odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

Eight prediction models were developed and validated in 2,526 AIS patients (median age 67.5 years; 38.4% female; 61.7% Asian) with complete brain imaging and 90-day EQ-5D utility score data. The best performance model included acute ischemic changes in the right (OR 1.69, 95% CI: 1.24-2.29) and deep (OR 1.50, 95% CI: 1.03-2.19) middle cerebral artery (MCA) regions. Several background features of brain frailty - atrophy, white matter change, and old infarcts - were significantly associated with adverse physical but not emotional HRQoL domains.

CONCLUSIONS

In thrombolysed AIS patients, right-sided and deep ischemia within the MCA territory predict poor overall HRQoL, whilst features of old cerebral ischemia are associated with reduced physical HRQoL.

Depressive symptoms after stroke are associated with worse recovery

OBJECTIVE

More studies are needed on how depressive symptoms in stroke patients can impact outcomes. We evaluated the relationship between depression symptom severity and motor outcomes in a cohort of patients with motor impairment from ischemic stroke.

METHOD

We enrolled consecutive ischemic stroke patients without a clinical diagnosis of depression who presented to a single-center urban academic referral hospital. The Patient Health Questionnaire-9 (PHQ-9) scale was used to measure depression symptom severity at three months. Three assessments of motor function were collected at stroke onset and three months: Fugl-Meyer upper extremity (FM-UE), Motricity Index, and Action Research Arm Test (ARAT). We assessed the association between three-month severity on PHQ-9 scores with the outcome measures using univariable and multivariable linear regression models.

RESULTS

Fifty-seven patients (mean age 67.8 ± 17.0 years; 50.9% male; 59.6% Caucasian) were included in the final analysis. Mean (standard deviation) outcome scores at three months were PHQ-9: 6.39 (5), Motricity Index: 86.93 (30.04), FM-UE: 52.67 (17.83), and ARAT: 43.77 (20.03). After adjusting for age, initial National Institute of Health Stroke Scale, and if patient discharged after hospitalization on a selective serotonin reuptake inhibitor, sex, and baseline motor outcome, we found that for every point increase in PHQ-9, the Motricity Index decreased by 0.82 points (p = 0.02) and the FM-UE decreased by 0.77 points (p = 0.049).

CONCLUSION

Depressive symptoms are common in the stroke population. Depressive symptoms after stroke are associated with multiple types of motor impairments. We need better understanding of the biologic and psychologic aspects of depression involved in stroke recovery.

Differential Effects of Time to Initiation of Therapy on Disability and Quality of Life in Patients With Mild and Moderate to Severe Ischemic Stroke

OBJECTIVE

To assess the effect of time to acute therapy on health-related quality of life (HRQoL) and disability after ischemic stroke.

DESIGN

Prospective cohort study.

SETTING

Comprehensive stroke care center in a large metropolitan city.

PARTICIPANTS

Patients (N=553; mean age, 67 y; 51.9% male; 64.4% white; 88.8% ischemic stroke) with ischemic stroke or transient ischemic attack (TIA) enrolled in a longitudinal observational study between August 2012 to January 2014 who received rehabilitation services.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Disability status was assessed with the modified Rankin Scale (mRS) and Barthel Index (BI). HRQoL was assessed using the Quality of Life in Neurological Disorders measures of executive function, general cognitive concerns, upper extremity dexterity, and lower extremity mobility. Time to therapy consult and treatment were defined as the number of days from hospital admission to initial consult by a therapist and number of days from hospital admission to initial treatment, respectively.

RESULTS

Among the participants, the median number of days from hospital admission to acute therapy consult was 2 days (interquartile range, 1-3d). Multivariable linear and logistic regression models indicated that for those with the National Institutes of Health Stroke Scale (NIHSS) score<5, longer time to therapy consult was associated with worse BI scores (BI=100; odds ratio [OR], 0.818; P=.008), executive function T scores (b=-0.865; P=.001), and general cognitive concerns T scores (b=-0.609; P=.009) at 1-month in adjusted analyses. In those with NIHSS score≥5, longer time to therapy treatment led to increased disability (ie, mRS≥ 2; OR, 1.15; P=.039) and lower extremity mobility T scores (b=-0.591; P=.046) at 1 month in adjusted analyses.

CONCLUSIONS

Longer time to initiation of acute therapy has differential effects on poststroke disability and HRQoL up to 1-month after ischemic stroke and TIA. The effect of acute therapy consult is more notable for those with mild deficits, while the effect of acute therapy treatment is more notable for those with moderate to severe deficits. Minimizing time to therapy consults and treatments in the acute hospital period might improve outcomes after ischemic stroke and TIA.

Sleep-related symptoms in patients with mild stroke

STUDY OBJECTIVES

Treatable sleep-related conditions are frequent in stroke patients, although their prevalence across stroke types and ideal method for screening is not clear. The objectives of this study were to evaluate the prevalence of sleep disturbance across different stroke types and identify approaches to the collection of sleep-related measures in clinical practice.

METHODS

We performed an observational cohort study of 2,213 patients with ischemic stroke, intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH), or transient ischemic attack seen in a cerebrovascular clinic February 17, 2015 through July 5, 2017 who completed at least one of the following sleep-related questionnaires: Patient-Reported Outcomes Measurement Information System (PROMIS) sleep disturbance, Insomnia Severity Index (ISI), Sleep Apnea Probability Scale (SAPS), and sleep duration. Prevalence of abnormal scores were calculated using the following thresholds: PROMIS sleep disturbance ≥ 55, ISI ≥ 15, SAPS score ≥ 0.50, and sleep duration fewer than 6 or more than 9 hours. Sensitivity, specificity, and positive and negative predictive values of PROMIS sleep disturbance T-score ≥ 55 to identify patients with moderate-severe insomnia (ISI ≥ 15) were computed.

RESULTS

In the cohort, 28.6% patients (624/2183) had PROMIS sleep disturbance score ≥ 55, 17.6% (142/808) had ISI ≥ 15, and 61.3% (761/1241) had a positive SAPS screen. The frequency of abnormal sleep scale scores was similar across time periods and stroke types. The sensitivity and specificity of PROMIS sleep disturbance T-score ≥ 55 to identify patients with ISI ≥ 15 were 0.89 (95% confidence interval 0.83-0.94) and 0.81 (95% confidence interval 0.78-0.84), respectively.

CONCLUSIONS

The prevalence of sleep-related symptoms in patients with mild stroke are similar across stroke types and time periods after stroke. Potential approaches to screening for sleep disturbance in stroke patients are provided.

Ethnicity and Other Determinants of Quality of Functional Outcome in Acute Ischemic Stroke: The ENCHANTED Trial

Background and Purpose- Patient-centered outcomes are important. We aimed to determine predictors of health-related quality of life (HRQoL) and develop utility-weighted modified Rankin Scale (mRS) scores in thrombolyzed acute ischemic stroke patients from both arms of ENCHANTED (Enhanced Control of Hypertension and Thrombolysis Stroke Study). Methods- ENCHANTED was an international quasi-factorial clinical trial of different doses of intravenous alteplase and intensities of blood pressure control in acute ischemic stroke patients, with outcomes on the 5-Dimensional European Quality of Life Scale and mRS assessed at 90 days post-randomization. Logistic regression models were used to identify baseline predictors of poor HRQoL (≤mean 5-Dimensional European Quality of Life Scale utility scores). Ordinary least squares regression derived utility-weighted mRS scores. Results- In 4016 acute ischemic stroke patients with complete 5-Dimensional European Quality of Life Scale and mRS data, independent predictors of poor HRQoL were older age (odds ratio, 1.19 [95% CI, 1.12-1.27], per 10-year increase), non-Asian ethnicity (1.91 [1.61-2.27]), greater stroke severity on the National Institutes of Health Stroke Scale (1.11 [1.09-1.12]), diabetes mellitus (1.41 [1.18-1.69]), premorbid disability (mRS score 1 versus 0; 1.62 [1.33-1.97]), large vessel atheromatous pathogenesis (1.32 [1.12-1.54]), and proxy respondent (2.35 [2.01-2.74]). Sensitivity analyses indicate the ethnicity influence on HRQoL was driven by the high proportion of Chinese (62.9% of Asian) participants with better HRQoL compared with non-Chinese or other Asian groups. Derived utility values across mRS scores 0 to 5 were 0.977, 0.885, 0.748, 0.576, 0.194, and -0.174, respectively. Correlations between mRS and 5-Dimensional European Quality of Life Scale scores were stronger in Asians. Conclusions- HRQoL is worse after thrombolyzed acute ischemic stroke in the elderly, non-Asians, with greater initial severity, diabetes mellitus, premorbid disability, due to large vessel atheroma, and proxy assessment. The broader significance of better HRQoL in Asians is tempered by Chinese participants dominating analyses. From utility-weighted mRS scores indicating the greatest steps in mRS scores are between 5 and 3, treatments to avoid major disability provide the greatest benefits for patients. Registration- URL: https://www.clinicaltrials.gov. Unique identifier: NCT01422616.

Affected health domains in patients with brainstem cavernous malformations

BACKGROUND

Brainstem cavernous malformations (CM) carry high risks of hemorrhage and neurologic morbidity. While much is published on physical effects of brainstem CM, very little is known about these patients' quality of life. This study aimed to assess the quality of life PROMIS-29 health domains of brainstem CM patients and identify quality of life predictors.

METHODS

This was a cross-sectional study of adult patients with at least one brainstem CM identified by advertising on the Angioma Alliance website and from our institutional CM registry. A web-based questionnaire was administered and included self-reported information about the patient, cavernous malformation, residual clinical symptoms, and treatment. In addition, patients filled out the PROMIS-29 (version 1.0). The PROMIS-29 has 7 health domains and is standardized against the general population. We defined impaired quality of life as at least one out of 7 abnormal domains and used a 1 standard deviation cutoff for abnormal. We verified clinical and radiographic data to self-reported data in 28.8% of patients.

RESULTS

A total of 104 patients (mean age of 46.5 ± 11.5 years; 77.9% females) were recruited. Most (82.7%) reported at least one symptomatic hemorrhagic event and 36.5% reported at least 1 surgical procedure. At least one abnormal PROMIS domain was present in 64.4% of patients with fatigue (34.6%), anxiety (35.6%), social (28.2%), and physical (27.9%) domains being the most common. Among patients with a Rankin Score of 0-2, 55% had at least one abnormal domain. Gait difficulty, but not age, sex, or surgery predicted impaired quality of life.

CONCLUSION

More than half of patients with brainstem CM have impaired quality of life. Fatigue, anxiety, and social function, in addition to physical dysfunction, are common; practitioners should be aware of these concerns. PROMIS-29 provides additional information than modified Rankin Score and should be considered in clinical trials and when assessing treatment outcomes until a disease-specific outcome tool is available.

Patients With Greater Stroke Severity and Premorbid Disability Are Less Likely to Receive Therapist Consultations and Intervention During Acute Care Hospitalization

BACKGROUND

A substantial number of patients with stroke never receive acute care therapy services, despite the fact that therapy after stroke reduces the odds of death and disability and improves patients' functioning.

OBJECTIVE

The aim of this study was to estimate the proportion of and factors associated with receipt of therapist consultations and interventions during acute care hospitalization following ischemic and hemorrhagic stroke.

DESIGN

This was a single-center longitudinal observational study.

METHODS

Adults with a diagnosis of ischemic or hemorrhagic stroke (N = 1366) were enrolled during their hospitalization in an acute stroke center in a large metropolitan area. The main outcomes were receipt of therapist consultations, interventions, or both.

RESULTS

Participants with acute hemorrhagic stroke (intracerebral: odds ratio [OR] = 0.34 [95% CI = 0.19-0.60]; subarachnoid: OR = 0.52 [95% CI = 0.28-0.99]) and with greater stroke severity by National Institutes of Health Stroke Scale (NIHSS) score (NIHSS score of > 15: OR = 0.34 [95% CI = 0.23-0.51]) were less likely to receive therapist consultations. Participants with moderate stroke severity (NIHSS score of 6-15: OR = 1.43 [95% CI = 1.01-2.33]) were more likely to receive therapy interventions. Those who were able to ambulate before admission were more than 5 times as likely to receive therapy interventions (OR = 5.08 [95% CI = 1.91-13.52]). Also, participants with longer lengths of stay (ie, more intensive care unit and non-intensive care unit days) were more likely to receive therapist consultations and interventions. Tests or procedures were the most common reasons for unsuccessful attempts to complete therapist consultations.

LIMITATIONS

Lack of operational and qualitative data prohibited detailed explorations of barriers to delivery of therapist consultations and interventions.

CONCLUSIONS

Approximately 1 in 4 participants with acute stroke received neither a consultation nor an intervention. Efforts to improve the delivery of acute care therapy services are needed to optimize care for these people.

Randomized Controlled Trial of the Lateral Push-Off Skater Exercise for High-Intensity Interval Training vs Conventional Treadmill Training

OBJECTIVE

To examine the therapeutic effects of the lateral push-off skater exercise vs conventional treadmill training on health-related quality of life, cardiorespiratory fitness (CRF), and balance.

DESIGN

Single-blinded, randomized controlled trial.

SETTING

Outpatient clinic at a tertiary hospital.

PARTICIPANTS

Patients after minor stroke (N=36) with National Institutes of Health Stroke Scale scores≤3 between 20 and 65 years of age were randomly assigned to the intervention group (n=18) or the control group (n=18).

INTERVENTIONS

Thirty-minute sessions of the skater exercise were performed 3 times weekly for 12 weeks in the intervention group. Conventional treadmill aerobic exercise was conducted in the control group at the same frequency and duration as the experimental group exercise.

MAIN OUTCOME MEASURES

The primary outcome was measured using the European Quality of Life-5 Dimension (EQ-5D). Secondary outcomes included CRF and balance indicators. Assessments were performed at baseline (T0), 12 weeks from T0 (T1), and 16 weeks from T0 (T2).

RESULTS

Significant improvements in EQ-5D, peak oxygen uptake (VO₂peak), peak oxygen pulse, peak minute ventilation (VE), Dynamic Gait Index (DGI), and Berg Balance Scale (BBS) were found in the intervention group after performing the skater exercise (P<.05, all), and these improvements were sustained at T2 (P<.05, all). Between-group comparisons demonstrated greater improvements in EQ-5D, VO₂peak, peak oxygen pulse, peak VE, DGI, and BBS in the intervention group than those in the control group at both T1 (P<.05, all) and T2 (P<0.05, all). Correlation analysis showed significant relationships between EQ-5D and VO₂peak, peak VE, DGI, and BBS (P<.05, all).

CONCLUSIONS

The skater exercise improved health-related quality of life, CRF, and balance in patients after minor stroke more effectively than conventional treadmill-based aerobic exercise. We recommend the skater exercise as a high-intensity interval training program for patients after minor stroke.

Cognition and Quality of Life in Symptomatic Carotid Occlusion

PURPOSE

Carotid occlusion may result in stroke, TIA, and cognitive reductions. Whether cognition predicts quality of life (QOL) for patients with carotid occlusion is unknown. Depression is also known to affect QOL. We examined whether cognition and depression predicted QOL in patients with carotid occlusive disease who have not had revascularization.

METHODS

Patients with unilateral carotid occlusion and history of TIA or a remote history of minor stroke were included. Patients underwent exam of memory, language, motor, and executive function skills and completed depression and QOL questionnaires (Center for Epidemiological Studies-Depression [CES-D], Stroke Specific QOL [SSQOL]). Deficits from remote stroke were assessed with the NIH Stroke Scale (NIHSS). Z-scores for cognitive tests were averaged (Cog-Z). The SSQOL scores were averaged across subgroup domains. Analyses of patients with all depression levels were followed by subgroup analyses for patients with minimal depression. Correlation findings were used to select the variables in a regression model to predict SSQOL.

RESULTS

Among 37 patients with all depression levels, QOL was predicted by deficits from remote stroke and depression (F(3, 36) = 21.15, P<.0005; NIHSS Beta = -.392, P = .001; CES-D Beta = -.577, P < .0005). Among 22 patients with minimal depression, QOL was predicted by cognitive and depression scores, (F(2,21) = 7.88, P = .003; Cog-Z Beta = .364, P = .05; CES-D Beta = -.495, P = .01).

CONCLUSIONS

In patients with carotid occlusive disease without major stroke and without revascularization, cognitive and depression scores independently predicted QOL. These data demonstrate the clinical relevance of cognitive and mood decline among patients with carotid occlusion.

Patient versus proxy response on global health scales: no meaningful DIFference

PURPOSE

Assessment of outcomes from a proxy is often substituted for the patient's self-report when the patient is unable or unwilling to report their status. Research has indicated that proxies over-report symptoms on the patient's behalf. This study aimed to quantify the extent of proxy-introduced bias on the Patient-Reported Outcomes Measurement Information System Global Health (PROMIS GH) scale for mental (GMH) and physical (GPH) scores.

METHODS

This retrospective cohort study included incident stroke patients seen in a cerebrovascular clinic who completed PROMIS GH between 10/12/15 and 6/6/18. Differential item functioning (DIF) evaluated measurement invariance of patient versus proxy responses. DIF impact was assessed by comparing the initial score to the DIF-adjusted score. Subgroup analyses evaluated DIF within strata of stroke severity, measured by modified Rankin Scale (≤ 1, 2, 3+), and time since stroke (≤ 30, 31-90, > 90 days).

RESULTS

Of 1351 stroke patients (age 60.5 ± 14.9, 45.1% female), proxy help completing PROMIS GH was required by 406 patients (30.1%). Proxies indicated significantly worse response to all items. No items for GMH or GPH were identified as having meaningful DIF. In subgroup analyses, no DIF was found by severity or 31-90 days post-stroke. In patients within 30 and > 90 days of stroke, DIF was detected for 2 items. Accounting for DIF had negligible effects on scores.

CONCLUSIONS

Our findings revealed the overestimation of symptoms by proxies is a real difference and not the result of measurement non-invariance. PROMIS GH items do not perform differently or have spuriously inflated severity estimates when administered to proxies instead of patients.

Patient-reported outcomes across cerebrovascular event types: More similar than different

OBJECTIVES

To compare the degrees to which 8 domains of health are affected across types of cerebrovascular events and to identify factors associated with domain scores in different event types.

METHODS

This was an observational cohort study of 2,181 patients with ischemic stroke, intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH), or TIA in a cerebrovascular clinic from February 17, 2015, to June 2, 2017 who completed Quality of Life in Neurologic Disorders executive function and the following Patient-Reported Outcomes Measurement Information System scales as part of routine care: physical function, satisfaction with social roles, fatigue, anxiety, depression, pain interference, and sleep disturbance.

RESULTS

All health domains were affected to similar degrees in patients with ICH, SAH, and ischemic stroke after adjustment for disability and other clinical factors, whereas patients with TIA had worse adjusted scores for 5 of the 8 domains of health. Female sex, younger age, lower income, and event <90 days were associated with worse scores in multiple domains. Factors associated with health domain scores were similar for all cerebrovascular events. Most affected domains for all were physical function, satisfaction with social roles, and executive function.

CONCLUSIONS

The subtype of stroke (ischemic stroke, ICH, and SAH) had similar effects in multiple health domains, while patients with TIA had worse adjusted outcomes, suggesting that the mechanisms for outcomes after TIA may differ from those of other cerebrovascular events. The most affected domains across all event types were physical function, satisfaction with social roles, and executive function, highlighting the need to develop effective interventions to improve these health domains in survivors of these cerebrovascular events.

Prophylactic Seizure Medication and Health-Related Quality of Life After Intracerebral Hemorrhage

OBJECTIVES

Prophylactic levetiracetam is currently used in ~40% of patients with intracerebral hemorrhage, and the potential impact of levetircetam on health-related quality of life is unknown. We tested the hypothesis that prophylactic levetiracetam is independently associated with differences in cognitive function health-related quality of life.

DESIGN

Patients with intracerebral hemorrhage were enrolled in a prospective cohort study. We performed mixed models for T-scores of health-related quality of life, referenced to the U.S. population at 50 ± 10, accounting for severity of injury and time to follow-up.

SETTING

Academic medical center.

PATIENTS

One-hundred forty-two survivors of intracerebral hemorrhage.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

T-scores of Neuro-Quality of Life Cognitive Function v2.0 was the primary outcome, whereas Neuro-Quality of Life Mobility v1.0 and modified Rankin Scale (a global functional scale) were secondary measures. We prospectively documented if prophylactic levetiracetam was administered and retrieved administration data from the electronic health record. Patients who received prophylactic levetiracetam had worse cognitive function health-related quality of life (T-score 5.1 points lower; p = 0.01) after adjustment for age (p = 0.3), National Institutes of Health Stroke Scale (p < 0.000001), lobar hematoma (p = 0.9), and time of assessment; statistical models controlling for prophylactic levetiracetam and the Intracerebral Hemorrhage Score, a global measure of intracerebral hemorrhage severity, yielded similar results. Lower T-scores of cognitive function health-related quality of life at 3 months were correlated with more total levetiracetam dosage (p = 0.01) and more administered doses of levetiracetam in the hospital (p = 0.03). Patients who received prophylactic levetiracetam were more likely to have a lobar hematoma (27/38 vs 19/104; p < 0.001), undergo electroencephalography monitoring (15/38 vs 21/104; p = 0.02), but not more likely to have clinical seizures (4/38 vs 7/104; p = 0.5). Levetiracetam was not independently associated with the modified Rankin Scale scores or mobility health-related quality of life (p > 0.1).

CONCLUSIONS

Prophylactic levetiracetam was independently associated with lower cognitive function health-related quality of life at follow-up after intracerebral hemorrhage.

Infarct location is associated with quality of life after mild ischemic stroke

Background In patients with mild ischemic stroke, small but eloquent infarcts may have devastating effects, particularly on health-related quality of life. Aim This study investigates the association between acute infarct location and three-month health-related quality of life in patients with mild ischemic stroke. Methods We evaluated consecutively enrolled patients from a single center between August 2012 and July 2013. Our primary outcome at three months was impairment in any health-related quality of life domain (upper extremity, lower extremity, executive function, and general concerns) defined by a T-score <45. We analyzed the association between acute infarct locations and impaired health-related quality of life at three months in univariate and multivariable analysis. Results Among 229 patients (mean age 64.9 years, 55% male, 29.7% black, and median initial NIHSS score 1), impaired health-related quality of life was noted in 84 (36.2%) patients at three months. In univariate analysis, patients with subcortical infarcts (56.0% vs. 39.3%, p = 0.02) and brainstem infarcts (21.4% vs. 10.3%, p = 0.02) were more likely to have impaired health-related quality of life. In multivariable analysis, patients with subcortical and/or brainstem infarcts had increased odds of impaired health-related quality of life (adjusted OR 2.54, 95% CI 1.29-5.01, p = 0.01). Conclusions After mild ischemic stroke, subcortical and brainstem infarct locations predict impairment in health-related quality of life.

Cincinnati Prehospital Stroke Scale Can Identify Large Vessel Occlusion Stroke

OBJECTIVE

Accurate prehospital identification of patients with acute ischemic stroke (AIS) from large vessel occlusion (LVO) facilitates direct transport to hospitals that perform endovascular thrombectomy. We hypothesize that a cut-off score of the Cincinnati Prehospital Stroke Scale (CPSS), a simple assessment tool currently used by emergency medical services (EMS) providers, can be used to identify LVO.

METHODS

Consecutively enrolled, confirmed AIS patients arriving via EMS between August 2012 and April 2014 at a high-volume stroke center in a large city with a single municipal EMS provider agency were identified in a prospective, single-center registry. Head and neck vessel imaging confirmed LVO. CPSS scores were abstracted from prehospital EMS records. Spearman's rank correlation, Wilcoxon rank-sum test, and Student's t-test were performed. Cohen's kappa was calculated between CPSS abstractors. The Youden index identified the optimal CPSS cut-off. Multivariate logistic regression controlling for age, sex, and race determined the odds ratio (OR) for LVO.

RESULTS

Of 144 eligible patients, 138 (95.8%) had CPSS scores in the EMS record and were included for analysis. The median age was 69 (IQR 58-81) years. Vessel imaging was performed in 97.9% of patients at a median of 5.9 (IQR 3.6-10.2) hours from hospital arrival, and 43.7% had an LVO. Intravenous tissue plasminogen activator was administered to 29 patients, in whom 12 had no LVO on subsequent vessel imaging. The optimal CPSS cut-off predicting LVO was 3, with a Youden index of 0.29, sensitivity of 0.41, and specificity of 0.88. The adjusted OR for LVO with CPSS = 3 was 5.7 (95% CI 2.3-14.1). Among patients with CPSS = 3, 72.7% had an LVO, compared with 34.3% of patients with CPSS ≤ 2 (p < 0.0001).

CONCLUSIONS

A CPSS score of 3 reliably identifies LVO in AIS patients. EMS providers may be able to use the CPSS, a simple, widely adopted prehospital stroke assessment tool, with a cut-off score to screen for patients with suspected LVO.

Modified Approach to Stroke Rehabilitation (MAStR): feasibility study of a method to apply procedural memory concepts to transfer training

OBJECTIVE

Training and implementation for a multidisciplinary stroke rehabilitation method emphasizing procedural memory.

BACKGROUND

Current practice in stroke rehabilitation relies on explicit memory, often compromised by stroke, failing to capitalize on better-preserved procedural memory skills. Recruitment of procedural memory requires consistency and practice, characteristics difficulty to promote on inpatient rehabilitation units. We designed a method Modified Approach to Stroke Rehabilitation (MAStR) to maximize consistency and practice for transfer training with stroke patients.

DESIGN

Phase I, single-group study. MAStR has two innovations: (1) simplification of instructions to only three words, other direction provided non-verbally; (2) having all rehabilitation staff apply the same approach for transfers. Staff training in MAStR included review of written material describing the rationale for MAStR and demonstration of a transfer using MAStR. Enrolled patients completed each transfer with MAStR in addition to standard rehabilitation therapy.

RESULTS

The MAStR method was taught to a large, multidisciplinary rehabilitation staff (n = 31). Training and certification required 15 min per staff member. Five stroke patients were enrolled. No transfers with MAStR resulted in injury, no negative feedback was received from staff or patients. Staff reported satisfaction with the brief MAStR training and reported transfers were easier to complete with the MAStR method.

CONCLUSIONS

Feasibility was demonstrated for an innovative application of procedural memory concepts to stroke rehabilitation. All rehabilitation disciplines were successfully trained. MAStR was well-tolerated and liked by rehabilitation staff and patients. These results support pursuit of a Phase II pilot study.

Activity limitations and subjective well-being after stroke

OBJECTIVE

As limitations in activities of daily living are major components of many stroke outcome scales, we examined how well activity limitations predicted subjective well-being among stroke survivors in a nationally representative survey.

METHODS

Individuals with a self-reported history of stroke were identified from the National Health and Aging Trends Study. Subjective well-being (primary outcome) was assessed with a validated 7-item measure (higher = greater well-being) assessing emotions (cheerful, bored, full of life, and upset) and self-realization (purpose in life, self-acceptance, and environmental mastery). Activity limitations were defined by the receipt of help in any of 11 activities of daily living/instrumental activities of daily living. Multivariable linear regression assessed predictors of well-being including medical, physical, cognitive, psychological, and environmental factors.

RESULTS

A total of 738 stroke survivors age 65 or older were included (57% female, 9% African American, 6% Hispanic). Activity limitations were modestly associated with well-being after adjusting for demographic characteristics and availability of assistance (estimate -0.49, 95% confidence interval -0.61 to -0.37). However, in the fully adjusted model (R2 = 0.28), neither activity limitations nor physical capacity was associated with subjective well-being. Predictors of lower well-being in the final model included depressive symptoms, chewing/swallowing problems, pain that limited activity, and restricted participation in valued life activities. Income and executive function were modestly associated with improved well-being, while comorbidities and communication technology access were not associated.

CONCLUSIONS

Activity limitations were not associated with stroke survivors' subjective well-being after adjustment for other factors. While some predictors of well-being after stroke were identified, the determinants of well-being remained largely unexplained.

Added Value of Patient-Reported Outcome Measures in Stroke Clinical Practice

Background

There is uncertainty regarding the clinical utility of the data obtained from patient‐reported outcome measures (PROMs) for patient care. We evaluated the incremental information obtained by PROMs compared to the clinician‐reported modified Rankin Scale (mRS).

Methods and Results

This was an observational study of 3283 ischemic stroke patients seen in a cerebrovascular clinic from September 14, 2012 to June 16, 2015 who completed the routinely collected PROMs: Stroke Impact Scale‐16 (SIS‐16), EQ‐5D, Patient Health Questionnaire‐9, PROMIS Physical Function, and PROMIS fatigue. The amount of variation in the PROMs explained by mRS was determined using r² after adjustment for age and level of stroke impairment. The proportion with meaningful change was calculated for patients with ≥2 visits. Concordance with change in the other scales and the ability to discriminate changes in health state as measured by c‐statistic was evaluated for mRS versus SIS‐16. Correlation between PROMs and mRS was highest for SIS‐16 (r=−0.64, P<0.01). The r² ranged from 0.11 (PROMIS fatigue) to 0.56 (SIS‐16). Change in scores occurred in 51% with mRS and 35% with SIS‐16. There was lower agreement and less ability to discriminate change in mRS than in SIS‐16 with change in the other measures.

Conclusions

PROMs provide additional valuable information compared to the mRS alone in stroke patients seen in the ambulatory setting. SIS‐16 may have a better ability to identify change than mRS in health status of relevance to the patient. PROMs may be a useful addition to mRS in the assessment of health status in clinical practice.

Patient-reported outcome measures in Huntington disease: Quality of life in neurological disorders (Neuro-QoL) social functioning measures

Social functioning is an essential but poorly understood component of health-related quality of life (HRQOL) for people with Huntington disease (HD). We report on the psychometric properties of 2 Neuro-QoL patient-reported outcome measures to assess social functioning in HD. Persons with prodromal (n = 198) or manifest HD (n = 195 early and n = 117 late) completed Neuro-QoL Ability to Participate in Social Roles and Activities, and Satisfaction with Social Roles and Activities. Items from 2 generic HRQOL patient-reported outcome measures were used to create a social functioning composite score; items from the Unified Huntington's Disease Rating Scale and Problem Behaviors Assessment Scale were used to create a clinician-rated composite score of social function. Internal consistencies for the scores on the Neuro-QoL measures were excellent (> .88). Computer adaptive test administration had some advantages over computer-administered static Short Forms. Validity was supported by significant associations between the scores on the Neuro-QoL measures and other self- and clinician-reports of social function. Individuals with prodromal HD had better social functioning than the manifest HD groups; individuals with late-HD had less satisfaction and ability to participate in social roles and activities than the other 2 groups. Neuro-QoL provides brief, reliable scores of social functioning that measure ability to participate in, and satisfaction with, social roles and activities in persons with prodromal and manifest HD. In addition, test score interpretations of these measures support their validity in people with prodromal and manifest HD. These measurement tools add breadth to treatment outcome measures in HD and can increase understanding of the social implications of living with HD. (PsycINFO Database Record

Predicting Domain-Specific Health-Related Quality of Life Using Acute Infarct Volume

BACKGROUND AND PURPOSE

Limited data exist on the relationship between acute infarct volume and health-related quality of life (HRQOL) measures after ischemic stroke. We evaluated whether acute infarct volume predicts domain-specific Neuro-Quality of Life scores at 3 months after stroke.

METHODS

Between 2012 and 2014, we prospectively enrolled consecutive patients with ischemic stroke and calculated infarct volume. Outcome scores at 3 months included modified Rankin Scale and Neuro-Quality of Life T scores. We evaluated whether volume organized by quartiles predicted modified Rankin Scale and HRQOL scores at 3 months using logistic and linear regression as appropriate, adjusting for relevant covariates. We calculated variance accounted for (R²) overall and by volume for each domain of HRQOL.

RESULTS

Among 490 patients (mean age 64.2±15.86 years; 51.2% male; 63.3% White) included for analysis, 58 (11.8%) were disabled (modified Rankin Scale score of >2) at 3 months. In unadjusted analysis, the highest volume quartile remained a significant predictor of 1 HRQOL domain, applied cognition-general concerns (R²=0.06; P<0.001). Our fully adjusted prediction model explained 32% to 51% of the variance in HRQOL: upper extremity (R²=0.32), lower extremity (R²=0.51), executive function (R²=0.45), and general concerns (R²=0.34).

CONCLUSIONS

Acute infarct volume is a poor predictor of HRQOL domains after ischemic stroke, with the exception of the cognitive domain. Overall, clinical and imaging variables explained <50% of the variance in HRQOL outcomes at 3 months. Our data imply that a broad range of factors, some known and others undiscovered, may better predict poststroke HRQOL than what is currently available.