Urinary incontinence and stroke outcomes

Dynamic interactions between impairment and activity after stroke: examining the utility of decision analysis methods

Objective: To examine the utility of decision analysis methods for examining the dynamic nature of impairment-activity interactions following stroke.

Design: Decision analyses (Chi-squared Automatic Interaction Detector) of a prospective cohort study.

Setting: Community and institutional settings based on the location of participants three months after stroke.

Participants: Individuals were recruited from consecutive admissions to a regional academic health center and were assessed three months after stroke (N=67).

Main outcome measures: Neurological impairment was measured with the National Institutes of Health Stroke Scale (NIHSS). Mobility, self-care and instrumental activities of daily living (instrumental ADL) performance were assessed with a performance observation measure, the Performance Assessment of Self-care Skills (PASS). Decision analysis methods were used to examine interactions between neurological impairments and activity outcomes.

Results: Unique neurological impairments were associated with each activity outcome (bowel and bladder urgency interacted with mobility; hand function interacted with self-care; mental functions interacted with instrumental ADL), and these findings are supported by previous studies. The predictive validity of mobility and self-care analyses was stronger than the instrumental ADL analyses.

Conclusions: Decision analysis methods show promise for understanding dynamic impairment-activity interactions. This understanding may enhance methods for informing rehabilitation decisions.

Explanatory factors for the association between depression and long-term physical disability after stroke

OBJECTIVES

To identify explanatory factors for the association between depression at 3 months after stroke and physical disability at 3 years.

METHODS

Data from the South London Stroke Register (1998-2013) were used. Patients (n = 3,612) were assessed at stroke onset. Follow-up at 3 months included assessment for depression with the Hospital Anxiety and Depression scale (scores ≥ 7 = depression), physical disability (Barthel index) cognitive function, smoking habit, selective serotonin reuptake inhibitors (SSRIs) use, perception of recovery and social support. Physical disability was reassessed at 3 years. The associations between depression at 3 months and physical disability at 3 years were estimated with multinomial regression adjusting for age, gender, ethnicity, stroke severity and possible explanatory factors for the association (introduced in the models first individually and then sequentially): pre-stroke medical history and physical disability, cognitive function, smoking, SSRIs, perception of recovery and social support at 3 months.

RESULTS

One thousand three hundred and seven survivors were assessed at 3 months, of which 418 (32.0%) had depression. Survivors with depression had a higher physical disability rate at 3 years. These associations remained significant after adjustment for individual explanatory factors but were not significant after adjustment for combined explanatory factors. Physical disability at 3 months was a relevant explanatory factor for this association. SSRIs were associated with severe, relative risk: 6.62 (2.92-15.02) P < 0.001, and moderate physical disability, relative risk: 3.45 (1.58-7.52) P = 0.002, at 3 years.

CONCLUSION

The association between depression and physical disability appears to be multifactorial. The use of SSRIs after stroke requires further research.

Non-motor Factors Associated with the Attainment of Community Ambulation after Stroke

OBJECTIVE

Detect the main predictive non-motor factors related to independent community ambulation after stroke. Furthermore, we propose a scale to estimate the probability of a stroke patient achieving independent community ambulation after 6 months of rehabilitation.

DESIGN AND SETTINGS

Prospective cohort. Subjects treated in a rehabilitation center in a large metropolitan area. Independent community ambulation was evaluated after rehabilitation according to the Hoffer classification. Functional ambulation was assessed at four levels: nonambulatory, nonfunctional ambulation, household ambulation, and community ambulation.

PARTICIPANTS

Patients (n=201) with a moderate disability after stroke.

RESULTS

The average time of hospitalization was 19.3 days. However, only 32.8% of the patients started the rehabilitation program during the first 6 months after stroke. We found that 121 patients achieved community ambulation (60.2%), 40 achieved household ambulation (19.9%), 12 achieved therapeutic ambulation (5.9%), and 28 were non-ambulatory after 6 months of treatment. Based on our final model, a scoring scale was created in order to evaluate the probability of stroke patients achieving independent community ambulation after 6 months of rehabilitation. Higher scores were associated with better chances of community ambulation within 6 months.

CONCLUSIONS

The scale that evaluated these factors proved to have acceptable sensitivity and specificity to establish the prognosis of community ambulation after 6 months of rehabilitation.

Relationship between urinary dysfunction and clinical factors in patients with traumatic brain injury

OBJECTIVES

Examination of relations between urinary dysfunction and Functional Independence Measurement (FIM) values and other clinical factors.

MATERIALS AND METHODS

Twenty-nine patients with TBI were included in the study. Patients' demographic values, lower urinary tract symptoms (LUTS) and urinary drainage methods were recorded. Functional assessment was performed using FIM. Urodynamic studies were carried out and maximum cystometric capacity (MCC), storage and voiding function, type of detrusor, urodynamic abnormality and post-void residual urine volume values were investigated.

RESULTS

Total FIM and FIM sphincter control sub-group scores were significantly lower in patients with storage dysfunction and urodynamic abnormality than patients without storage dysfunction and urodynamic abnormality (p < 0.05). In tetraparetic patients, frequency of storage dysfunction was significantly higher than hemiparetic patients (p < 0.05). Urodynamic abnormality was detected in five of nine patients with LUTS and in 12 of 20 patients without LUTS. There was no significant correlation between LUTS and urodynamic abnormality (p > 0.05).

CONCLUSIONS

Storage dysfunction and urodynamic abnormality is associated with poorly functional outcomes in TBI patients. There is a direct correlation between motor deficit and urodynamic abnormality. All of the TBI patients with or without LUTS should be evaluated neuro-urologically; urodynamic evaluation and treatment should be arranged if needed.

Bladder management and the functional outcome of elderly ischemic stroke patients

The purpose of this study was to investigate how bladder management, rather than urinary incontinence, may affect the functional outcome of ischemic stroke patients. We studied 919 consecutive patients admitted for ischemic stroke rehabilitation. Level of bladder management was determined by Functional Independence Measurement (FIM TM) sub-scale scores relevant to bladder control. FIM scores less than 5 points was determined as low-bladder management score (Low-BMS) while FIM scores greater than 5 was determined as high-bladder management score (High-BMS). Data were analyzed by t-test, Pearson correlation, and chi-square test as well as by multiple linear regression analysis. There were 594 low-bladder score patients (Low-BMS) and 325 high-bladder score patients (High-BMS), at admission. Compared with High-BMS, Low-BMS patients were slightly older (p = 0.002), had longer rehabilitation stays (p < 0.001) and lower mini-mental state examination (MMSE) scores (p < 0.001). Total FIM at admission and discharge were lower in Low-BMS, yet their total FIM gain upon discharge was higher, compared with High-BMS (19.5 ± 16.46 vs. 17.59 ± 12.55, p = 0.07). Multiple linear regression analyses showed that total FIM at discharge was inversely associated with Low-BMS at admission (beta = -0.407; p<0.001) and age (beta = -0.127; p < 0.001). A high MMSE score (beta = 0.334; p < 0.001) emerged as predicting higher total FIM scores upon discharge. Low-BMS was independently predictive for total FIM gain at discharge (beta = 0.166; p < 0.001). The findings suggest that Low-BMS should be held as adversely affecting the rehabilitation outcomes of elderly stroke patients. However, Low-BMS patients do obtain significant gains and should not be deprived of rehabilitation.

Comparison of urodynamics between ischemic and hemorrhagic stroke patients; can we suggest the category of urinary dysfunction in patients with cerebrovascular accident according to type of stroke?

AIMS

The aim of this study is to compare the urodynamic parameters in ischemic and hemorrhagic stroke patients with bladder dysfunction.

MATERIALS AND METHODS

We retrospectively reviewed medical records such as computed tomography (CT) or magnetic resonance imaging (MRI) and urodynamic study and identified 84 cases among 150 stroke patients underwent urodynamic test due to lower urinary tract symptoms (LUTS) from June 2003 to May 2008. Exclusion criteria are diabetes mellitus (DM) cystopathy, previous pelvic surgery, spinal cord injury, benign prostate hyperplasia (BPH), and other neurologic etiology.

RESULTS

Among analyzed variables of urodynamic study, total bladder capacity, postvoid residual urine volume and bladder compliance have a significant value between ischemic and hemorrhagic stroke group (P = 0.004, P = 0.017, P = 0.007). Ischemic group have detrusor overactivity (DO) (70.7%), detrusor underactivity (DU) (29.3%), and hemorrhagic group have DO (34.6%), DU (65.4%). (P = 0.003).

CONCLUSIONS

Evaluation of the stroke type may be helpful in the determination of the type of urinary dysfunction and in deciding the appropriate bladder management. The urodynamic study, however, is essential to manage LUTS in stroke patients.

Urinary tract infection and bacteriurua in stroke patients: frequencies, pathogen microorganisms, and risk factors

OBJECTIVE

To investigate the frequencies, pathogen microorganisms involved, and possible risk factors of urinary tract infections, asymptomatic bacteriuria, and significant bacteriuria in subacute and chronic stroke patients.

DESIGN

The frequencies were determined and compared for subgroups with respect to age, gender, level of education, type of lesion, side of lesion, bladder-emptying method, postvoid residual urine, ambulation-level class, and Brunnstrom recovery stage class of upper and lower extremities in 110 consecutive stroke patients.

RESULTS

Frequencies were 27.3, 11.8, and 39.1% for urinary tract infections, asymptomatic bacteriuria, and significant bacteriuria, respectively. Bladder-emptying method (P < 0.05), presence of postvoid residual urine >50 ml (P < 0.04), and Brunnstrom recovery stage class of upper extremity (P < 0.02) were significant factors for the frequency of urinary tract infections. Bladder-emptying method, ambulation-level class, Brunnstrom recovery stage class of upper and lower extremities (P < 0.01), presence of postvoid residual urine >50 ml (P < 0.02), gender, and level of education (P < 0.05) were significant factors for the frequency of significant bacteriuria.

CONCLUSIONS

Early treatment of urinary dysfunction for elimination of indwelling catheter use and high postvoid residue, early physical rehabilitation for better ambulation and hand function, patient education about prevention, and close monitoring of patients with unmodifiable risk factors may decrease the frequency of urinary tract infections and significant bacteriuria in stroke patients.

Bladder Storage and Emptying Disorder Frequencies in Hemorrhagic and Ischemic Stroke Patients with Bladder Dysfunction

BACKGROUND

Bladder dysfunction is common in stroke patients and it has a considerable impact on their lives. The objective of this study was to investigate the frequencies of urine storage and emptying disorders in hemorrhagic and ischemic stroke patients with persistent bladder dysfunction.

METHODS

A total of 48 stroke patients who underwent urodynamic tests because of persistent bladder dysfunction were evaluated retrospectively. Urine storage and emptying disorder frequencies were determined and compared in hemorrhagic and ischemic stroke subgroups.

RESULTS

Storage disorder frequencies were 73.3 and 63.6% in hemorrhagic and ischemic stroke groups, respectively (p > 0.05), while emptying disorder frequencies were 13.3 and 51.5% (p < 0.02).

CONCLUSIONS

Evaluation of the stroke type may be helpful in the determination of the type of urinary dysfunction and in choosing the appropriate bladder management strategy, but further studies with larger sample sizes are needed.

Validity of functional independence staging in patients receiving rehabilitation in skilled nursing facilities

OBJECTIVES

To determine the psychometric performance and clinical applicability of the Functional Independence Staging (FIS) system for activities of daily living (ADLs), sphincter management, mobility, and executive function in patients receiving rehabilitation in the skilled nursing facility (SNF) setting.

DESIGN

A retrospective analysis of secondary data using data from a privately owned administrative dataset. Setting Seventy SNFs under contract with SeniorMetrix Inc health plan clients.

PARTICIPANTS

Patients (N=7526) covered by Medicare+Choice plans and admitted to an SNF in 2002.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Analysis of construct validity, sensitivity to change, and predictive validity.

RESULTS

The FIS score in each domain except mobility at admission was higher for patients with no concomitant disease than for patients classified as moribund ( P <.001). The odds of being discharged to the community were consistently greater for patients with higher discharge FIS scores in sphincter management (odds ratio [OR] range, 1.32-1.76), mobility (OR range, 1.93-4.66), and executive function (OR range, 1.50-4.15). Discharge FIS score was greater than admission FIS score for all domains ( P <.001). The odds of being discharged to the community were fairly consistently predicted by admission FIS score in ADLs (OR range, 1.26-3.73) and executive function (OR range, 1.60-5.05).

CONCLUSIONS

The FIS system has reasonable psychometric properties that suggest it may be applied to the assessment and monitoring of functional status in patients admitted for rehabilitation in SNF settings. The system may be useful for determining the type of therapy that might be required or to predict the likely discharge needs of the patient.

An fMRI study of the role of suprapontine brain structures in the voluntary voiding control induced by pelvic floor contraction

We have learned that micturition is comprised of two basic phases: storage and emptying; during bladder emptying, the pontine and periaqueductal gray (PAG) micturition center ensures coordinated inhibition of striated sphincter and pelvic floor muscles and relaxation of the internal urethral sphincter while the detrusor muscle contracts. Due to several disorders of the brain and spinal cord, the achieved voluntary control of bladder function can be impaired, and involuntary mechanisms of bladder activation again become evident. However, little has been discovered so far how higher brain centers strictly regulate the intricate process of micturition. The present functional magnetic resonance imaging (fMRI) study attempted to identify brain areas involved in such voluntary control of the micturition reflex by performing functional magnetic resonance imaging during a block design experiment in 12 healthy subjects. The protocol consisted of alternating periods of rest and pelvic muscle contraction during empty-bladder condition (EBC) and full-bladder condition (FBC). Repeated pelvic floor muscle contractions were performed during full bladder to induce a stronger contrast of bladder sensation, desire to void and inhibition of the micturition reflex triggering, since the subjects were asked not to urinate. Empty-bladder conditions were applied as control groups. Activation maps calculated by contrast of subtracting the two different conditions were purposed to disclose these brain areas that are involved during the inhibition of the micturition reflex, in which contrast, the SMA, bilateral putamen, right parietal cortex, right limbic system, and right cerebellum were found activated. The combined activation of basal ganglia, parietal cortex, limbic system, and cerebellum might support the assumption that a complex visceral sensory-motor program is involved during the inhibitory control of the micturition reflex.

Post stroke urinary loss, incontinence and life satisfaction: When does post-stroke urinary loss become incontinence?

AIMS

While urinary incontinence (UI) has been extensively studied after stroke, the threshold for when it becomes a social problem by affecting life satisfaction or social participation has not been established. The study goal was to establish this threshold, examine the impact of UI on life satisfaction and participation, and determine whether UI contributes independently to poor stroke outcome.

METHODS

Retrospective analysis was performed on prospectively collected data from a cohort of consecutive admissions to the acute Neurology Stroke Service of a large metropolitan teaching hospital. Four hundred and sixty patients with ischemic stroke were prospectively evaluated for stroke severity, medical, and demographic factors. Telephone interviews were completed with 361 community-dwelling subjects 6 months after stroke onset.

RESULTS

The FIM bladder item was used to determine the frequency of urinary loss. All patients were continent before stroke onset, 16% reported UL at 6-month follow-up. ROC analysis suggested that UI once per month or more is associated with diminished quality of life and activity participation. Logistic regression found poor life satisfaction associated with ADL impairment, cognitive disability, low SF12 physical and mental health scores, and incontinence. Poor outcome was independent of stroke severity.

CONCLUSIONS

Urinary loss became incontinence when it occurred at least monthly. UI was associated with greater dependence in basic and instrumental ADL, decreased participation and low life satisfaction.

Registered Nurses' perceptions of geriatric rehabilitation nursing in three Scandinavian countries

This study describes Registered Nurses' perceptions of geriatric rehabilitation nursing as well as their experiences of working in the rehabilitation of older patients in Denmark, Finland and Norway. The aim was to gain deeper insights into how Registered Nurses think about geriatric rehabilitation nursing and how their perceptions differ in these countries. The data were collected among 600 Registered Nurses using a structured questionnaire with five background items and 88 geriatric rehabilitation nursing items. The response rate was 65%. Data analysis was with SPSS statistical software. Geriatric rehabilitation nursing was experienced as something that required knowledge and experience, patience and creativity, as well as professional skills. The nurses talked with their patients about their rehabilitation goals, but not all nurses were aware of those goals. Progress in the rehabilitation process was evaluated on a daily basis and results were noted in the patients' records. The nurses motivated patients by giving them positive feedback, by preventing pain, by pausing to share with the patients their joy about progress, and by giving the patients the opportunity to cope with daily activities. The Registered Nurses in Denmark were more team oriented and they set out the goals in the patient's records more often than their colleagues did in Finland and Norway.

Medical complications experienced by a cohort of stroke survivors during inpatient, tertiary-level stroke rehabilitation

OBJECTIVE

To identify the most common medical complications experienced by stroke survivors during inpatient, tertiary-level stroke rehabilitation.

DESIGN

Prospective, descriptive analysis.

SETTING

A tertiary-level, 23-bed, inpatient stroke rehabilitation unit in Nova Scotia, Canada.

PARTICIPANTS

All stroke survivors (N=133) admitted for tertiary-level stroke rehabilitation during a 1-year period.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The attending physiatrist determined the presence or absence of specific complications during the interdisciplinary team conference held during the week of discharge for each patient.

RESULTS

The 4 most common medical complications were depression (26%), shoulder pain (24%), falls (20%), and urinary tract infection (UTI) (15%). Other less common complications included back and hip pain (5%), gastrointestinal disturbances (4%), and pneumonia (2%). Seizures, pressure ulcers, and shoulder-hand syndrome each occurred in 1.5% of the population.

CONCLUSIONS

Depression, shoulder pain, falls, and UTIs are common complications experienced by stroke survivors during inpatient rehabilitation. Heightened awareness of these potential complications may lead to prevention or to earlier recognition and improved management of these conditions.

Rehabilitation outcome of Turkish stroke patients: in a team approach setting

The aim of this study was to identify the efficacy of in-patient stroke rehabilitation, to evaluate the relationship between clinical characteristics and functional outcome, and to determine factors predicting functional outcome at discharge in Turkish stroke patients with a team approach. Retrospective data were collected from 102 of 116 patients with first stroke who were admitted to our rehabilitation unit at Ankara University. Demographic data, length of hospital stay (LOHS), onset to admission interval (OAI), type, side and location of stroke lesion, and most common medical complications were recorded. Functional Independence Measure (FIM) and Brunnstrom's motor recovery stages (BMRS) were assessed on admission and at discharge. The mean age was 61.6 +/- 10.9 years and the mean LOHS was 69.7 +/- 28.2 days. The mean FIM total scores were 69.2 +/- 27.4 and 83.2 +/- 25.7 on admission, and at discharge, respectively. The mean FIM total score was significantly correlated to age, LOHS and motor recovery. The FIM total scores of patients with aphasia and depression were found to be lower than those of patients without aphasia and depression. In a stepwise multiple regression analysis, FIM total score on admission, age and OAI were found to be valid predictors of FIM total score at discharge. Functional Independence Measure total score on admission was the strongest variable. Our results suggest that knowledge of the poor prognostic factors effecting functional outcome on admission can provide information to clinicians in identifying severity of stroke. Admission FIM total score, can be used to predict the patients' functional recovery. Advanced age, aphasia and post-stroke depression contribute to lower FIM scores.

Urinary incontinence after traumatic brain injury: incidence, outcomes and correlates

OBJECTIVES

To document the incidence and outcome of urinary incontinence (UI) and urinary retention (UR) during acute traumatic brain injury (TBI) rehabilitation and determine associated clinical variables.

METHODS

Retrospective case series.

RESULTS

Eighty-four patients (mean age 44.7 +/- 17.9 years; 66 males, 18 females) with first-ever TBI within 6 weeks of injury. On admission, UI was present in 52 (62%). UR defined as post-void residual urine volumes of > 100 mls was present in eight (9.5%). Forty-six (54.8%) needed external collecting devices and six (7.1%) used indwelling catheters. Bilateral lesions, diabetes mellitus and faecal impaction were present in 70.2, 10.7 and 6.0%, respectively. UI was associated with poorer functional status (measured by the modified Barthel index) and presence of bilateral lesions (p < 0.01). UR was associated with diabetes mellitus and faecal impaction (p < 0.01). On discharge, 31 (36.9%) remained incontinent.

CONCLUSION

UI is common after acute TBI and is associated with poorer functional outcome.

[Portable ultrasonographic device and bladder dysfunction management in stroke patients]

OBJECTIVE

To determine the usefulness of a portable ultrasonographic device in the management and rehabilitation of stroke patients' bladder voiding impairment in the early stage and to propose a well-fitted screening protocol.

MATERIAL AND METHOD

A prospective observational study of 33 inpatients admitted into our stroke rehabilitation program. A urinary elimination assessment protocol defines the criteria of intermittent catheterization. The determination of bladder volume was performed with a Bladderscan BVI 3000 portable ultrasonographic device.

RESULTS

Urinary retention was present in ten of the 33 patients at admission, who were started on one or many intermittent catheterizations. Retention was resolved for seven of them at discharge. The portable ultrasonographic device allows a very accurate bladder volume assessment, especially useful in at-risk patients: those with cognitive impairments, diabetes mellitus, and prestroke urinary pathology. A new version of our first screening protocol increases the ability to detect patients with true urinary retention. Results are discussed according to the literature data.

CONCLUSION

The portable ultrasonographic device is a simple and noninvasive tool, useful for diagnosis, follow-up and therapy guidance of urinary retention after stroke. An adapted protocol is proposed in order to assess and rehabilitate this trouble. The goal is to avoid long-term catheterization and its linked infectious risk.