Caring for patients with hemiplegia in an arm following a stroke

Impact of Post-Stroke Recanalization on General and Upper Limb Functioning: A Prospective, Observational Study

The objective of this study is to assess the impact of recanalization (spontaneous and therapeutic) on upper limb functioning and general patient functioning after stroke. This is a prospective, observational study of patients hospitalized due to acute ischemic stroke in the territory of the middle cerebral artery (n = 98). Patients completed a comprehensive rehabilitation program and were followed-up for 24 weeks. The impact of recanalization on patient functioning was evaluated using the modified Rankin Scale (mRS) and Stroke Upper Limb Capacity Scale (SULCS). General and upper limb functioning improved markedly in the first three weeks after stroke. Age, gender, and National Institutes of Health Stroke Scale (NIHSS) score at admission were associated with general and upper limb functioning at 12 weeks. Successful recanalization was associated with better functioning. Among patients who underwent therapeutic recanalization, NIHSS scores ≥16.5 indicate lower general functioning at 12 weeks (sensibility = 72.4%; specificity = 78.6%) and NIHSS scores ≥13.5 indicate no hand functioning at 12 weeks (sensibility = 83.8%; specificity = 76.5%). Recanalization, either spontaneous or therapeutic, has a positive impact on patient functioning after acute ischemic stroke. Functional recovery occurs mostly within the first 12 weeks after stroke, with greater functional gains among patients with successful recanalization. Higher NIHSS scores at admission are associated with worse functional recovery.

Electromyogram-Related Neuromuscular Electrical Stimulation for Restoring Wrist and Hand Movement in Poststroke Hemiplegia: A Systematic Review and Meta-Analysis

Background. Clinical trials have demonstrated some benefits of electromyogram-triggered/controlled neuromuscular electrical stimulation (EMG-NMES) on motor recovery of upper limb (UL) function in patients with stroke. However, EMG-NMES use in clinical practice is limited due to a lack of evidence supporting its effectiveness. Objective. To perform a systematic review and meta-analysis to determine the effects of EMG-NMES on stroke UL recovery based on each of the International Classification of Functioning, Disability, and Health (ICF) domains. Methods. Database searches identified clinical trials comparing the effect of EMG-NMES versus no treatment or another treatment on stroke upper extremity motor recovery. A meta-analysis was done for outcomes at each ICF domain (Body Structure and Function, Activity and Participation) at posttest (short-term) and follow-up periods. Subgroup analyses were conducted based on stroke chronicity (acute/subacute, chronic phases). Sensitivity analysis was done by removing studies rated as poor or fair quality (PEDro score <6). Results. Twenty-six studies (782 patients) met the inclusion criteria. Fifty percent of them were considered to be of high quality. The meta-analysis showed that EMG-NMES has a robust short-term effect on improving UL motor impairment in the Body Structure and Function domain. No evidence was found in favor of EMG-NMES for the Activity and Participation domain. EMG-NMES had a stronger effect for each ICF domain in chronic (≥3 months) compared to acute/subacute phases. Conclusion. EMG-NMES is effective in the short term in improving UL impairment in individuals with chronic stroke.

Effectiveness of a structured circuit class therapy model in stroke rehabilitation: a protocol for a randomised controlled trial

BACKGROUND

Currently, the key advocacy in neuroscientific studies for stroke rehabilitation is that therapy should be directed towards task specificity performed with multiple repetitions. Circuit Class Therapy (CCT) is well suited to accomplish multiple task-specific activities. However, while repetitive task practice is achievable with circuit class therapy, in stroke survivors repetitive activities may be affected by poor neurologic inputs to motor units, resulting in decreases in discharging rates which consequently may reduce the efficiency of muscular contraction. To accomplish multiple repetitions, stroke survivors may require augmented duration of practice. To date, no study has examined the effect of augmented duration of CCT in stroke rehabilitation, and specifically what duration of CCT is more effective in influencing functional capacity among stroke survivors.

METHODS/DESIGN

Using a randomised controlled trial with blinded outcome assessment, this study is aimed at determining the effectiveness of structured augmented CCT in stroke rehabilitation. Sixty-eight stroke survivors (to be recruited from a tertiary health institution in Kano, Northwest, Nigeria) will be randomised into one of four groups: three intervention groups of differing CCT durations namely: 60 min, 90 min, and 120 minuntes respectively, and a control group. Participants will take part in an 8-week structured intensive CCT intervention. Participants will be assessed at baseline, post-intervention, and six-month follow-up for the effectiveness of the varied durations of therapy, using standardised tools. Based on the WHO-ICF model, the outcomes are body structure/function, activity limitation, and participation restriction measures.

DISCUSSION

It is expected that the outcome of this study will clarify whether increasing CCT duration leads to better recovery of motor function in stroke survivors.

TRIAL REGISTRATION

Pan African Clinical Trial Registry (PACTR): PACTR201311000701191.

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

BACKGROUND AND PURPOSE

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

METHOD

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

RESULTS

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

DISCUSSION AND CONCLUSION

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

Commercial gaming devices for stroke upper limb rehabilitation: a survey of current practice

PURPOSE

Stroke upper limb impairment is associated with disability in activities of daily living. Gaming (Nintendo Wii) is being introduced to rehabilitation despite limited evidence regarding effectiveness. Little data exists on how gaming is implemented resulting in a lack of clinical information. We aimed to gather therapists' opinions on gaming.

METHODS

A survey was posted to therapists, identified from stroke services across Scotland. A second survey was posted to non-responders. Survey data were analysed using descriptive statistics and thematic coding.

RESULTS

Surveys were sent to 127 therapists (70 stroke services) and returned by 88% (112/127). Gaming was used by 18% of therapists, 61% (68/112) stated they would use this intervention should equipment be available. The most commonly used device was Nintendo Wii (83% of therapists using gaming) for 30 min or less once or twice per week. Half of therapists (51%) reported observing at least one adverse event, such as fatigue, stiffness or pain. Gaming was reported to be enjoyable but therapists described barriers, which relate to time, space and cost.

CONCLUSIONS

Gaming is used by almost a fifth of therapists. Adverse events were reported by 51% of therapists; this should be considered when recommending use and dosage. Implications for Rehabilitation Commercial gaming devices are reported to be used by 1/5th of therapists for stroke upper limb rehabilitation, 3/5ths would use gaming if available. Adverse events were reported by 51% of therapists; this should be considered when recommending use and dosage. Current use of gaming in practice may not be achieving intense and repetitive upper limb task-specific practice.

Motor and functional recovery after stroke: a comparison between rehabilitation settings in a developed versus a developing country

BACKGROUND

Recovery post stroke is well documented in the field of stroke rehabilitation. The structure and process of rehabilitation are different between developed and developing countries. The aim of the present study was to compare the motor and functional recovery of stroke patients in Germany versus stroke patients receiving rehabilitation in South Africa.

METHODS

This study used secondary data analysis of patient protocols collected in two independent studies conducted in Germany and South Africa respectively. A total of 73 patients from the two separate studies were matched for age at stroke onset, gender, and initial motor functioning. Motor and functional recovery were assessed at baseline, two and six months post stroke using the Rivermead Motor Assessment Scale and the Barthel Index (BI) respectively. Significant differences in motor and functional recovery were found, using the Wilcoxon rank sum test on admission to the centre, and at two and six months after stroke. A generalized linear mixed-methods model (GLIMMIX) was used to compare the recovery patterns between the participants from the two settings over time.

RESULTS

The results of the GLIMMIX revealed a significant difference in favour of the German participants for gross motor (RMA-GF) and upper limb (RMA-A) recovery, while no significant difference was found for lower limb (RMA-LT) and functional (BI) recovery patterns between the participants of the two settings. No significant differences existed in RMA-A and BI-scores on admission to the CHC/SRU. At two and six months after stroke, both the RMA-A and BI-scores were significantly lower in the South African than the German sample.

CONCLUSION

The results of this study provide empirical evidence for differential recovery patterns for patients in developed and developing countries. A detailed exploration of the factors to which this difference in recovery patterns can be attributed was beyond the scope of the present study, and is recommended for future research.

Predictors of upper limb recovery after stroke: a systematic review and meta-analysis

OBJECTIVE

To systematically review and summarize the current available literature on prognostic variables relating to upper limb recovery following stroke. To identify which, if any variables predict upper limb recovery following stroke.

DATA SOURCES

We completed searches in MEDLINE, EMBASE, AMED, CINAHL and Cochrane CENTRAL databases. Searches were completed in November 2010.

REVIEW METHODS

Studies were included if predictor variables were measured at baseline and linked to an outcome of upper limb recovery at a future time point. Exclusion criteria included predictor variables relating to response to treatment and outcome measurements of very specific upper limb impairments such as spasticity or pain. Two independent reviewers completed data extraction and assessed study quality.

RESULTS

Fifty-eight studies met the inclusion criteria. Predictor variables which have been considered within these studies include; age, sex, lesion site, initial motor impairment, motor-evoked potentials and somatosensory-evoked potentials. Initial measures of upper limb impairment and function were found to be the most significant predictors of upper limb recovery; odds ratio 14.84 (95% confidence intervals (CI) 9.08-24.25) and 38.62 (95% CI 8.40-177.53), respectively.

CONCLUSIONS

Interpretation of these results is complicated by methodological factors including variations in study populations, upper limb motor outcome scales, timing of baseline and outcome assessments and predictors selected. The most important predictive factors for upper limb recovery following stroke appears to the initial severity of motor impairment or function.

Clinical skills: bed making and patient positioning

Providing a clean, comfortable bed and positioning a patient in the optimum posture for prevention of complications and to enable maximum independence are fundamental nursing skills. Bed-making is a daily routine that requires practical and technical skills. Selecting the correct posture for a patient in bed or in a chair is essential for physiological functioning and recovery. In this article bed-making is described, as are positioning and re-positioning in relation to patients in bed, armchairs and wheelchairs. Infection control and moving and handling issues are also considered.