Developmental trajectory of care dependency in older stroke patients

Background

Stroke is the leading cause of death in China. Older stroke survivors often have other chronic conditions, not only musculoskeletal deterioration due to age, but also changes in body image that can be brought on by stroke and other diseases, making them unable to take good care of themselves and dependent on others. The degree of dependency affects the rehabilitation progress of stroke survivors and shows dynamic changes that need to be recognized.

Objectives

This study investigates the trajectory of dependency changes in older stroke patients with comorbidities and analyze the influencing factors.

Methods

Grounded in the Chronic Illness Trajectory Framework (CITF), a longitudinal study was conducted from February 2023 to October 2023, tracking 312 older stroke patients with comorbidities admitted to two tertiary hospitals in Guangzhou. Care dependency levels were assessed using Care Dependency Scale on admission day 5 (T0), at discharge (T1), 1 month post-discharge (T2), and 3 months post-discharge (T3). Growth Mixture Model were utilized to identify trajectory categories, and both univariate analysis and multivariate logistic regression methods were employed to explore factors associated with different developmental trajectories.

Results

A total of four developmental trajectories were fitted, C1 (high independence-slow increased group, 52.0%), C2 (moderate independence-rapid increased group, 13.0%), C3 (moderate independence-slow increased group, 25.0%), and C4 (low independence-increased and decreased group, 10.0%). Length of hospital stay, place of residence, level of social support, residual functional impairments, NIHSS score, and BI index independently influence the trajectory categories.

Conclusion

There is heterogeneity in care dependency among older stroke patients with comorbidities. Most patients gradually reduce their dependency and become more independent, but others remain dependent for an extended period of time. It is recommended to focus on patients who live in rural areas, have low social support, have high admission NIHSS scores and have residual functional impairment, and provide them with personalized continuity of care and rehabilitation services in order to reduce care dependency and the burden of care, and to improve patients' quality of life.

Prediction of Changes in Functional Outcomes During the First Year After Inpatient Stroke Rehabilitation: A Longitudinal Study

OBJECTIVE

To identify meaningful changes in patients in 3 functional domains (basic mobility [BM], daily activity [DA], and applied cognition [AC]) after discharge from inpatient stroke rehabilitation and to identify the predictors of 1-year functional improvement.

DESIGN

A longitudinal, multicenter, prospective cohort study.

SETTING

The acute care wards of 3 hospitals in the Greater Taipei area of Taiwan.

PARTICIPANTS

Five hundred patients with stroke in acute care wards (mean age=60±12.2 years, 62% men, N=500).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE(S)

The Mandarin version of the Activity Measure for Post-Acute Care (AM-PAC) short forms were assessed at discharge and 3-, 6-, and 12-month follow-up. The minimal detectable change (MDC) was used to categorize changes in the scores as improved and unimproved at the 4 time points.

RESULTS

The mean scores of the AM-PAC BM and DA subscales substantially increased over the first 3 months after discharge (86% of participants exhibited improvement) and slightly increased during the subsequent 9 months (5∼26% of participants exhibited improvement). However, the mean score of the AC subscale decreased within the first 3 months and increased over the subsequent 9 months (22-23% of participants exhibited improvement). The BM, AC scores at discharge were the dominant predictors of subsequent functional improvement (P<.05). Patients with a higher functional stage at discharge were more likely to experience significant improvement.

CONCLUSION

This study established the capacity of the AM-PAC to predict functional improvement in 3 domains during the early, middle, and late stages of recovery. The findings can assist clinicians in identifying patients at risk of unfavorable long-term functional recovery and providing such patients with tailored interventions during the early stage of rehabilitation.

Efficacy of a Rehabilitation Program Using Mirror Therapy and Cognitive Therapeutic Exercise on Upper Limb Functionality in Patients with Acute Stroke

Applying evidence-based therapies in stroke rehabilitation plays a crucial role in this process, as they are supported by studies and results that demonstrate their effectiveness in improving functionality, such as mirror therapy (MT), cognitive therapeutic exercise (CTE), and task-oriented training. The aim of this study was to assess the effectiveness of MT and CTE combined with task-oriented training on the functionality, sensitivity, range, and pain of the affected upper limb in patients with acute stroke. A longitudinal multicenter study recruited a sample of 120 patients with acute stroke randomly and consecutively, meeting specific inclusion and exclusion criteria. They were randomly allocated into three groups: a control group only for task-oriented training (TOT) and two groups undergoing either MT or CTE, both combined with TOT. The overall functionality of the affected upper limb, specific functionality, sensitivity, range of motion, and pain were assessed using the Fugl-Meyer Assessment Upper Extremity (FMA-UE) scale validated for the Spanish population. An initial assessment was conducted before the intervention, a second assessment after completing the 20 sessions, and another three months later. ANCOVA analysis revealed statistically significant differences between the assessments and the experimental groups compared to the control group, indicating significant improvement in the overall functionality of the upper limb in these patients. However, no significant differences were observed between the two experimental groups. The conclusion drawn was that both therapeutic techniques are equally effective in treating functionality, sensitivity, range of motion, and pain in the upper limb following a stroke.

Riding waves to improve functioning: a quantitative evaluation of a Surf Week in individuals with chronic phase brain injury with six months follow-up

PURPOSE

Environmental enrichment seems to enable people in the chronic phase of acquired brain injury (ABI) to experience new functional abilities and motor/coping strategies and consequently to become more adaptable which might prevent/reverse functional decline. This study describes the influence of a five-days Surf Week program on participants on physical function, self-efficacy, functional balance performance and self-perceived recovery.

MATERIALS AND METHODS

A multiple-baseline single-case design was used. Adults participating in the Surf Week in chronic phase of ABI were eligible to participate. Participants completed a battery of tests monitoring physical function, self-efficacy, functional balance performance and self-perceived recovery. This battery was repeated 5 times over a 1-year period, two times pre-Surf Week, three times post-Surf Week. Visual data inspection with two non-overlap methods were used to determine if patients showed sustained improvement in outcomes post-intervention.

RESULTS

A moderate to strong indication for improvements on physical function, functional balance performance and self-perceived recovery exists till six months follow-up. No indication was observed on self-efficacy till six months follow-up.

CONCLUSIONS

A five-days Surf Week is a physically, cognitively and socially intensive stimulating activity that can positively challenge individuals after ABI and seems to improve physical functioning, functional balance performance and self-perceived recovery.

Evaluation of the functional outcome and mobility of patients after stroke depending on their cognitive state

The study aimed to analyze the functional outcome and mobility in stroke patients depending on their cognitive state. 180 patients after first stroke were divided into four groups: 48 patients without symptoms of cognitive impairment (G1); 38 with mild cognitive impairment without dementia (G2); 47 with mild dementia (G3); 47 with moderate dementia (G4). The Mini Mental State Examination (MMSE), Barthel Index (BI), Sitting Assessment Scale (SAS), Berg Balance Scale, Trunk Control Test and Test Up & Go were used. The tests were carried out at the time of admission to the ward (T1) and at the time of discharge (T2). A statistically significant improvement was demonstrated in all parameters in almost all groups. No significant difference was observed only in groups G1 and G4 in SAS head. Statistically significant differences in BI results in T2 between groups G1 and G4 were noted. The lowest change in BI was observed in the G4. Regression analysis showed that MMSE and BI at T1 and MMSE score at T2 explained the functional status at T2. Cognitive dysfunction at the time of admission to the ward and discharge may determining the patient's functional status at the time of discharge from the ward.

The factors associated with the deterioration of activities of daily life in stroke patients: A retrospective cohort study

BACKGROUND

The activities of daily life (ADL) of stroke patients generally improves after rehabilitation. However, some patients remain at risk of ADL deterioration in the future. So far, there have been few studies on the factors related to ADL deterioration in stroke patients.

OBJECTIVE

To identify the factors related to ADL deterioration in stroke patients with independent mobility after discharge.

METHODS

We assessed 336 stroke patients with independent mobility who were discharged from the rehabilitation center between January 2016 and December 2018. The primary outcome was ADL deterioration, defined as that ADL assessed at 2 years after discharge decreased more than 15 points compared with that assessed at discharge. Univariate and multivariate statistical analyses were conducted to screen for factors related to ADL deterioration.

RESULTS

Overall, 62 (18.4%) patients exhibited ADL deterioration at 2 years after discharge.Age (OR = 1.114, 95%CI = 1.045-1.188, p = 0.001), vascular risk factors>3 (OR = 3.269, 95%CI = 1.189-8.986, p = 0.022) and with post-stroke depression (OR = 2.486, 95%CI = 1.011-6.114, p = 0.047) were risk factors for ADL deterioration in stroke patients. In contrast, elevated Berg Balance Scale (BBS) scores at discharge was a protective factor for ADL deterioration (OR = 0.484, 95%CI = 0.386-0.606, p < 0.001).

CONCLUSIONS

Nearly 1 in 5 stroke patients with independent mobility experienced ADL deterioration at 2 years after discharge. Aging, vascular risk factors>3, BBS at discharge, and post-stroke depression (PSD) were identified as factors associated with ADL deterioration.

How Do Motor and Sensory Function Correlate with Daily Performance Recovery after Post-Stroke Robotic Intervention? A Secondary Analysis of a Non-Randomized Controlled Trial

New technologies have been developed to complement conventional interventions to better target the specific needs of people with stroke, and they have been shown to improve both function and performance. However, it is unknown whether the baseline levels of sensorimotor function and performance interrelate with the improvement in upper limb and daily performance. Thus, the aim of this study was to examine the relationship between baseline levels of sensorimotor function and daily performance and its impact on post-intervention improvement in people with stroke following a robotic intervention. A single-blind, non-randomized, controlled clinical trial was conducted. Participants in the experimental group (n = 9) received a robotic intervention in addition to conventional treatment. Sensorimotor function was measured with Semmes-Weinstein Monofilaments® and the Fugl-Meyer Assessment Upper Extremity Scale. Upper limb and daily performance were measured with the MAL and SIS-16 scales. The multivariate regression models showed that baseline levels of upper limb performance and motor function predicted >95% of the variance in upper limb performance (p < 0.001), while pre-intervention levels of daily performance explained >75% of the post-intervention variance (p < 0.05). These findings indicate that basal upper limb motor function is associated with improved performance following a combined intervention of conventional treatment and robotic intervention.

The association of comorbidities with the 25-question geriatric locomotive function scale and the diagnosis of locomotive syndrome

BACKGROUND

No studies have provided statistical evidence of the relationship between comorbidities and locomotive syndrome (LS). We therefore investigated the association of comorbidities with the 25-question Geriatric Locomotive Function Scale (GLFS-25) and the diagnosis of LS in community-dwelling residents.

METHODS

This cross-sectional study was conducted on 2612 community-dwelling residents (≥40 years old) who attended a 'basic health checkup'. There were 432 participants with comorbidities (45 with cerebrovascular diseases, 133 with cardiovascular diseases, 83 with pulmonary diseases, 108 with renal diseases, and 63 with multiple diseases) and 2180 participants without comorbidities. Subjects with a GLFS-25 total score of ≤6 points, 7-15 points, 16-23 points, and ≥24 points were diagnosed with non-LS, LS-1, LS-2, and LS-3, respectively. The domain scores covered body pain (items 1-4), movement-related difficulty (items 5-7), usual care (items 8-11 and 14), social activities (items 12, 13, and 15-23), and cognition (items 24 and 25). A multivariate regression analysis and multivariate logistic regression analysis were performed to assess the association between the GLFS-25 scores and comorbidities and between the diagnosis of LS and comorbidities after adjusting for age, sex, body mass index, and smoking status.

RESULTS

A multivariate regression analysis showed that comorbidities were significantly related to the GLFS-25 total score and all domain scores. A multivariate logistic regression analysis revealed that comorbidities were significantly related to a diagnosis of LS-1 or more, LS-2 or more, and LS-3 or more.

CONCLUSIONS

Comorbidities were associated with increased GLFS-25 domain scores and total score and consequent diagnosis of LS. Therefore, attention should also be paid to the presence of comorbidities when diagnosing LS. Nevertheless, the causal relationship between comorbidities and the GLFS-25 remains unclear, and further studies are therefore required.

Subanesthetic dose of S-ketamine improved cognitive dysfunction via the inhibition of hippocampal astrocytosis in a mouse model of post-stroke chronic stress

Post-stroke chronic stress (PSCS) is generally associated with the poorer recovery and more pronounced cognitive dysfunction. Recent evidence has implied that S-ketamine can reduce suicidal ideation in treatment-resistant depression. In this current study, we aimed to investigate whether the administration of S-ketamine ameliorated cognitive deficits under PSCS conditions, which was established by a model combining middle cerebral artery occlusion (MCAO) and chronic restraint stress. Our data suggested that mice exposed to PSCS exhibited depression-like behavior and cognitive impairment, which coincided with astrocytosis as indicated by increased GFAP-positive cells and impairment of long-time potentiation (LTP) in the hippocampal CA1. Subanesthetic doses (10 mg/kg) of S-ketamine have significantly mitigated depression-like behaviors, cognitive deficits and LTP impairment, reduced astrocytosis, excessive GABA, and inflammatory factors, including NLRP3 and IL-18 in astrocytes in the CA1. Besides, neuroprotective effects induced by S-ketamine administration were found in vitro but could be partially reversed by an agonist of the NLRP3 nigericin. Our current data also suggests that the subanesthetic doses of S-ketamine improved cognitive dysfunction via the inhibition of hippocampal astrocytosis in a mouse model of PSCS.

Clinical Predictors for Upper Limb Recovery after Stroke Rehabilitation: Retrospective Cohort Study

After stroke, recovery of upper limb (UL) motor function is enhanced by a high dose of rehabilitation and is supposed to be supported by attentive functions. However, their mutual influence during rehabilitation is not well known yet. The aim of this retrospective observational cohort study was to investigate the association between rehabilitation dose and motor and cognitive functions, during UL motor recovery. Inpatients with first unilateral stroke, without time restrictions from onset, and undergoing at least 15 h of rehabilitation were enrolled. Data on dose and modalities of rehabilitation received, together with motor and cognitive outcomes before and after therapy, were collected. Fugl-Meyer values for the Upper Extremity were the primary outcome measure. Logistic regression models were used to detect any associations between UL motor improvement and motor and cognitive-linguistic features at acceptance, regarding dose of rehabilitation received. Thirty-five patients were enrolled and received 80.57 ± 30.1 h of rehabilitation on average. Manual dexterity, level of independence and UL motor function improved after rehabilitation, with no influence of attentive functions on motor recovery. The total amount of rehabilitation delivered was the strongest factor (p = 0.031) influencing the recovery of UL motor function after stroke, whereas cognitive-linguistic characteristics were not found to influence UL motor gains.

Standardized tools for assessing balance and mobility in stroke clinical practice guidelines worldwide: A scoping review

Background

Use of standardized tools to assess balance and mobility limitations is a recommended practice in stroke rehabilitation. The extent to which clinical practice guidelines (CPGs) for stroke rehabilitation recommend specific tools and provide resources to support their implementation is unknown.

Purpose

To identify and describe standardized, performance-based tools for assessing balance and/or mobility and describe postural control components challenged, the approach used to select tools, and resources provided for clinical implementation, in CPGs for stroke.

Methods

A scoping review was conducted. We included CPGs with recommendations on the delivery of stroke rehabilitation to address balance and mobility limitations. We searched seven electronic databases and grey literature. Pairs of reviewers reviewed abstracts and full texts in duplicate. We abstracted data about CPGs, standardized assessment tools, the approach for tool selection, and resources. Experts identified postural control components challenged by each tool.

Results

Of the 19 CPGs included in the review, 7 (37%) and 12 (63%) were from middle- and high-income countries, respectively. Ten CPGs (53%) recommended or suggested 27 unique tools. Across 10 CPGs, the most commonly cited tools were the Berg Balance Scale (BBS) (90%), 6-Minute Walk Test (6MWT) (80%), Timed Up and Go Test (80%) and 10-Meter Walk Test (70%). The tool most frequently cited in middle- and high-income countries was the BBS (3/3 CPGs), and 6MWT (7/7 CPGs), respectively. Across 27 tools, the three components of postural control most frequently challenged were underlying motor systems (100%), anticipatory postural control (96%), and dynamic stability (85%). Five CPGs provided information in varying detail on how tools were selected; only 1 CPG provided a level of recommendation. Seven CPGs provided resources to support clinical implementation; one CPG from a middle-income country included a resource available in a CPG from a high-income country.

Conclusion

CPGs for stroke rehabilitation do not consistently provide recommendations for standardized tools to assess balance and mobility or resources to facilitate clinical application. Reporting of processes for tool selection and recommendation is inadequate. Review findings can be used to inform global efforts to develop and translate recommendations and resources for using standardized tools to assess balance and mobility post-stroke.

Systematic Review Registration

https://osf.io/, identifier: 10.17605/OSF.IO/6RBDV.

Nationwide Database Analysis of Risk Factors Associated with Decreased Activities of Daily Living in Patients with Alzheimer's Disease

BACKGROUND

Preserving activities of daily living (ADL) is the key issue for Alzheimer's disease (AD) patients and their caregivers.

OBJECTIVE

To clarify the ADL level of AD patients at diagnosis and the risk factors associated with decreased ADL during long-term care (≤3 years).

METHODS

Medical records of AD patients in a Japanese health insurance claims database were analyzed retrospectively to determine ADL using the Barthel Index (BI) and identify the risk factors associated with decreased ADL.

RESULTS

A total of 16,799 AD patients (mean age at diagnosis: 83.6 years, 61.5% female) were analyzed. Female patients were older (84.6 versus 81.9 years; p < 0.001) and had lower BI (46.8 versus 57.6; p < 0.001) and body mass index (BMI) (21.0 versus 21.7 kg/m2; p < 0.001) than male patients at diagnosis. Disability (BI≤60) increased at age≥80 years and was significantly higher in females. Complete disability was most frequent for bathing and grooming. Risk factors for decreased ADL were determined separately by sex through comparing the ADL-preserved and ADL-decreased groups using propensity score matching by age and BI and multivariable logistic regression analysis. In males, decreased ADL was significantly associated with BMI < 21.5 kg/m2, stroke, and hip fracture, and inversely associated with hyperlipidemia. In females, decreased ADL was significantly associated with BMI < 21.5 kg/m2 and vertebral and hip fractures, and inversely associated with lower back pain.

CONCLUSION

AD patients with low BMI, stroke, and fractures had increased risks of decreased ADL; such patients should be identified early and managed appropriately, including rehabilitation to preserve ADL.

Repetitive transcranial magnetic stimulation (rTMS) for post-stroke sleep disorders: a systematic review of randomized controlled trials

OBJECTIVE

Survivors of stroke often experience post-stroke sleep disorders (PSSDs), but pharmacotherapy risks adverse side effects. Transcranial magnetic stimulation (TMS) is potentially a nonpharmacotherapeutic option. This meta-analysis investigated the effects of rTMS to treat PSSD.

METHODS

Databases were searched for randomized controlled trials (RCTs) of rTMS to treat PSSD, conducted in accordance with the PRISMA 2020 guidelines. Risk-of-bias assessments were performed using the Cochrane risk-of-bias tool. A meta-analysis of the following indexes was performed using RevMan 5.4 software: Pittsburgh sleep quality index; effective rate of sleep improvement; Hamilton Anxiety Rating Scale (for mood); and National Institute of Health Stroke Scale (NIHSS, stroke severity). Mean differences (MDs) and confidence intervals (CIs) were calculated.

RESULTS

The meta-analysis included 17 RCTs, with 1411 patients overall. The indexes indicated that rTMS could improve the sleep quality, mood, and stroke severity of patients with PSSD: Pittsburgh sleep quality index (12 studies; MD =  - 2.51, 95% CI [- 3.24, - 1.79], P < 0.00001); effective rate of sleep improvement (7 studies; MD = 4.03, 95% CI [2.43, 6.68], P < 0.0001); Hamilton Anxiety Rating Scale (2 studies; MD =  - 4.05, 95% CI [- 4.77, - 3.32], P < 0.00001); and NIHSS (2 studies; MD = -2.71, 95% CI [- 3.36, - 2.06], P < 0.00001).

CONCLUSION

The results suggest that rTMS may have positive effects on the sleep quality, mood, and stroke severity of patients with PSSD.

Prenatal alcohol exposure exacerbates acute sensorimotor deficits and impedes long-term behavioral recovery from the effects of an adult-onset cerebrovascular ischemic stroke

BACKGROUND

Prenatal alcohol exposure (PAE) is a significant risk factor for developmental disability, although its health consequences across the lifespan are poorly understood. Here, we hypothesized that latent brain and systemic consequences of PAE influence resiliency to adult-onset neurological disease, specifically, cerebrovascular ischemic stroke.

METHODS

Pregnant Sprague-Dawley rats were exposed episodically to ethanol during the fetal neurogenic period. Adult (5 months) male and female PAE and control offspring were subjected to endothelin-1-induced unilateral middle cerebral artery occlusion. In the acute injury phase outcomes including stroke volume and neurological, endocrine, and gut permeability markers were assessed. Because the effects of stroke in human populations evolve over months to years, we also assessed hippocampal- and amygdala-dependent memory function and social interaction preference up to 6 months following a stroke, in middle-aged offspring.

RESULTS

Prenatal alcohol exposure did not alter infarct volume, but significantly increased neurological deficits in both sexes, and impaired interhemispheric sensorimotor integration in PAE females. The IGF-1/IGFBP3 ratio, a measure of bioavailable IGF-1, was significantly reduced, while circulating levels of bacterial lipopolysaccharide, an inflammagen, were significantly increased in PAE males. In PAE females, the circulating IGF-1/IGFBP3 ratio was significantly increased and estradiol-17b levels were significantly reduced. The intestinal fatty acid binding protein, a surrogate marker of gut permeability was also significantly increased in PAE females. Longer-term deficits in hippocampal-associated memory and social interactions were observed in PAE males, while deficits in amygdala-dependent memory were observed in PAE females.

CONCLUSIONS

PAE contributes to adverse effects on brain health and decreased resiliency in response to a common adult-onset neurovascular disease, cerebrovascular ischemic stroke.

One-year recurrence of stroke and death in Lebanese survivors of first-ever stroke: Time-to-Event analysis

BACKGROUND

To date, despite the application of secondary prevention worldwide, first-ever stroke survivors remain at imminent risk of stroke recurrence and death in the short and long term. The present study aimed to assess the cumulative risk rates and identify baseline differences and stroke characteristics of Lebanese survivors.

METHODS

A prospective longitudinal study was conducted among survivors ≥18 years old who were followed-up for 15 months through a face-to-face interview. Kaplan-Meier method was used to calculate the cumulative rates of stroke mortality and recurrence. Cox-regression univariate and multivariable analyses were performed to identify the predictors of both outcomes.

RESULTS

Among 150 subjects (mean age 74 ± 12 years; 58.7% men vs. 44.3% women; 95.3% with ischemic stroke vs. 4.3% with intracerebral hemorrhage), high cumulative risk rates of stroke recurrence (25%) and death (21%) were highlighted, especially in the acute phase. Survival rates were lesser in patients with stroke recurrence compared to those without recurrence (Log rank test p < 0.001). Older age was the main predictor for both outcomes (p < 0.02). Large artery atherosclerosis was predominant in patients with stroke recurrence and death compared to small vessel occlusion (p < 0.02). Higher mental component summary scores of quality of life were inversely associated with stroke recurrence (p < 0.01). Lebanese survivors exhibited the highest percentages of depression and anxiety; elevated Hospital Anxiety and Depression Scale (HADS) scores were seen in those with stroke recurrence and those who died (≥80% with mean HADS scores ≥8). Lower Mini-Mental State Examination scores at the acute phase increased the risk of both outcomes by 10% (p < 0.03). Three out of 13 mortalities (23.1%) were presented with early epileptic seizures (p = 0.012). High educational level was the protective factor against stroke recurrence (p = 0.019). Administration of intravenous thrombolysis decreased the risk of both outcomes by 10% (p > 0.05).

CONCLUSION

Higher rates of stroke recurrence and death were observed in the first year following a stroke in Lebanon. Various factors were identified as significant determinants. Thus, health care providers and officials in Lebanon can use these findings to implement effective preventive strategies to best address the management of these factors to reduce the stroke burden and improve the short and long-term prognosis of stroke survivors.

The role of social resources and trajectories of functional health following stroke

Stroke is a major cause of disability in old age. Research has revealed that social resources available after the onset of stroke can mitigate functional prognosis. However, most studies have conceptualized resources as static rather than dynamic and have not measured changes in social resources from the pre-to post-stroke periods. To better understand the recovery process following stroke, we examined how social resources available before its onset and changes from pre-to post-stroke were associated with trajectories of functional health following stroke. Data were derived from an up to 19-year longitudinal study of a nationally representative sample of Japanese adults aged 60 years and older. We identified 389 people who experienced self- or proxy-reported first stroke during follow-up (age at stroke onset: M = 75.9, SD = 6.8; 49.1% women). The average number of observations was 4.6 (SD = 1.6, range 2-7). Functional health was measured with self- or proxy-reported basic and instrumental activities of daily living. Social resources were indexed as residential status, contact with own non-coresident children, social participation, and perceived support. Analyses were adjusted for age at stroke onset, sex, education, health condition, and cognitive function. A multiphase growth model indicated that individuals who participated more frequently in social groups prior to stroke exhibited less functional deterioration post-stroke than those who participated less frequently. Whereas contact frequency with non-coresident children typically declined following stroke, the analysis further revealed that individuals who maintained contact frequency from pre-to post-stroke showed less steep functional decline over time in the post-stroke period despite minor individual differences. We found that social resources before stroke onset and changes in the resources following stroke may play a protective role against adverse prognoses. Inclusive communities may help older adults remain independent even after serious health events.

Measurement properties of the Brazilian version of the Stroke Upper Limb Capacity Scale (SULCS-Brazil)

BACKGROUND

The Stroke Upper Limb Capacity Scale (SULCS) is a clinically useful measure of upper-limb (UL) capacity, which assesses both basic and advanced capacities.

OBJECTIVES

To examine the reliability, construct validity, and interpretability of the SULCS-Brazil with community-dwelling individuals with stroke.

METHODS

The SULCS-Brazil and measures of impairment (handgrip strength and motor function of the paretic UL), capacity (manual and digital dexterities), and performance were applied during the first session, to establish construct validity (80 patients). The SULCS-Brazil was applied again during a second session (a sub-set of 30 patients), to investigate test-retest reliability. Test-retest reliability was evaluated using kappa statistics (k) for the individual items, intraclass correlation coefficient (ICC) for the total scores, standard error of measurement (SEM), minimal detectable change (MDC), and Bland-Altman plot. For the evaluation of construct validity, pre-defined hypotheses were created to estimate the strength of the correlations between the SULCS-Brazil scores and established measures of UL function, using Spearman correlation coefficients. Interpretability was investigated by evaluating both ceiling/ floor effects.

RESULTS

High level of agreement was found between the SUCLS-Brazil total scores obtained on both applications (ICC = 0.98; 95%CI:0.96-0.99) and 80% of the individual items had almost perfect agreement (k= 0.81-1.0). The SEM (0.46) and the MDC (1.27) showed clinically acceptable values. All pre-defined hypotheses were confirmed, indicating adequate construct validity of the SULCS-Brazil. No significant ceiling/floor effects were observed.

CONCLUSIONS

The SULCS-Brazil showed to be reliable and valid for the evaluation of upper-limb capacity of individuals with stroke.

Association of Pre-stroke Frailty With Prognosis of Elderly Patients With Acute Cerebral Infarction: A Cohort Study

Background

Frailty is a state of cumulative degradation of physiological functions that leads to adverse outcomes such as disability or mortality. Currently, there is still little understanding of the prognosis of pre-stroke frailty status with acute cerebral infarction in the elderly.

Objective

We investigated the association between pre-stroke frailty status, 28-day and 1-year survival outcomes, and functional recovery after acute cerebral infarction.

Methods

Clinical data were collected from 314 patients with acute cerebral infarction aged 65–99 years. A total of 261 patients completed follow-up in the survival cohort analysis and 215 patients in the functional recovery cohort analysis. Pre-stroke frailty status was assessed using the FRAIL score, the prognosis was assessed using the modified Rankin Scale (mRS), and disease severity using the National Institutes of Health Stroke Scale (NIHSS).

Results

Frailty was independently associated with 28-day mortality in the survival analysis cohort [hazard ratio (HR) = 4.30, 95% CI 1.35–13.67, p = 0.014]. However, frailty had no independent effect on 1-year mortality (HR = 1.47, 95% CI 0.78–2.79, p = 0.237), but it was independently associated with advanced age, the severity of cerebral infarction, and combined infection during hospitalization. Logistic regression analysis after adjusting for potential confounders in the functional recovery cohort revealed frailty, and the NIHSS score was significantly associated with post-stroke severe disability (mRS > 2) at 28 days [pre-frailty adjusted odds ratio (aOR): 8.86, 95% CI 3.07–25.58, p < 0.001; frailty aOR: 7.68, 95% CI 2.03–29.12, p = 0.002] or 1 year (pre-frailty aOR: 8.86, 95% CI 3.07–25.58, p < 0.001; frailty aOR: 7.68, 95% CI 2.03–29.12, p = 0.003).

Conclusions

Pre-stroke frailty is an independent risk factor for 28-day mortality and 28-day or 1-year severe disability. Age, the NIHSS score, and co-infection are likewise independent risk factors for 1-year mortality.

Breathing Exercises for Improving Cognitive Function in Patients with Stroke

Patients with stroke may experience a certain degree of cognitive decline during the period of recovery, and a considerable number of such patients have been reported to show permanent cognitive damage. Therefore, the period of recovery and rehabilitation following stroke is critical for rapid cognitive functional improvements. As dysfunctional breathing has been reported as one of the factors affecting the quality of life post stroke, a number of studies have focused on the need for improving the breathing function in these patients. Numerous breathing exercises have been reported to enhance the respiratory, pulmonary, cognitive, and psychological functions. However, scientific evidence on the underlying mechanisms by which these exercises improve cognitive function is scattered at best. Therefore, it has been difficult to establish a protocol of breathing exercises for patients with stroke. In this review, we summarize the psychological, vascular, sleep-related, and biochemical factors influencing cognition in patients and highlight the need for breathing exercises based on existing studies. Breathing exercises are expected to contribute to improvements in cognitive function in stroke based on a diverse array of supporting evidence. With relevant follow-up studies, a protocol of breathing exercises can be developed for improving the cognitive function in patients with stroke.

Factors associated with gravity-dependent distribution on chest CT in elderly patients with community-acquired pneumonia: a retrospective observational study

Although lung involvement in aspiration pneumonia typically has a gravity-dependent distribution on chest images, which patient’s conditions contribute to its radiological pattern has not been fully elucidated. This study was designed to determine the factors associated with the gravity-dependent distribution of community-acquired pneumonia (CAP) on chest computed tomography (CT). This retrospective study included elderly patients aged ≥ 65 years with CAP who underwent chest CT within 1 week before or after admission. The factors associated with lower lobe- and posterior-predominant distributions of ground glass opacity or airspace consolidation were determined. Of the 369 patients with CAP, 348 (94%) underwent chest CT. Multivariate analyses showed that impaired consciousness, a low Barthel index of activities of daily living, and high hemoglobin levels were associated with lower lobe-predominant distribution, while male sex and impaired consciousness were associated with posterior-predominant distribution. Cerebrovascular diseases were unrelated to these distributions. While male sex, impaired consciousness, high hemoglobin levels, low albumin levels, and the number of involved lobes were associated with in-hospital mortality, gravity-dependent distributions were not. Impaired consciousness might be the most significant predictor of aspiration pneumonia; however, the gravity-dependent distribution of this disease is unlikely to affect disease prognosis.

Rivaroxaban versus aspirin on functional and cognitive outcomes after embolic stroke of undetermined source: NAVIGATE ESUS trial

BACKGROUND

The effect of interventions on functional impairment is an important outcome in stroke prevention trials and should be considered as an adjunct to counting discrete events. In the NAVIGATE-ESUS trial, 7213 patients with recent embolic strokes of undetermined source were randomized to rivaroxaban (15 mg once daily) or aspirin (100 mg daily). After 11 months there was no effect on the prevention of recurrent stroke.

AIMS

To determine the effect of rivaroxaban compared to aspirin on functional and cognitive outcomes.

METHODS

Function and cognition were measured at baseline, 1 year, and study end using the Standard Assessment of Global Everyday Activities (SAGEA), a 15-item scale assessing cognitive, instrumental, and basic activities of daily living as well as mobility, and the Montreal Cognitive Assessment (MoCA). Changes in scores were calculated by subtracting either study end or 1-year scores from baseline, and differences in distributions were compared using the Mann-Whitney U test. SAGEA and MoCA scores were also correlated with recurrent stroke.

RESULTS

Follow-up SAGEA scores were available in 6378 (88%) participants. There was no difference in change in function for those allocated to rivaroxaban compared to aspirin (Mann-Whitney U test, p = 0.8), with both distributions having a median (25p,75p) change of 0 (-2,1). Overall, more of those who experienced a recurrent stroke (n=247; mostly minor ischemic), reported functional difficulty at study end versus entry, compared with those who did not (51% versus 30%, chi-square test, p< 0.001), and this was consistent across global regions. There was no difference in the change in cognition by treatment group, nor were recurrent strokes associated with a change in cognition.

CONCLUSIONS

Rivaroxaban, compared to aspirin, was not associated with changes in functional or cognitive status in patients with recent ESUS. The SAGEA scale detected changes in functional status associated with recurrent strokes in an international stroke population.

General and comparative self-rated health in chronic stroke: an important outcome measure for health professionals

BACKGROUND

After a stroke, several aspects of health and function may influence how individuals perceive their own health. However, self-rated health (SRH), as well as its relationship with functioning, has been little explored in individuals with stroke. The aims of this study were to determine how individuals with chronic post-stroke disabilities evaluate their health, considering general, time- and age-comparative SRH questions and to investigate whether SRH measures would be influenced by the following health and functioning domains: mental/physical functions and personal factors.

METHODS

Sixty-nine individuals with chronic post-stroke disabilities answered the three types of SRH questions and were assessed regarding depressive symptoms (emotional function domain), physical activity levels (physical function domain), and engagement in physical activity practice (personal factor domain). Subjects were divided into the following groups: good/poor for the general SRH question; better, similar, and "worse" for both time- and age-comparative questions. Between-group differences in the three domains for each SRH question were investigated (α = 5%).

RESULTS

General SRH was rated as good by 73% of the participants. Time- and age-comparative SRH was rated as better by 36% and 47% and as similar by 31% and 28% of the subjects, respectively. Significant between-group differences in emotional function were found for both the general and age-comparative questions. For the time-comparative question, significant differences were only observed for physical function.

CONCLUSION

SRH evaluation differed in individuals with chronic post-stroke disabilities according to the types of questions and health/functioning domains.

Visualization-Driven Time-Series Extraction from Wearable Systems Can Facilitate Differentiation of Passive ADL Characteristics among Stroke and Healthy Older Adults

Wearable technologies allow the measurement of unhindered activities of daily living (ADL) among patients who had a stroke in their natural settings. However, methods to extract meaningful information from large multi-day datasets are limited. This study investigated new visualization-driven time-series extraction methods for distinguishing activities from stroke and healthy adults. Fourteen stroke and fourteen healthy adults wore a wearable sensor at the L5/S1 position for three consecutive days and collected accelerometer data passively in the participant’s naturalistic environment. Data from visualization facilitated selecting information-rich time series, which resulted in classification accuracy of 97.3% using recurrent neural networks (RNNs). Individuals with stroke showed a negative correlation between their body mass index (BMI) and higher-acceleration fraction produced during ADL. We also found individuals with stroke made lower activity amplitudes than healthy counterparts in all three activity bands (low, medium, and high). Our findings show that visualization-driven time series can accurately classify movements among stroke and healthy groups using a deep recurrent neural network. This novel visualization-based time-series extraction from naturalistic data provides a physical basis for analyzing passive ADL monitoring data from real-world environments. This time-series extraction method using unit sphere projections of acceleration can be used by a slew of analysis algorithms to remotely track progress among stroke survivors in their rehabilitation program and their ADL abilities.

The association between functional status and physical pain with depressive symptoms after a stroke event: A cross-sectional analysis of the China Health and Retirement Longitudinal Study 2018

BACKGROUND

Stroke is a major cause of mortality and long-term physical and cognitive impairment. This study aims to: (1) examine the prevalence of depressive symptoms, disability and pain among Chinese adults with stroke; (2) test the associations of functional limitations and body pain with occurrence of depressive symptoms; (3) investigate gender and urban-rural disparities in these associations.

METHODS

This study utilized the data from the China Health and Retirement Longitudinal Study in 2018, involving 969 patients with stroke among 17,970 participants aged ≥ 45 years. Depressive symptoms were assessed using the 10-item Center for Epidemiologic Studies Depression (CES-D) Scale. We performed multivariable logistic regression models to estimate the associations between activities of daily life (ADL), instrumental activities of daily life (IADL) and pain with depressive symptoms.

RESULTS

Depressive symptoms were found among 40.2% of stroke patients, with a higher prevalence in females (48.2%) than males (32.7%). Prevalence of ADL limitations, IADL limitations and pain among stroke patients were 39.2, 49.8 and 14.0%, respectively. ADL and IADL limitations and pain were more prevalent among females and residents in rural areas. Multivariable regression analyses showed a significant association between ADL limitation (OR = 1.535, 95% CI = 1.168, 2.018), IADL limitation (OR = 1.666, 95% CI = 1.260, 2.203) and pain (OR = 2.122, 95% CI = 1.466, 3.073) with depressive symptoms. Stratified analyses revealed stronger associations among urban residents. Females had a higher association of ADL and IADL with depressive symptoms but similar in that of pain to the males. The impact of ADL and IADL in male patients is higher than in females, but the impact of pain on depressive symptoms is higher in female patients.

CONCLUSION

Depressive symptoms are common amongst post-stroke patients in China and are significantly associated with functional disability and physical pain. Our findings have implications for practitioners on the early assessment of pain and depression after stroke. Future research should explore effective intervention measures for physical-mental stroke complications.

Pre-stroke Disability and Long-Term Functional Limitations in Stroke Survivors: Findings From More of 12 Years of Follow-Up Across Three International Surveys of Aging

Background

Almost 50% of the post-stroke disabled population already have a premorbid disability before stroke. These patients may be offered a different care pathway in the acute and subacute phase than those without pre-morbid disability. Therefore, the aim of this study was to assess the association of the severity of premorbid disability with change of limitations in basic and instrumental activities of daily living (ADL/IADL) 1 year after stroke and over the following decade.

Methods

Among 3,432 participants from HRS, SHARE and ELSA cohorts with a first stroke, ADL/IADL limitations were measured at 1-2 years prior to stroke, at 1 year post-stroke, and during the chronic phase. Modified Ranking Scale (P-mRS) was used to categorize the participants by level of premorbid disability (1-2 years pre-stroke). Change in ADL/IADL limitations by P-mRS level (0-1, 2-3, and 4-5) was assessed using a piecewise linear mixed model with a breakpoint set at 1 year post-stroke, stratified by median age groups.

Results

Increase in ADL limitations at 1 year post-stroke was less pronounced in P-mRS ≥2 (p < 0.005). After years of relative stability, limitations of ADL increased for all P-mRS levels (p = 0.003). In those aged ≥75 years at stroke event, the increase was similar irrespective of P-mRS (p = 0.090). There were no significant differences in IADL trajectories between P-mRS levels (p ≥ 0.127).

Conclusion

These results suggest similar trajectories of functional limitations between P-mRS levels up to 9 years post-stroke, highlighting the possible benefit of including patients with pre-morbid disability to certain treatments during the acute phase.

Long-Term Evolution of Functional Limitations in Stroke Survivors Compared With Stroke-Free Controls: Findings From 15 Years of Follow-Up Across 3 International Surveys of Aging

BACKGROUND AND PURPOSE

In the chronic phase 2 to 5 years poststroke, limitations in activities of daily living (ADL) and instrumental ADL (IADL) initially plateau before steady increasing. However, the impact of age and differences in initial levels of disability on the evolution of these limitations remains unclear. As such, this study aims to evaluate differences in long-term evolution of ADL/IADL limitations between stroke survivors and stroke-free population, and how limitations differ by initial level of disability for stroke survivors.

METHODS

Thirty-three thousand six hundred sixty participants (5610 first-ever stroke cases with no recurrence during follow-up and 28 050 stroke-free controls) aged ≥50 from the Health and Retirement Study, Survey of Health, Ageing and Retirement in Europe, and English Longitudinal Study of Ageing were assessed for number of ADL/IADL limitations during the poststroke chronic phase (for cases) and over follow-up years 1996 to 2018 (for controls). Three thousand seven hundred eighteen stroke cases were additionally categorized by disability level using the modified Rankin Scale score of 1 to 2 years poststroke. Evolution of ADL/IADL limitations was assessed in stroke cases and controls and by modified Rankin Scale score (0-1, 2-3, 4-5) using linear mixed models. Models were stratified by age group (50-74 and ≥75 years) and adjusted for baseline characteristics, health behaviors, BMI, and comorbidities.

RESULTS

Findings showed relative stability of ADL/IADL limitations during 3 to 6 years poststroke followed by an increase for both populations, which was faster for younger stroke cases, suggesting a differential age-effect (P<0.001). Disability level at 1 to 2 years poststroke influenced the evolution of limitations over time, especially for severe disability (modified Rankin Scale score, 4-5) associated with a reduction in limitations at 5 to 6 years poststroke.

CONCLUSIONS

Our findings showed that during the poststroke chronic phase functional limitations first plateau and then increase and the evolution differs by disability severity. These results highlight the importance of adaptive long-term health and social care measures for stroke survivors.

Clinical reasoning underlying acute care occupational therapists' assessment of rehabilitation potential after stroke or brain injury: A constructivist grounded theory study

INTRODUCTION

In acute care hospitals, clinicians are expected to rapidly provide recommendations regarding patients' rehabilitation potential and candidacy for postacute rehabilitation. Some studies have investigated factors influencing referral to rehabilitation, but few have examined clinical reasoning underlying referral decisions. This study aimed to investigate what occupational therapists were thinking about (factors influencing reasoning), how they reasoned (thought processes) when evaluating stroke or traumatic brain injury patients' rehabilitation potential, and how they decided on referral to postacute rehabilitation.

METHODS

Using a constructivist grounded theory approach, the clinical reasoning of 10 acute care occupational therapists working in a large Canadian city was examined. Participant recruitment, data collection, and analysis were performed simultaneously following theoretical sampling procedures. Therapists' thoughts on patients' rehabilitation potential were collected twice (during chart consultation and initial patient assessment) using think-aloud protocols and semi-structured interviews. Constant comparison, memoing, and diagramming methods were employed during coding to help categorisation and conceptualisation.

FINDINGS

Numerous patient, clinician, and organisation-related factors were found to influence clinical reasoning. Occupational therapists interpreted these factors in an attempt to (1) predict recovery, (2) estimate rehabilitation potential, and (3) determine rehabilitation candidacy. They used two types of thought processes: (1) building a representation of patients' rehabilitation potential (involving eight steps including gathering and interpreting factors); (2) activating bottom-up and top-down scripts (comparing the expected impact of impairments on activity performance to behaviours observed during activity performance). Furthermore, an algorithm was developed describing how occupational therapists decide on referral to postacute rehabilitation.

CONCLUSION

Findings can be used to teach students and novice occupational therapists how to identify and interpret key factors in the assessment of stroke or traumatic brain injury patients' rehabilitation potential. Results also provide insight on cognitive processes that can be taught for efficient assessment of rehabilitation potential and decision-making regarding referral to postacute rehabilitation.

Dependency in Activities of Daily Living During the First Year After Stroke

Background: Dependency in personal activities of daily living (ADL) is a common short-term and long-term consequence of stroke and requires targeted rehabilitation. As the duration of hospital stay has become shorter in recent decades, early identification of patients who require rehabilitation has become vital. To our knowledge, no study has investigated whether ADL dependency in the very early stages after admission to the stroke unit can explain ADL dependency 3 and 12 months later. This knowledge would facilitate planning for very early discharge and patient-centered rehabilitation.

Objective: This study evaluated whether ADL dependency within 2 days after stroke could explain ADL dependency at 3 and 12 months after stroke.

Methods: This longitudinal cohort study included patients with stroke who were treated at a stroke unit in the Sahlgrenska University Hospital (Gothenburg, Sweden) between May 2011 and March 2016. The primary independent variable was ADL dependency at 36–48 h after admission to the stroke unit, which was assessed using a Barthel Index (BI) score of ≤90. The dependent variables were self-reported personal ADL dependency at 3 and 12 months after stroke. Binary logistic regression analyses were performed.

Results: Of 366 eligible patients (58% male; median age 71 years), a majority (76%) had mild stroke and 60% were ADL dependent 36–48 h after stroke. Univariable and multivariable logistic regression analyses showed that patients who were dependent within the first 2 days after stroke had higher odds for being dependent 3 months as well as 12 months after stroke.

Conclusion: The results indicated that dependency in personal ADL during the first 2 days can explain dependency at 3- and 12-month post-stroke. Therefore, early ADL assessments post-stroke can be used for understanding rehabilitation needs after stroke.

The relationship between upper limb function and activities of daily living without the effects of lower limb function: A cross-sectional study

Introduction

Upper limb motor function and activities of daily living (ADL) are related in chronic stroke patients. This study investigated this relationship after removal of the influence of motor function of the affected lower limb, which until now has remained unclear.

Methods

This retrospective cross-sectional study included 53 patients with chronic stroke. Upper and lower limb motor function and ADL were assessed using the Fugl-Meyer assessment of the upper (FMA-UL) and lower limbs (FMA-LL) and functional independence measure motor score (FIM-M). To clarify the relationship between FMA-UL and total FIM-M before and after removal of the influence of FMA-LL, Spearman’s rank correlation coefficient and partial correlation analysis were used. The relationship between FMA-UL and each item of FIM-M after removal of the influence of FMA-LL was assessed using partial correlation analysis.

Results

Before the influence of FMA-LL was removed, FMA-UL was moderately to well correlated with total FIM-M. This became weak after the influence was removed. Regarding each item of FIM-M, FMA-UL was correlated with dressing (upper body), toileting, and walking or wheelchair after removal of the influence.

Conclusion

The relationship between upper limb motor function and ADL is strongly influenced by lower limb motor function.

Protective Role of Caregiver Preparedness on the Relationship Between Depression and Quality of Life in Stroke Dyads

BACKGROUND AND PURPOSE

Depression and quality of life (QOL) have an interdependent and transactional nature in stroke survivor-caregiver dyads. While the strong relationship between depression and physical and emotional QOL in stroke survivor-caregiver dyads is well known, it is less clear if this relationship is moderated by caregiver preparedness, which could easily be targeted with interventions. In this study, we examined the moderating role of caregiver preparedness on the association between depression and QOL in stroke survivor-caregiver dyads.

METHODS

We used a longitudinal design with follow-ups every 3 months over a 1-year period. Considering the nonindependent nature of the data (survivors and their caregivers), we used multilevel modeling to analyze data at the dyad level. We implemented 4 longitudinal dyadic moderation models (one for each QOL domain: physical, psychological, social, and environmental) using hierarchical linear modeling.

RESULTS

A sample of 222 stroke survivor-caregiver dyads was analyzed. Stroke survivors were older (M=70.8, SD=11.9) than their caregivers (M=52.4, SD=13.1). Stroke survivors predominantly had an ischemic stroke, equally distributed by site. Caregivers were primarily female (66%), with a medium to high educational level (57%). Caregiver preparedness significantly moderated the association between survivor depression and survivor psychological (B=0.56, P<0.01) and environmental (B=0.58, P<0.01) QOL at baseline and social QOL over time (B=0.24, P<0.05). Similarly, caregiver preparedness significantly moderated the association between caregiver depression and caregiver physical (B=0.25, P<0.01) and environmental (B=0.18, P<0.05) QOL over time.

CONCLUSIONS

Caregiver preparedness has a positive influence on both members of the dyad. Assessment of stroke-caregiver preparedness could be helpful to motivate clinicians to develop and implement interventions for stroke survivor-caregiver dyads.

Profiles of patients' self-reported health after acute stroke

BACKGROUND

We aimed to identify groups of patients with similar health status after stroke, assessed by patient reported outcome measures (PROMs), to improve initial risk stratification.

METHODS

In a prospective study, inpatients were recruited during acute stroke treatment. Demographics, history, and cardio-vascular risk factors were assessed at baseline. Self-reported functional status, physical and mental health as well as anxiety and depressive symptoms were assessed 3 and 12 months after stroke and used to identify latent classes. The association of patient characteristics with latent class membership was investigated with multinomial logistic regression.

RESULTS

Of the 650 patients included with a mean age of 75 years and 48% female, 70% had ischemic, 6% hemorrhagic strokes, and 24% transient ischemic attacks. Median NIHSS on admission was 2 (IQR:0,5). Values of PROMs remained comparable at 3 and 12 months. A three-class model was developed, differentiating between patients with mildly (75%), moderately (17%), and severely (8%) impaired self-reported health status. Adjusted for univariately significant baseline characteristics, initial NIHSS distinguished mild- from moderate-, and moderate- from severe-class-membership (p < 0.001). Length of inpatient stay (p < 0.001;OR = 1.1), diabetes (p = 0.021;OR = 1.91), and atrial fibrillation (p = 0.004;OR = 2.20) predicted allocation to the moderately vs. mildly affected class.

CONCLUSIONS

Grading stroke patients by a standard set of PROMs up to 1 year after stroke allows to distinguish the diverse impact of baseline characteristics on differently affected groups. In addition to initial stroke severity, longer inpatient stay, presence of diabetes and atrial fibrillation correlate with greater impairment of self-reported health in the less affected groups.

TRIAL REGISTRATION

http://www.ClinicalTrials.gov ; Unique identifier: NCT03795948 .

Very early mobilization in the stroke unit: Functionality, quality of life and disability at 90 days and 1 year post-stroke

BACKGROUND

The evidence of early mobilization after stroke is conflicting, and the recovery period is an important concern.

OBJECTIVE

To analyse the functionality, quality of life and disability at 90 days and 1 year post-stroke of patients who received a Very Early Mobilization Protocol (VEMP).

METHODS

Prospective cohort study in a tertiary stroke unit. Consecutive patients aged≥18 years and without prior significant disability, who presented motor deficit after acute stroke, were included. A symmetry test was performed to compare the changes in the main variables: Barthel Index (BI), Functional Ambulation Category (FAC), modified Rankin Scale (mRS) and EuroQol five-dimensions three-level (EQ-5D-3L) between 90 days and 1 year post-stroke.

RESULTS

A total of 123 patients were recruited. The BI reflected an improvement at 1 year in transfer to chair/bed in 25.8%(p <  0.01) of patients and in toilet use in 25.8%(p = 0.02). The FAC showed an improvement at 1 year in 44.4%(p <  0.01) of patients and the mRS in 19.1%(p = 0.01). The usual activities dimension of the EQ-5D-3L showed a clinically relevant improvement after 1 year in 15.9%(p = 0.23) of patients.

CONCLUSIONS

A significant percentage of patients show improvements in some functional areas and in disability between 90 days and 1 year post-stroke.

Relationship between trajectories of post-stroke disability and self-rated health (NeuroAdapt): protocol for a prospective observational study

INTRODUCTION

Stroke is the leading neurological cause of adult long-term disability in Europe. Even though functional consequences directly related to neurological impairment are well studied, post-stroke trajectories of functional health according to the International Classification of Functioning, Disability and Health are poorly understood. Particularly, no study investigated the relationship between post-stroke trajectories of activities of daily living (ADL) and self-rated health (SRH). However, such knowledge is of major importance to identify patients at risk of unfavourable courses. This prospective observational study aims to investigate trajectories of ADL and SRH, and their modifying factors in the course of the first year after stroke.

METHODS AND ANALYSIS

The study will consecutively enrol 300 patients admitted to a tertiary care hospital with acute ischaemic stroke or transient ischaemic attack (TIA; Age, Blood Pressure, Clinical Features, Duration of symptoms, Diabetes score ≥3). Patient inclusion is planned from May 2021 to September 2022. All participants will complete an interview assessing ADL, SRH, mental health, views on ageing and resilience-related concepts. Participants will be interviewed face-to-face 1-5 days post-stroke/TIA in the hospital; and will be followed up after 6 weeks, 3 months, 6 months and 12 months via telephone. The 12-month follow-up will also include a neurological assessment. Primary endpoints are ADL operationalised by modified Rankin Scale scores and SRH. Secondary outcomes are further measures of ADL, functional health, physical activity, falls and fatigue. Views on ageing, social support, resilience-related concepts, affect, frailty, illness perceptions and loneliness will be examined as modifying factors. Analyses will investigate the bidirectional relationship between SRH and ADL using bivariate latent change score models.

ETHICS AND DISSEMINATION

The study has been approved by the institutional review board of the University Medicine Greifswald (Ref. BB 237/20). The results will be disseminated through scientific publications, conferences and media. Moreover, study results and potential implications will be discussed with patient representatives.

TRIAL REGISTRATION NUMBER

NCT04704635.

Exercise intervention for sleep disorders after stroke: A protocol for systematic review and meta-analysis

BACKGROUND

Sleep disorders after stroke is one of the most common neuropsychiatric complications and is associated with increased risk of death and poor functional outcomes. Some evidence shows that patients with sleep disorders after stroke benefit from exercise intervention. However, this result is still conflicting. This study aims to explore the effects of exercise on sleep disorders after stroke and to establish safe and effective exercise prescriptions.

METHODS AND ANALYSIS

The databases including Google Scholar, Pubmed, Embase, and Cochrane library will be searched using pre-specified search strategies. Randomized controlled trials and non-randomized prospective controlled cohort studies regarding exercise for sleep disorders after stroke will be included. The primary outcome is the Pittsburgh Sleep Quality Index (PSQI) scale. The secondary outcomes are adverse events associated with exercise and all deaths. The methodological quality of each study will be evaluated by the physiotherapy evidence database scale. The heterogeneity will be evaluated using the I2 test. If I2 > 50%, random effects models will be used in the analysis; otherwise, fixed effects models will be used to pool the data.

RESULTS

This study will assess the efficacy and safety of exercise for sleep disorders after stroke.

CONCLUSIONS

Our findings will be helpful for clinicians to examine the clinical decision-making in the treatment of sleep disorders after stroke using exercise intervention.

ETHICS AND DISSEMINATION

Ethical approval is not required because this study is a secondary analysis. The results of this study will be disseminated through journals and academic exchanges.

SYSTEMATIC REVIEW REGISTRATION NUMBER

INPLASY202130106.

The course of physical functioning in the first two years after stroke depends on peoples' individual movement behavior patterns

BACKGROUND AND PURPOSE

Deterioration of physical functioning after stroke in the long term is regarded as a major problem. Currently, the relationship between "peoples'" movement behavior patterns (the composition of sedentary behavior and physical activity during waking hours) directly after stroke and the development of physical functioning over time is unknown. Therefore, the objectives of this study were to investigate (1) the course of physical functioning within the first two years after returning home after stroke, and (2) the association between physical functioning and baseline movement behavior patterns.

METHOD

In the longitudinal RISE cohort study, 200 persons with a first-ever stroke discharged to the home-setting were included. Participants' physical functioning was assessed within three weeks, at six months, and one and two years after discharge using the Stroke Impact Scale (SIS) 3.0 subscale physical and the five-meter walk test (5MWT). Three distinct movement behavior patterns were identified in a previous study at baseline and were used in the current study: (1) sedentary exercisers (sufficiently active and 64% of waking hours sedentary), (2) sedentary movers' (inactive and 63% of waking hours sedentary), and (3) sedentary prolongers (inactive and >78% of waking hours sedentary accumulated in long prolonged bouts). The association between movement behavior patterns and the course of physical functioning was determined using longitudinal generalized estimating equations analyses.

RESULTS

Overall participants' physical functioning increased between discharge and six months and declined from six months up to two years. Physical functioning remained stable during the first two years after stroke in sedentary exercisers. Physical functioning improved during the first six months after discharge in sedentary movers and sedentary prolongers and deteriorated in the following six months. Only physical functioning (SIS) of sedentary prolongers further declined from one up to two years. A similar pattern was observed in the 5MWT.

CONCLUSION

Movement behavior patterns identified directly after returning home in people with stroke are associated with and are predictive of the course of physical functioning. Highly sedentary and inactive people with stroke have unfavorable outcomes over time than individuals with higher amounts of physical activity.

Factors related to daily use of the paretic upper limb in patients with chronic hemiparetic stroke-A retrospective cross-sectional study

AIMS

The present study aimed to determine factors associated with the frequency of paralyzed upper extremity (UE) use in chronic stroke patients with severe UE functional deficiency.

METHODS

We retrospectively reviewed the medical records of 138 consecutive patients, and 117 was analyzed (median age, 55 [range, 18-85] years; median stroke duration, 24.5 [range, 7-302] months) with chronic hemiparetic stroke who were admitted to our hospital for intensive upper extremity rehabilitation. The mean Fugl-Meyer Assessment (FMA) UE score was 28.6. All of them are independent in their activity of daily living (ADL) and without remarkable cognitive deficits. Amount-of-use score of Motor Activity Log-14 (MAL-AOU) was applied as the index of daily use of affected UE. The following parameters were examined as the explanatory variables: demographics, proximal and distal sub-scores of FMA UE, Modified Ashworth Scale (MAS), and sensory function scores in the Stroke Impairment Assessment Set (SIAS).

RESULTS

The median MAL-AOU score was 0.57 [range, 0.28-0.80]. Ordinal regression analysis revealed that FMA proximal, FMA distal, and SIAS sensory function (touch) were associated with AOU score of MAL-14 (Pseudo R-square = 0.460).

CONCLUSION

Not only motor but also sensory function, especially tactile sensation, play a crucial role in the daily use of affected UE in chronic stroke patients with severe UE hemiparesis.

Associations between post-stroke motor and cognitive function: a cross-sectional study

BACKGROUND

Motor and cognitive impairments are frequently observed following stroke, but are often managed as distinct entities, and there is little evidence regarding how they are related. The aim of this study was to describe the prevalence of concurrent motor and cognitive impairments 3 months after stroke and to examine how motor performance was associated with memory, executive function and global cognition.

METHODS

The Norwegian Cognitive Impairment After Stroke (Nor-COAST) study is a prospective multicentre cohort study including patients hospitalized with acute stroke between May 2015 and March 2017. The National Institutes of Health Stroke Scale (NIHSS) was used to measure stroke severity at admission. Level of disability was assessed by the Modified Rankin Scale (mRS). Motor and cognitive functions were assessed 3 months post-stroke using the Montreal Cognitive Assessment (MoCA), Trail Making Test Part B (TMT-B), 10-Word List Recall (10WLR), Short Physical Performance Battery (SPPB), dual-task cost (DTC) and grip strength (Jamar®). Cut-offs were set according to current recommendations. Associations were examined using linear regression with cognitive tests as dependent variables and motor domains as covariates, adjusted for age, sex, education and stroke severity.

RESULTS

Of 567 participants included, 242 (43%) were women, mean (SD) age was 72.2 (11.7) years, 416 (75%) had an NIHSS score ≤ 4 and 475 (84%) had an mRS score of ≤2. Prevalence of concurrent motor and cognitive impairment ranged from 9.5% for DTC and 10WLR to 22.9% for grip strength and TMT-B. SPPB was associated with MoCA (regression coefficient B = 0.465, 95%CI [0.352, 0.578]), TMT-B (B = -9.494, 95%CI [- 11.726, - 7.925]) and 10WLR (B = 0.132, 95%CI [0.054, 0.211]). Grip strength was associated with MoCA (B = 0.075, 95%CI [0.039, 0.112]), TMT-B (B = -1.972, 95%CI [- 2.672, - 1.272]) and 10WLR (B = 0.041, 95%CI [0.016, 0.066]). Higher DTC was associated with more time needed to complete TMT-B (B = 0.475, 95%CI [0.075, 0.875]) but not with MoCA or 10WLR.

CONCLUSION

Three months after suffering mainly minor strokes, 30-40% of participants had motor or cognitive impairments, while 20% had concurrent impairments. Motor performance was associated with memory, executive function and global cognition. The identification of concurrent impairments could be relevant for preventing functional decline.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02650531 .

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.

Risk factors of poor prognosis and impairment of activities of daily living in patients with hemorrhagic gastroduodenal ulcers

Background

Impairment of activities of daily living (ADL) due to hemorrhagic gastroduodenal ulcers (HGU) has rarely been evaluated. We analyzed the risk factors of poor prognosis, including mortality and impairment of ADL, in patients with HGU.

Methods

In total, 582 patients diagnosed with HGU were retrospectively analyzed. Admission to a care facility or the need for home adaptations during hospitalization were defined as ADL decline. The clinical factors were evaluated: endoscopic features, need for interventional endoscopic procedures, comorbidities, symptoms, and medications. The risk factors of outcomes were examined with multivariate analysis.

Results

Advanced age (> 75 years) was a significant predictor of poor prognosis, including impairment of ADL. Additional significant risk factors were renal disease (odds ratio [OR] 3.43; 95% confidence interval [CI] 1.44–8.14) for overall mortality, proton pump inhibitor (PPIs) usage prior to hemorrhage (OR 5.80; 95% CI 2.08–16.2), and heart disease (OR 3.05; 95% CI 1.11–8.43) for the impairment of ADL. Analysis of elderly (> 75 years) subjects alone also revealed that use of PPIs prior to hemorrhage was a significant predictor for the impairment of ADL (OR 8.24; 95% CI 2.36–28.7).

Conclusion

In addition to advanced age, the presence of comorbidities was a risk of poor outcomes in patients with HGU. PPI use prior to hemorrhage was a significant risk factor for the impairment of ADL, both in overall HGU patients and in elderly patients alone. These findings suggest that the current strategy for PPI use needs reconsideration.

Early Rehabilitation in Acute Care Inpatient Wards May Be Crucial to Functional Recovery 3 Months After Ischemic Stroke

OBJECTIVE

Early rehabilitation in acute care inpatient wards may maximize functional outcome at 3 months after stroke in survivors of stroke. It is unknown whether functional change during acute care hospitalization is significantly associated with functional recovery at 3 months in survivors of acute stroke. The purposes of this study were to examine the association of the Barthel Index (BI) at 3 months with functional change as measured with the Barthel Index (ΔBI) in an acute care inpatient ward and to identify the factors associated with ΔBI and who could benefit from an early rehabilitation program.

METHODS

In this prospective longitudinal study, 76 patients with ischemic stroke in an acute care inpatient ward received early rehabilitation of up to 2 sessions per day for 5 d/wk during their stay. Therapy density was calculated as the proportion of total therapy sessions completed. At admission and discharge, they were assessed with the BI and the Postural Assessment Scale for Stroke Patients (PASS). Demographic and health-related information was also collected. The Barthel Index (BI) was reassessed at 3 months.

RESULTS

ΔBI in the acute care inpatient ward significantly predicted the BI at 3 months, over and above the other significant variables; in addition, therapy density and change in PASS were significantly associated with ΔBI. Patients with moderate initial functional dependence had the largest ΔBI, followed by the group with a more severe condition.

CONCLUSIONS

ΔBI in acute care inpatient wards may be an important predictor of the BI at 3 months. Therapy density and change in PASS were significantly associated with ΔBI.

IMPACT

Survivors of acute stroke who receive up to 2 rehabilitation sessions per day for 5 d/wk early in their hospitalization have better functional recovery at 3 months after stroke.

Prevalence and risk factors of dysphagia among nursing home residents in eastern China: a cross-sectional study

Background

Dysphagia is a common health care problem and poses significant risks including mortality and hospitalization. China has many unsolved long-term care problems, as it is a developing country with the largest ageing population in the world. The present study aimed to identify the prevalence and risk factors of dysphagia among nursing home residents in China to direct caregivers towards preventative and corrective actions.

Methods

Data were collected from 18 public or private nursing homes in 9 districts of Nanjing, China. A total of 775 older adults (aged 60 ~ 105 years old; 60.6% female) were recruited. Each participant underwent a standardized face-to-face interview by at least 2 investigators. The presence of risk of dysphagia was assessed using the Chinese version of the EAT-10 scale. The Barthel Index (BI) was used to evaluate functional status. Additionally, demographic and health-related characteristics were collected from the participants and their medical files. Univariate analyses were first used to find out candidate risk factors, followed by binary logistic regression analyses to determine reliable impact factors after adjusting for confounders.

Results

Out of 775 older adults, the prevalence of dysphagia risk was calculated to be 31.1%. A total of 85.0% of the older adults reported at least one chronic disease, and diseases with the highest prevalence were hypertension (49.5%), stroke (40.4%), diabetes (25.5%) and dementia (18.2%). Approximately 11.9% of participants received tube feeding. The mean BI score was 56.2 (SD = 38.3). Risk factors for dysphagia were texture of diet (OR = 2.978, p ≤ 0.01), BI level (OR = 1.418, p ≤ 0.01), history of aspiration, pneumonia and heart attack (OR = 22.962, 4.909, 3.804, respectively, p ≤ 0.01), types of oral medication (OR = 1.723, p ≤ 0.05) and Parkinson disease (OR = 2.566, p ≤ 0.05).

Conclusions

A serious risk of dysphagia was observed among Chinese nursing home residents. Overall, nursing home residents were moderately dependent, according to the BI level. The risk for dysphagia increased with thinner diet texture, worse functional status, history of aspiration, pneumonia and heart attack, more oral medications and Parkinson disease. The findings of our study may serve to urge nursing home staff to pay more attention to the swallowing function of all residents and to take more actions in advance to prevent or reduce dysphagia.

The efficacy of Qigong exercises for post-stroke mental disorders and sleep disorders: Protocol for a systematic review and meta-analysis

BACKGROUND

Post-stroke mental disorders (PSMDs) and post-stroke sleep disorders (PSSDs) are quite common condition in stroke's patients. Qigong has been widely applied as a replaced and useful treatment for PSMDs and PSSDs. However, the exact effects and safety of Qigong have yet be systematically investigated. Our study focused on summary of efficacy and safety of Qigong for the treatment of advanced PSMDs and PSSDs through the systematic analysis and meta-analysis, in order to provide scientific reference for the clinical.

METHODS

The protocol followed Preferred Reporting Items for Systematic Review and Meta-Analyses Protocols. Relevant randomized controlled trials were only considered. Search strategy will be performed in 4 English database including Cochrane Library, PubMed, Web of Science, Excerpt Medical Database, 4 Chinese Database including Chinese Biomedical Literature Database, China National Knowledge Infrastructure, China Scientific Journal Database, Wanfang Database, and WHO International Clinical Trials Registry Platform. Papers in English or Chinese published from their inception to 30 June 2020. Study selection and data extraction will be performed independently by 2 investigators. The clinical outcomes including overall Hamilton depression scale, Hamilton anxiety scale, the mental health part of the MOS item short from health survey, Generic Quality of Life Inventory-74, Center for Epidemiologic Studies Depression Scale, Pittsburgh sleep quality index. Based on the Cochrane Assessment tool and Physiotherapy Evidence Database scale, a modified assessment form should be used to evaluate the methodological quality. Review Manager 5.3 was used for data analysis and risk of bias.

RESULTS AND CONCLUSION

We provide some more practical and targeted results examine the effect of Qigong exercises for PSMDs and PSSDs in the relative meta-analysis. We find out defects or inadequacies of Qigong in previous studies. The findings of this research will provide more evidence-based guidance in clinical practice and more rigorous study.International Platform of Registered Systematic Review and Meta-Analysis Protocols (INPLASY) registration number: INPLASY202070051.

Life-Space Mobility and Relevant Factors in Community-dwelling Individuals with Stroke in Japan: A Cross-sectional Study

Objective

Individuals with stroke frequently experience mobility deficits and limited community reintegration. This study aimed to investigate life-space mobility and relevant factors in community-living individuals with stroke.

Methods

This was a cross-sectional study of 46 community-dwelling individuals with chronic stroke in Japan (mean age 72.7 ± 7.4 years; mean time post-stroke 63.6 ± 43.3 months; 26 men/20 women). We measured life-space mobility using a Japanese translation of the Life-Space Assessment. The following factors that might affect life-space mobility were assessed: the ability to perform activities of daily living, physical performance, fear of falling, and cognitive function.

Results

A total of 41 participants (89.1%) had restricted life-space mobility (Life-Space Assessment score <60 points). A multiple linear regression analysis showed that limitations in activities of daily living, walking speed, and Falls Efficacy Scale-International scores were independently related to Life-Space Assessment scores. This model explained 51.3% of the variance in Life-Space Assessment scores.

Conclusions

Most individuals with stroke had restricted life-space mobility. Life-space mobility was associated with the ability to perform activities of daily living, walking speed, and fear of falling. These findings could contribute to the development of rehabilitation interventions for regaining life-space mobility in individuals with stroke.

Differences in self-perceived general health, pain, and depression 1 to 5 years post-stroke related to work status at 1 year

Stroke is one of the most common diseases and has several potential consequences, such as psychological problems and pain. Return to work (RTW) after stroke in working-age individuals is incomplete. The present study aimed to investigate differences in self-perceived general health, pain, and depression between 1 and 5 years post-stroke related to RTW status. The study was nationwide, registry-based and the study population (n = 398) consisted of working-age people who had a stroke in 2011 and participated in 1-year and 5-year follow-up questionnaire surveys. Shift analyses with the Wilcoxon signed rank test and logistic regression were used. RTW within the first year post-stroke was associated with better self-perceived general health, less pain, and less depression both at 1 and 5 years post-stroke, compared with the no-RTW group. However, the RTW group had significant deterioration in general health and pain between 1 and 5 years, while the no-RTW group had no significant change. RTW was a significant predictor of lower odds of improvement in general health and pain between 1 and 5 years. This emphasizes the need for continued follow-up and support to ensure a balance between work and health for RTW individuals after stroke.

A SCANO Nomogram for Individualized Prediction of the Probability of 1-Year Unfavorable Outcomes in Chinese Acute Ischemic Stroke Patients

Background and Purpose: Accurate prediction of functional outcomes after stroke would provide evidence for reasonable poststroke management. This study aimed to develop and validate a nomogram for individualized prediction of 1-year unfavorable outcomes in Chinese acute ischemic stroke (AIS) patients.

Methods: We gathered AIS patients at the National Advanced Stroke Center of Nanjing First Hospital (China) between August 2014 and May 2017 within 12 h of symptom onset. The outcome measure was 1-year unfavorable outcomes (modified Rankin Scale 3–6). The patients were randomly stratified into the training (66.7%) and testing (33.3%) sets. With the training data, pre-established predictors were entered into a logistic regression model to generate the nomogram. Predictive performance of the nomogram model was evaluated in the testing data by calculating the area under the receiver operating characteristic curve (AUC-ROC), Brier score, and a calibration plot.

Results: A total of 807 patients were included into this study, and 262 (32.5%) of them had unfavorable outcomes. Systolic blood pressure, Creatinine, Age, National Institutes of Health Stroke Scale (NIHSS) score on admission, and fasting blood glucose were significantly associated with unfavorable outcomes and entered into the SCANO nomogram. The AUC-ROC of the SCANO nomogram in the testing set was 0.781 (Brier score: 0.166; calibration slope: 0.936; calibration intercept: 0.060).

Conclusions: The SCANO nomogram is developed and validated in Chinese AIS patients to firstly predict 1-year unfavorable outcomes, which is simple and convenient for the management of stroke patients.

Can inspiratory muscle training benefit patients after stroke? A systematic review and meta-analysis of randomized controlled trials

Objectives:

The aim of this study was to investigate the effects of inspiratory muscle training in post-stroke patients and to explore the effective training protocol.

Data sources:

PubMed/Medline, Web of Science, Scopus, Embase, Cochrane database, China National Knowledge Infrastructure, and China Science Periodical Database were searched through April 2020.

Review methods:

Trials examining effects of inspiratory muscle training on pulmonary function, cardiopulmonary endurance, pulmonary infection incidence, and quality of life in post-stroke patients were included. Subgroup analysis was performed to compare different training programs. Mean differences and risk ratios with 95% confidence intervals were presented. Risk of bias was assessed with the Cochrane tool.

Results:

Thirteen randomized controlled trials involving a total of 373 participants were identified. Meta-analysis conducted in 8 out of 13 trials revealed evidence for beneficial effects of inspiratory muscle training on forced vital capacity (MD: 0.47, 95% CI: 0.28–0.66), forced expired volume in 1 second (MD: 0.26, 95% CI: 0.18–0.35), 6-minute walk test (MD: 52.61, 95% CI: 25.22–80.01), maximum inspiratory pressure (MD: 18.18, 95% CI: 5.58–30.78), inspiratory muscle endurance (MD: 19.99, 95% CI: 13.58–26.40), and pulmonary infection incidence (RR: 0.11, 95% CI: 0.03–0.40). Omitting individual trials from the meta-analysis did not significantly change the results. The effective inspiratory muscle training protocol was suggested by subgroup analysis with three repetitions per week and more than 20 minutes per day for three weeks.

Conclusion:

Inspiratory muscle training can be considered as an effective intervention for improving pulmonary function and cardiopulmonary endurance, and reducing pulmonary infection incidence in patients after stroke.

Phase I/II Study of Safety and Preliminary Efficacy of Intravenous Allogeneic Mesenchymal Stem Cells in Chronic Stroke

Background and Purpose- Stroke is a leading cause of long-term disability. Limited treatment options exist for patients with chronic stroke and substantial functional deficits. The current study examined safety and preliminary efficacy estimates of intravenous allogeneic mesenchymal stem cells in this population. Methods- Entry criteria included ischemic stroke >6 months prior and substantial impairment (National Institutes of Health Stroke Scale score ≥6) and disability. Enrollees received a single intravenous dose of allogeneic ischemia-tolerant mesenchymal stem cells. Phase 1 used a dose-escalation design (3 tiers, n=5 each). Phase 2 was an expanded safety cohort. The primary end point was safety over 1-year. Secondary end points examined behavioral change. Results- In phase 1 (n=15), each dose (0.5, 1.0, and 1.5 million cells/kg body weight) was found safe, so phase 2 subjects (n=21) received 1.5 million cells/kg. At baseline, subjects (n=36) averaged 4.2±4.6 years poststroke, age 61.1±10.8 years, National Institutes of Health Stroke Scale score 8 (6.5-10), and Barthel Index 65±29. Two were lost to follow-up, one was withdrawn and 2 died (unrelated to study treatment). Of 15 serious adverse events, none was possibly or probably related to study treatment. Two mild adverse events were possibly related to study treatment, a urinary tract infection and intravenous site irritation. Treatment was safe based on serial exams, electrocardiograms, laboratory tests, and computed tomography scans of chest/abdomen/pelvis. All behavioral end points showed significant gains over the 12-months of follow-up. For example, Barthel Index scores increased by 6.8±11.4 points (mean±SD) at 6-months (P=0.002) and by 10.8±15.5 points at 12-months (P<0.001) post-infusion; the proportion of patients achieving excellent functional outcome (Barthel score ≥95) increased from 11.4% at baseline to 27.3% at 6-months and to 35.5% at 12-months. Conclusions- Intravenous transfusion of allogeneic ischemia-tolerant mesenchymal stem cell in patients with chronic stroke and substantial functional deficits was safe and suggested behavioral gains. These data support proceeding to a randomized, placebo-controlled study of this therapy in this population. Clinical Trial Registration- URL: https://www.clinicaltrials.gov. Unique identifier: NCT01297413.

Association between fulfilling the recommendations for health-enhancing physical activity with (instrumental) activities of daily living in older Austrians

Aim

The aim of the study was to describe the association between fulfilling the recommendation for health-enhancing physical activity (PA), and deficits in activities of daily living (ADL) and instrumental activities of daily living (IADL) in 3308 subjects aged 65+ years from the Austrian Health Interview Survey 2014.

Methods

The proportion of subjects who fulfilled the minimal recommendations for health-enhancing PA was assessed with the Physical Activity Questionnaire of the European Health Interview Survey (EHIS-PAQ). The ADLs were assessed based on the Barthel index, and IADLs by the IADL scale of Lawton and Brody. Additionally, various sociodemographic and health-related factors were assessed.

Results

Of the participants 54.7% did not fulfil the minimal requirements for aerobic PA, and 67.1% not for muscle strengthening PA, 16.4% reported ADL deficits, and 47.1% IADL deficits. Adjusted for sociodemographic and health-related parameters, not fulfilling the recommendations for aerobe PA was associated with a higher chance for ADL deficits (odds ratio, OR 1.73, 95%-confidence interval 1.36–2.21), and IADL deficits (1.57; 1.34–1.84). Not fulfilling the recommendations for muscle strengthening PA also increased the chance for ADL and IADLs deficits (1.34; 1.04–1.72, and 1.29; 1.09–1.53, respectively).

Conclusion

The number of participants who did not fulfil the minimal requirements for aerobic or strengthening PA was very high, and these participants showed significantly more problems in ADLs and IADLs. Therefore, all future efforts should focus on increasing participation and adherence in exercise programs for older people with the intention to improve their performance status and functions in daily life.

Validation and responsiveness of the Late-Life Function and Disability Instrument Computerized Adaptive Test in community-dwelling stroke survivors

BACKGROUND

Follow-up of stroke survivors is important to objectify activity limitations and/or participations restrictions. Responsive measurement tools are needed with a low burden for professional and patient.

AIM

To examine the concurrent validity, floor and ceiling effects and responsiveness of both domains of the Late-Life Function and Disability Index Computerized Adaptive Test (LLFDI-CAT) in first-ever stroke survivors discharged to their home setting.

DESIGN

Longitudinal study.

SETTING

Community.

POPULATION

First ever stroke survivors.

METHODS

Participants were visited within three weeks after discharge and six months later. Stroke Impact Scale (SIS 3.0) and Five-Meter Walk Test (5MWT) outcomes were used to investigate concurrent validity of both domains, activity limitations, and participation restriction, of the LLFDI-CAT. Scores at three weeks and six months were used to examine floor and ceiling effects and change scores were used for responsiveness. Responsiveness was assessed using predefined hypotheses. Hypotheses regarding the correlations with change scores of related measures, unrelated measures, and differences between groups were formulated.

RESULTS

The study included 105 participants. Concurrent validity (R) of the LLFDI-CAT activity limitations domain compared with the physical function domain of the SIS 3.0 and with the 5MWT was 0.79 and -0.46 respectively. R of the LLFDI-CAT participation restriction domain compared with the participation domain of the SIS 3.0 and with the 5MWT was 0.79 and -0.41 respectively. A ceiling effect (15%) for the participation restriction domain was found at six months. Both domains, activity limitations and participation restrictions, of the LLFDI-CAT, scored well on responsiveness: 100% (12/12) and 91% (12/11) respectively of the predefined hypotheses were confirmed.

CONCLUSIONS

The LLFDI-CAT seems to be a valid instrument and both domains are able to detect change over time. Therefore, the LLFDI-CAT is a promising tool to use both in practice and in research.

CLINICAL REHABILITATION IMPACT

The LLFDI-CAT can be used in research and clinical practice.