Functional independence measure scores predict level of long-term care required by patients after stroke: a multicenter retrospective cohort study

Construction and application of a home exercise rehabilitation management program for elderly stroke patients based on the Functional Independence Measure score

OBJECTIVE

The objective of this study was to develop a home exercise rehabilitation management program for elderly stroke patients based on the Functional Independence Measure (FIM) score and assess its effectiveness through practical application.

METHODS

A prospective asynchronous controlled trial was conducted involving 290 elderly stroke patients, with 145 assigned to the control group and 145 to the intervention group. The control group received standard home rehabilitation instructions, while the intervention group followed a home exercise rehabilitation program guided by FIM scores. The program was developed through research group discussions, evidence-based literature review, and expert input. The efficacy of the program was evaluated by comparing self-care ability and exercise function between the two patient groups.

RESULTS

After 4 and 8 weeks of intervention, the motor assessment scale (MAS), Barthel Index scores and Mini-Mental State Examination (MMSE) of the intervention group were higher than those of the control group, and the modified Rankin scale (mRS) was lower than this of the control group (P < 0.05).

CONCLUSION

The home exercise rehabilitation management program for elderly stroke patients based on FIM scores was developed in a scientifically sound manner. This program holds significant theoretical implications for enhancing the home exercise regimen of elderly stroke patients and facilitating the rehabilitation of their limb functions.

Changes in Demand Volume and Patient/Health Care Provider Characteristics of First-Time Telehealth Users: A Comparative Analysis Before and After the COVID-19 Policy Response Using the Administrative Claims Database

Introduction: The COVID-19 pandemic has led to a decrease in demand for medical services in Japan, but the utilization of telehealth, which the Japanese government has recently promoted, has seen a temporary increase. This study aims to analyze the trend of telehealth utilization and changes in patient characteristics following the policy response to COVID-19. Methods: This retrospective study analyzed data from 26,152 adult patients who used telehealth for the first time between April 2019 and April 2021 in Mie Prefecture, Japan. An interrupted time series analysis was conducted to evaluate changes in the number of first-time patients before and after April 2020. Results: The number of telehealth users increased by 111.87% after April 2020, but the trend showed a declining slope thereafter. Patient characteristics and disease types showed different trends. The percentage of patients choosing a hospital over a clinic increased for the first time. Conclusions: After the policy response to COVID-19, the number of first-time telehealth users overall increased immediately, but gradually showed a declining trend. However, some diseases have shown both an immediate increase and a continued upward trend in telehealth utilization. Patients with these diseases may be candidates for adopting telehealth services in clinical settings.

Cross-Sectional Analysis of Periodontal Disease and Cognitive Impairment Conducted in a Memory Clinic: The Pearl Study

BACKGROUND

Periodontal disease (PeD) is a risk factor of Alzheimer's disease and is associated with cognitive decline in older adults. However, the relationships between subitems of neuropsychological tests and PeD have not been fully clarified.

OBJECTIVE

To evaluate associations between PeD and subitems of neuropsychological tests.

METHODS

We performed a cross-sectional analysis of data of 183 participants (women: 50%, mean age: 79 years) from a clinical study. We enrolled patients who visited our memory clinic and assessed demographics, dementia-related risk factors, neuropsychological tests, brain magnetic resonance images, and a dental screening check. We evaluated the relationships between cognitive function and PeD using multivariable logistic regression analyses.

RESULTS

Participants with dementia were less likely to make periodical visits to the dentist, had fewer teeth, had less frequent tooth brushing habits, and were more likely to have PeD. Impaired cognitive function was significantly associated with an increasing degree of PeD. In multivariable logistic regression analyses, impaired visuospatial function and attention were associated with twice the risk of moderate or severe PeD compared with individuals with preserved visuospatial function and attention (odds ratio: 2.11, 95% confidence interval: 1.04-4.29, p = 0.037). Impaired word recall and recognition and following commands were associated with increased risk of PeD (odds ratio: 2.80, 95% confidence interval: 1.41-5.32, p = 0.003).

CONCLUSIONS

Cognitive decline, such as impaired visuospatial function, attention, word recall and recognition, and inability to follow commands were independently and strongly associated with PeD. These items can be assessed easily on a daily basis.

Inpatient Rehabilitation After Acute Severe Stroke: Predictive Value of the National Institutes of Health Stroke Scale Among Other Potential Predictors for Discharge Destination

Background

Research focusing on predictors for discharge destination after rehabilitation of inpatients recovering from severe stroke is scarce. The predictive value of rehabilitation admission NIHSS score among other potential predictors available on admission to rehabilitation has not been studied.

Aim

The aim of this retrospective interventional study was to determine the predictive accuracy of 24 hours and rehabilitation admission NIHSS scores among other potential socio-demographic, clinical and functional predictors for discharge destination routinely collected on admission to rehabilitation.

Material and Methods

On a university hospital specialized inpatient rehabilitation ward 156 consecutive rehabilitants with 24 hours NIHSS score ⩾15 were recruited. On admission to rehabilitation, routinely collected variables potentially associated with discharge destination (community vs institution) were analyzed using logistic regression.

Results

70 (44.9%) of rehabilitants were discharged to community, and 86 (55.1%) were discharged to institutional care. Those discharged home were younger and more often still working, had less often dysphagia/tube feeding or DNR decision in the acute phase, shorter time from stroke onset to rehabilitation admission, less severe impairment (NIHSS score, paresis, neglect) and disability (FIM score, ambulatory ability) on admission, and faster and more significant functional improvement during the in-stay than those institutionalized.

Conclusion

The most influential independent predictors for community discharge on admission to rehabilitation were lower admission NIHSS score, ambulatory ability and younger age, NIHSS being the most powerful. The odds of being discharged to community decreased with 16.1% for every 1 point increase in NIHSS. The 3-factor model explained 65.7% of community discharge and 81.9% of institutional discharge, the overall predictive accuracy being 74.7%. The corresponding figures for admission NIHSS alone were 58.6%, 70.9% and 65.4%.

Developing a Clinical Prediction Rule for Gait Independence at Discharge in Patients with Stroke: A Decision-Tree Algorithm Analysis

OBJECTIVES

To develop a clinical prediction rule (CPR) for gait independence at discharge in patients with stroke, using the decision-tree algorithm and to investigate the usefulness of CPR at admission to the rehabilitation ward.

MATERIALS AND METHODS

We included 181 subjects with stroke during the postacute phase. The Chi-squared automatic interaction detection analysis method with 10-fold cross-validation was used to develop two CPRs; CPR 1 using easily obtainable data available at admission; CPR 2 using easily obtainable data available 1 month after admission, for prediction of gait independence at discharge.

RESULTS

The degree of independence of toileting was extracted as a first node in the development of two CPRs to predict gait independence at discharge. CPR 1 included the presence of delirium. CPR 2 included problem-solving abilities. The accuracy and area under the curve of CPR 1 were 84.5% and 0.911, respectively; those of CPR 2 were 89.0% and 0.958, respectively.

CONCLUSIONS

Toileting independence is a key factor in predicting the gait independence for the discharge of patients with stroke during the postacute phase. Early intervention, during the acute phase, for delirium and cognitive decline, as well as for toileting, increases the possibility of gait independence at discharge.

Young individuals with stroke in rehabilitation: a cohort study

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

Predicting Independence 6 and 18 Months after Ischemic Stroke Considering Differences in 12 Countries: A Secondary Analysis of the IST-3 Trial

Objectives

This study is aimed at identifying the best clinical model to predict poststroke independence at 6 and 18 months, considering sociodemographic and clinical characteristics, and then identifying differences between countries.

Methods

Data was retrieved from the International Stroke Trial 3 study. Nine clinical variables (age, gender, severity, rt-PA, living alone, atrial fibrillation, history of transient ischemic attack/stroke, and abilities to lift arms and walk) were measured immediately after the stroke and considered to predict independence at 6 and 18 months poststroke. Independence was measured using the Oxford Handicap Scale. The adequacy, predictive capacity, and discriminative capacity of the models were checked. Countries were added to the final models.

Results

At 6 months poststroke, 35.8% (n = 1088) of participants were independent, and at 18 months, this proportion decreased to 29.9% (n = 747). Both 6 and 18 months poststroke predictive models obtained fair discriminatory capacities. Gender, living alone, and rt-PA only reached predictive significance at 18 months. Poststroke patients from Poland and Sweden showed greater chances to achieve independence at 6 months compared to the UK. Poland also achieved greater chances at 18 months. Italy had worse chances than the UK at both follow-ups. Discussion. Six and eight variables predicted poststroke independence at 6 and 18 months, respectively. Some variables only reached significance at 18 months, suggesting a late influence in stroke patients' rehabilitation. Differences found between countries in achieving independence may be related to healthcare system organization or cultural characteristics, a hypothesis that must be addressed in future studies. These results can allow the development of tailored interventions to improve the outcomes.

Dietary habits and medical examination findings in Japanese adults middle-aged or older who live alone

OBJECTIVE

The influence of living alone on multiple food and nutrition behaviors across a range of ages and genders has not been sufficiently investigated. Moreover, to our knowledge, no studies have described both dietary status and medical examination findings in persons living alone. Among individuals who attended a health checkup in a rural town in Japan, we investigated dietary habits and medical examination findings in persons living alone and those living with one or more other persons.

METHODS

The participants in this investigation were 501 community-dwelling individuals aged 40 to 91 y (mean, 63.8 ± 9.9 y). Thirty-four (16.4%) of the 207 men and 45 (15.3%) of the 294 women lived alone. Dietary intake frequency of 28 types of foods and drinks, including various vegetables, fruits, meat, seafood, and dairy products, was investigated based on responses to a self-completed questionnaire. During the physical examination, body weight, body mass index, body fat percentage, and blood pressure (systolic and diastolic) were measured. Blood examination included red blood cell count, white blood cell count, platelet count, hemoglobin, hematocrit, total protein, albumin/globulin ratio, total cholesterol, triglyceride, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, creatinine, blood urea nitrogen, uric acid, and serum calcium.

RESULTS

Multivariate analysis revealed that living alone independently was associated with a reduced intake frequency of various vegetables and seafood, especially in men. Diastolic blood pressure and triglyceride levels were significantly higher in men living alone than in men living with other persons. The albumin/globulin ratio in women living alone was significantly lower than in women living with other persons.

CONCLUSIONS

It was found that living alone was associated not only with a reduced quality of dietary intake but also with an unfavorable trend in some of the medical examination findings.

Changes in the Activity Measure for Post-Acute Care Domains in Persons With Stroke During the First Year After Discharge From Inpatient Rehabilitation

OBJECTIVE

To describe functional changes after inpatient stroke rehabilitation using the Activity Measure for Post-Acute Care (AM-PAC), an assessment measure sensitive to change and with a low risk of ceiling effect.

DESIGN

Retrospective, longitudinal cohort study.

SETTING

Inpatient rehabilitation unit of an urban academic medical center.

PARTICIPANTS

Among 433 patients with stroke admitted from 2012-2016, a total of 269 (62%) were included in our database and 89 of 269 patients (33.1%) discharged from inpatient stroke rehabilitation had complete data. Patients with and without complete data were very similar. The group had a mean age of 68.0±14.2 years, National Institutes of Health Stroke Score of 8.0±8.0, and rehabilitation length of stay of 14.7±7.4 days, with 84% having an ischemic stroke and 22.5% having a recurrent stroke.

INTERVENTION

None.

MAIN OUTCOME MEASURES

Changes in function across the first year after discharge (DC) were measured in a variety of ways. Continuous mean scores for the basic mobility (BM), daily activity (DA), and applied cognitive domains of the AM-PAC were calculated at and compared between inpatient DC and 6 (6M) and 12 months (12M) post DC. Categorical changes among individuals were classified as "improved," "unchanged," or "declined" between the 3 time points based on the minimal detectable change, (estimated) minimal clinically important difference, and a change ≥1 AM-PAC functional stage (FS).

RESULTS

For the continuous analyses, the Friedman test was significant for all domains (P≤.002), with Wilcoxon signed-rank test significant for all domains from DC to 6M (all P<.001) but with no change in BM and DA between 6M and 12M (P>.60) and a decline in applied cognition (P=.002). Despite group improvements from DC to 6M, for categorical changes at an individual level 10%-20% declined and 50%-70% were unchanged. Despite insignificant group differences from 6M-12M, 15%-25% improved and 20%-30% declined in the BM and DA domains.

CONCLUSIONS

Despite group gains from DC to 6M and an apparent "plateau" after 6M post stroke, there was substantial heterogeneity at an individual level. Our results underscore the need to consider individual-level outcomes when evaluating progress or outcomes in stroke rehabilitation.

Hearing impairment is associated with cognitive function in community-dwelling older adults: A cross-sectional study

BACKGROUND

Hearing impairment (HI) is associated with dementia. However, the cognitive screening tasks effective in older community dwellers presenting with HI are unclear.

METHODS

We retrospectively and cross-sectionally investigated the associations between HI and cognitive function assessed with screening tasks using data from two healthcare check-up programs for community dwellers ≥65 years old in 2018. We examined demographics, risk factors, cognitive function, hearing condition, lifestyles, and self-care levels. Cognitive function was assessed using the clock drawing task and the delayed three words recall task. Hearing condition was assessed using questionnaires on the use of hearing aids and HI during conversation situations. Multivariate analysis was used to identify independent associations between HI and cognitive assessment tasks.

RESULTS

We analyzed 1602 eligible participants (61.9% women; 74.3 ± 6.5 years old). Hearing aid users (n = 90) were older (80 vs. 73 years, respectively; p < 0.001) and less likely to draw the clock correctly (71.1% vs. 80.1% years, respectively; p = 0.044) than non-hearing aid users. Multivariate logistic regression analysis showed that HI was associated with inability to draw the clock correctly (odds ratio 1.60, 95% confidence interval 1.12-2.26; p = 0.011), independent of age, living alone, memory impairment, and impaired self-care levels.

CONCLUSION

Hearing impairment is independently associated with cognitive decline assessed by the clock drawing task. The clock drawing task may be useful for identifying an increased risk of dementia in older subjects presenting with HI.

Predicting clinically significant motor function improvement after contemporary task-oriented interventions using machine learning approaches

BACKGROUND

Accurate prediction of motor recovery after stroke is critical for treatment decisions and planning. Machine learning has been proposed to be a promising technique for outcome prediction because of its high accuracy and ability to process large volumes of data. It has been used to predict acute stroke recovery; however, whether machine learning would be effective for predicting rehabilitation outcomes in chronic stroke patients for common contemporary task-oriented interventions remains largely unexplored. This study aimed to determine the accuracy and performance of machine learning to predict clinically significant motor function improvements after contemporary task-oriented intervention in chronic stroke patients and identify important predictors for building machine learning prediction models.

METHODS

This study was a secondary analysis of data using two common machine learning approaches, which were the k-nearest neighbor (KNN) and artificial neural network (ANN). Chronic stroke patients (N = 239) that received 30 h of task-oriented training including the constraint-induced movement therapy, bilateral arm training, robot-assisted therapy and mirror therapy were included. The Fugl-Meyer assessment scale (FMA) was the main outcome. Potential predictors include age, gender, side of lesion, time since stroke, baseline functional status, motor function and quality of life. We divided the data set into a training set and a test set and used the cross-validation procedure to construct machine learning models based on the training set. After the models were built, we used the test data set to evaluate the accuracy and prediction performance of the models.

RESULTS

Three important predictors were identified, which were time since stroke, baseline functional independence measure (FIM) and baseline FMA scores. Models for predicting motor function improvements were accurate. The prediction accuracy of the KNN model was 85.42% and area under the receiver operating characteristic curve (AUC-ROC) was 0.89. The prediction accuracy of the ANN model was 81.25% and the AUC-ROC was 0.77.

CONCLUSIONS

Incorporating machine learning into clinical outcome prediction using three key predictors including time since stroke, baseline functional and motor ability may help clinicians/therapists to identify patients that are most likely to benefit from contemporary task-oriented interventions. The KNN and ANN models may be potentially useful for predicting clinically significant motor recovery in chronic stroke.

Effects of Exoskeletal Lower Limb Robot Training on the Activities of Daily Living in Stroke Patients: Retrospective Pre-Post Comparison Using Propensity Score Matched Analysis

PURPOSE

There is limited evidence of gait training using newly developed exoskeletal lower limb robot called Hybrid Assistive Limb (HAL) on the function and ability to perform ADL in stroke patients. In clinical settings, we frequently find it challenging to conduct a randomized controlled trial; thus, a large-scale observational study using propensity score analysis methods is a feasible alternative. The present study aimed to determine whether exoskeletal lower limb robot training improved the ability to perform ADL in stroke patients.

MATERIALS AND METHODS

Acute stroke patients who were admitted to our facility from April 2016 to March 2017 were evaluated in the conventional rehabilitation period (CRP) and those admitted from April 2017 to June 2019 were evaluated in the HAL rehabilitation period (HRP). We started a new gait rehabilitation program using HAL at the midpoint of these two periods. The functional outcomes or ADL ability outcomes of the patients in the CRP and the subsequent HRP were compared using propensity score matched analyses.

RESULTS

Propensity score matching analysis was performed for 108 stroke patients (63 from the CRP and 45 from the HRP), and 36 pairs were matched. The ADL ability, defined by the FIM scores and FIM score change, was significantly higher in patients admitted during the HRP. In addition, more stroke patients obtained practical walking ability during hospitalization in the HRP.

CONCLUSION

Gait training using HAL affects the ADL ability and obtaining of practical walking ability of stroke patients.

Effects of transcranial magnetic stimulation on the performance of the activities of daily living and attention function after stroke: a randomized controlled trial

OBJECTIVE

We aimed to interrogate the effects of transcranial magnetic stimulation (TMS) on the performance in activities of daily living (ADL) and attention function after stroke.

DESIGN

Randomized controlled trial.

SETTING

Inpatient rehabilitation hospital.

SUBJECTS

We randomized 62 stroke patients with attention dysfunction who were randomly assigned into two groups, and two dropped out from each group. The TMS group (n = 29) and a sham group (n = 29), whose mean (SD) was 58.12 (6.72) years. A total of 33 (56.9%) patients had right hemisphere lesion while the rest 25 (43.1%) patients had left hemisphere lesion.

INTERVENTIONS

Patients in the TMS group received 10 Hz, 700 pulses of TMS, while those in the sham group received sham TMS for four weeks. All the participants underwent comprehensive cognitive training.

MAIN MEASURES

At baseline, and end of the four-week treatment, the performance in the activities of daily living was assessed by Functional Independence Measure (FIM). On the other side, attention dysfunction was screened by Mini-Mental State Examination (MMSE), while the attention function was assessed by the Trail Making Test-A (TMT-A), Digit Symbol Test (DST) and Digital Span Test (DS).

RESULTS

Our data showed a significant difference in the post-treatment gains in motor of Functional Independence Measure (13.00 SD 1.69 vs 4.21 SD 2.96), cognition of Functional Independence Measure (4.69 SD 1.56 vs 1.52 SD 1.02), total of Functional Independence Measure (17.69 SD 2.36 vs 5.72 SD 3.12), Mini-Mental State Examination (3.07 SD 1.36 vs 1.21 SD 0.62), time taken in Trail Making Test-A (96.67 SD 25.18 vs 44.28 SD 19.45), errors number in Trail Making Test-A (2.72 SD 1.03 vs 0.86 SD 1.03), Digit Symbol Test (3.76 SD 1.09 vs 0.76 SD 0.87) or Digital Span Test (1.69 SD 0.54 vs 0.90 SD 0.72) between the TMS group and the sham group (P < 0.05).

CONCLUSIONS

Taken together, we demonstrate that TMS improves the performance in the activities of daily living and attention function in patients with stroke.

Development and validation of a prediction model for home discharge in patients with moderate stroke: The Korean stroke cohort for functioning and rehabilitation study

BACKGROUND

Previous studies have investigated the predictors for home discharge without considering stroke severity.

OBJECTIVES

To develop a practical assessment tool that predicts home discharge for moderate stroke patients after subacute rehabilitation therapy in the tertiary hospitals.

METHODS

Stroke patients with National Institutes of Health Stroke Scale scores of 6 to 13 were included in this prospective cohort study. Various demographic, clinical, and functional factors were analyzed as potential predictive factors. A weighted scoring model was developed through the following three-step process: 1) selection of the factors by logistic regression analyses, 2) development of a weighted scoring model, and 3) validation of the generalizability of the model.

RESULTS

The home discharge rate was 51% (n = 372), and the overall mean length of stay of hospitalization was 32.5 days. 1) The Cognitive Functional Independence Measure, 2) the Functional Ambulation Categories, 3) the modified Charlson Comorbidity Index, and 4) marital status were independent predictors of home discharge. The coefficient value for marital status was adjusted to 1 in the scoring system, and the values of the other parameters were proportionally converted to the nearest integer. Possible total scores ranged from 0 to 13 in the model, with a higher score indicating a higher probability of home discharge. With a cutoff point of 7, this model showed 87.0% sensitivity and 86.2% specificity (area under the curve = 0.90).

CONCLUSIONS

This novel assessment tool can be useful in predicting home discharge after subacute rehabilitation of moderate stroke patients.

Risk factors for long-term care after hemiplegia from cancer-related brain surgery: a pilot study for new prediction model

BACKGROUND

Hemiplegia is a worldwide-represented neurological condition leading to long-term disability. The most common cause of hemiplegia is stroke; 25% to 50% of stroke survivors require some assistance after hospital discharge; approximately half of them become dependent, while only 14% achieve full recovery of activities of daily living (ADL). Cancer and cancer-related surgery are other causes of hemiplegia and rehabilitation in cancer patients has been recognized as important factor in order to help maintaining quality of life as long as possible. Many studies have been done in order to assess a reliable prediction about outcome of hemiplegia from stroke, but outcome prediction for cancer-related hemiplegia still remains a challenge and no clinical prediction tool has been developed being better than physician's informal prediction.

AIM

Aim of this pilot study was: a) to detect risk factors associated with need for long-term care for patients suffering from hemiplegia due to cancer-related brain surgery, b) to build an algorithm-based model from detected risk factors in order to predict the need for long-term care after rehabilitation 3) to assess the feasibility of a subsequent study on a larger sample of subjects, in order to validate of the model. The subsequent study will be considered feasible if the model developed by the pilot study will be able to correctly predict more than 85% of patients needing or not long-term care after rehabilitation.

DESIGN

Observational retrospective study.

SETTING

Neurorehabilitation Unit.

POPULATION

Inpatients affected by hemiplegia due to cancer-related surgery.

METHODS

The observational retrospective study involved 158 subjects affected by hemiplegia due to cancer-related brain surgery. All of the subjects underwent rehabilitation therapy, while radio /chemotherapy was administered if needed. Stroke prognostic factors and other clinical variables were recorded for all subjects. The endpoint variable was Functional Independence Measure (FIM®) Score at discharge after rehabilitation. Variables were then associated with patient's FIM Score <61 at discharge after rehabilitation, as predictor of long-term care at home.

RESULTS

After statistical evaluation, age, comorbidity Charlson Index >3, complete absence of motricity of the affected limbs, hypoesthesia, trunk-control deficit, dysphagia, language disorder, urinary or fecal incontinence were found to be risk factors for FIM Score <61 at discharge. From detected factors an algorithm-based model was built in order to estimate patient's overall probability to need or not an intensive long-term care after rehabilitation.

CONCLUSIONS

The model developed by the pilot study allowed correct positive or negative prediction for long-term care need after rehabilitation for 90.6% of the patients suffering from cancer-related hemiplegia. A subsequent study on a larger sample of subjects resulted therefore feasible because overall correct prediction was higher than 85%.

CLINICAL REHABILITATION IMPACT

Risk factors for intensive care at home (complete absence of motricity of affected limbs, trunk control deficit, fecal incontinence, dysphagia and comorbidity Charlson Index >3) can be useful to evaluate patients suffering from hemiplegia due to cancer-related brain surgery, at admission into Rehabilitation Unit. The algorithm-based model seems to be a promising tool to estimate the probability of intensive home care for that type of hemiplegic patients.

Leukoaraiosis Predicts Short-term Cognitive But not Motor Recovery in Ischemic Stroke Patients During Rehabilitation

BACKGROUND

Leukoaraiosis has been shown to impact functional outcomes after acute ischemic stroke. However, its association with domain specific recovery after ischemic stroke is uncertain. We sought to determine whether pre-existing leukoaraiosis is associated with short-term motor and cognitive recovery after stroke.

METHODS

We retrospectively studied ischemic stroke patients admitted to acute inpatient rehabilitation (AIR) between January 2013 and September 2015. Patient baseline characteristics, infarct volume, prestroke modified Rankin Scale, stroke cause, rehabilitation length of stay, and Functional Independence Measure (FIM) scores were recorded. Leukoaraiosis severity was graded on brain magnetic resonance imaging using the Fazekas scale. Multiple linear regression was used to determine factors independently associated with the total, cognitive, and motor FIM scores at AIR discharge, respectively.

RESULTS

Of 1600 ischemic stroke patients screened, 109 patients were included in the final analysis. After adjustment, the initial National Institute of Health Stroke Scale (β -0.541, confidence interval [CI] -0.993 to -0.888; P = 0.020) and pre-existing leukoaraiosis severity (β -1.448, CI -2.861 to -0.034; P = 0.045) independently predicted the total FIM score. Domain specific analysis showed that infarct volume (β -0.012, CI -0.019 to -0.005; P = 0.002) and leukoaraiosis severity (β -0.822, CI -1.223 to -0.410; P = 0.0001) independently predicted FIM cognitive scores at discharge from AIR. Leukoaraiosis did not predict FIM motor score (P = 0.17).

CONCLUSIONS

Leukoaraiosis severity is an independent predictor of total and cognitive, but not motor FIM scores after AIR for acute ischemic stroke. This highlights that leukoaraiosis affects poststroke recovery in a domain specific fashion, information that may aid counseling of patients and families as well as tailor rehabilitative efforts.

Low Free Triiodothyronine Predicts 3-Month Poor Outcome After Acute Stroke

BACKGROUND AND PURPOSE

The association between thyroid hormone levels and long-term clinical outcome in patients with acute stroke has not yet been thoroughly studied. The purpose of the present study was to test the hypothesis that thyroid hormone levels are associated with 3-month functional outcome and mortality after acute stroke.

METHODS

We retrospectively analyzed 702 consecutive patients with acute stroke (251 women; median age, 73 years) who were admitted to our department. General blood tests, including thyroid stimulating hormone (TSH), free triiodothyronine (FT3), and free thyroxine (FT4), were performed on admission. Neurological severity was evaluated using National Institutes of Health Stroke Scale (NIHSS) scores on admission and modified Rankin Scale (mRS) scores at 3 months after stroke onset. Poor outcome was defined as an mRS score of 3-5 or death. The impact of thyroid function on 3-month outcome was evaluated using multiple logistic regression analysis.

RESULTS

Poor functional outcome was observed in 295 patients (42.0%). Age (P < .0001), female sex (P < .0001), admission NIHSS score (P < .0001), smoking (P = .0026), arterial fibrillation (P = .0002), preadmission mRS (P < .0001), estimated glomerular filtration rate (P = .0307), and ischemic heart disease (P = .0285) were significantly associated with poor functional outcome, but no relationship between FT4, TSH, and poor functional outcome was found. A multivariate logistic regression analysis showed that low FT3 values (<2.00 pg/mL) were independently associated with poor functional outcome (odds ratio [OR], 3.16; 95% confidence interval [CI], 1.60-6.24) and mortality (OR, 2.55; 95% CI, 1.33-4.91) at 3 months after stroke onset.

CONCLUSIONS

Our data suggest that a low FT3 value upon admission is associated with a poor 3-month functional outcome and mortality in patients with acute stroke.

Use of a functional mobility measure to predict discharge destinations for patients admitted to an older adult rehabilitation ward: A feasibility study

OBJECTIVE

To investigate whether the discharge destination for older adults can be predicted using functional mobility as measured by the Modified Elderly Mobility Scale (MEMS), associated with demographic and primary reason for admission variables.

METHODS

A retrospective cohort population audit of 257 patients admitted and discharged from four tertiary older adult rehabilitation wards in a three-month period. A number of predictor variables were considered alongside the discharge destination.

RESULTS

Multinomial statistical modelling established that MEMS prior to (P < 0.001), MEMS on completion (P = 0.009) of rehabilitation physiotherapy and primary reason for admission (P = 0.002) were significant variables to predict discharge destination. The model correctly predicted 71% of observed patient discharge destinations.

CONCLUSION

The MEMS in conjunction with primary reason for admission was able to predict discharge destination with 71% accuracy in a heterogeneous population of older adults following rehabilitation.

White matter hyperintensities and geriatric syndrome: An important role of arterial stiffness

White matter hyperintensities (WMH) are defined as cerebral white matter changes presumed to be of vascular origin, bilateral and mostly symmetrical. They can appear as hyperintense on T2-weighted and fluid-attenuated inversion recovery sequences, and as isointense or hypointense on T1-weighted magnetic resonance imaging of the brain. WMH have been focused on because of their clinical importance as a risk factor for cerebrovascular diseases and cognitive impairment. WMH are associated with geriatric syndrome, which is defined by clinical symptoms characteristic of older adults, including cognitive and functional impairment and falls. Cerebral small vessel diseases, such as WMH, might play an important role as risk factors for cerebrovascular diseases, cognitive impairment and geriatric syndrome through the mechanism of arterial stiffness. However, the vascular, physiological and metabolic roles of arterial stiffness remain unclear. Basically, arterial stiffness indicates microvessel arteriosclerosis presenting with vascular endothelial dysfunction. These changes might arise from hemodynamic stress as a result of a "tsunami effect" on cerebral parenchyma. In the present article, we review the clinical characteristics of WMH, focusing particularly on two associations: (i) those between cerebral small vessel diseases including WMH and arterial stiffness; and (ii) those between WMH and geriatric syndrome.

The effectiveness of powered, active lower limb exoskeletons in neurorehabilitation: A systematic review

OBJECTIVE

This review examines the utility of current active, powered, wearable lower limb exoskeletons as aids to rehabilitation in paraplegic patients with gait disorders resulting from central nervous system lesions.

METHODS

The PRISMA guidelines were used to review literature on the use of powered and active lower limb exoskeletons for neurorehabilitative training in paraplegic subjects retrieved in a search of the electronic databases PubMed, EBSCO, Web of Science, Scopus, ProQuest, and Google Scholar.

RESULTS

We reviewed 27 studies published between 2001 and 2014, involving a total of 144 participants from the USA, Japan, Germany, Sweden, Israel, Italy, and Spain. Seventy percent of the studies were experimental tests of safety or efficacy and 29% evaluated rehabilitative effectiveness through uncontrolled (22%) or controlled (7%) clinical trials.

CONCLUSIONS

Exoskeletons provide a safe and practical method of neurorehabilitation which is not physically exhausting and makes minimal demands on working memory. It is easy to learn to use an exoskeleton and they increase mobility, improve functioning and reduce the risk of secondary injury by reinstating a more normal gait pattern. A limitation of the field is the lack of experimental methods for demonstrating the relative effectiveness of the exoskeleton in comparison with other rehabilitative techniques and technologies.

Cerebral Small Vessel Disease and Arterial Stiffness: Tsunami Effect in the Brain?

BACKGROUND

Cerebral small vessel diseases, including silent lacunar infarcts, white matter hyperintensities, and microbleeds, pose a risk for cerebrovascular disease, cognitive impairment, and the geriatric syndrome via effects on arterial stiffness. However, the vascular, physiological, and metabolic roles of arterial stiffness in cerebral small vessel diseases remain unclear.

SUMMARY

Arterial stiffness can be assessed using various indicators such as the ankle-brachial index, pulse wave velocity, cardio-ankle vascular index, and augmentation index. Arterial stiffness is independently associated with all components of cerebral small vessel disease including silent lacunar infarcts, white matter hyperintensities, and microbleeds, although there are some methodological differences between the various surrogate markers. Evidence of arterial stiffness indicates microvessel arteriosclerosis presenting with vascular endothelial dysfunction. Further, vascular narrowing due to atherosclerosis and vascular stiffness due to lipohyalinosis can accelerate the pulse waves. This hemodynamic stress, pulsatile pressure, or blood pressure variability can cause a 'tsunami effect' towards the cerebral parenchyma and lead to cerebral small vessel disease. Previous studies have shown that silent lacunar infarcts and white matter hyperintensities are strongly associated with arterial stiffness. However, the association between microbleeds and arterial stiffness remains controversial, as there are two vessel mechanisms related to microbleeds: cerebral amyloid angiopathy and hypertensive small vessel disease.

KEY MESSAGES

Cerebral small vessel disease with associated arterial stiffness is a risk factor for silent cerebral lesions, stroke, and cognitive impairment. Improvement of the living environment, management of risk factors, and innovation and development of novel drugs that improve arterial stiffness may suppress the progression of cerebral small vessel disease, and may reduce the risk for stroke and dementia.