Veterans Affairs/Department of Defense Clinical Practice Guideline for the Management of Adult Stroke Rehabilitation Care: executive summary

Developing post-stroke psychometric properties for an Adherence to rehabilitation regimen scale: A sequential exploratory mixed-method study

INTRODUCTION

Adherence to rehabilitation in patients post-stroke plays a significant role in the effectiveness of rehabilitation and patient recovery. This study aimed to design and determine the psychometric properties of a scale for measuring adherence to the rehabilitation regimen in patients post-stroke in the Iranian community.

METHODS

The present study used a sequential exploratory mixed method and was conducted in two phases (phase one qualitative and phase two quantitative). Participants in the first phase were patients post-stroke, caregivers, and rehabilitation team members (n=20). The second phase was conducted on patients post-stroke (n=198), and the psychometric steps, including face, content, and construct validity, as well as reliability, were assessed.

RESULTS

The Adherence to Rehabilitation Regimen Scale (ARRS)was designed with 26 items and four factors of participation: 1) physical exercises, 2) following prescribed regimens, 3) performing the activities of daily living, and 4) psychological follow-up. The internal consistency was 0.96 by calculating Cronbach's alpha coefficient. The Interclass Correlation Coefficient was 0.99 with a confidence interval of 0.96-0.99.

CONCLUSION

The scale measuring adherence to the rehabilitation regimen in patients post-stroke has optimal psychometric properties. Therefore, as the first specific scale to measure the degree of rehabilitation regimen adherence in patients post-stroke, this tool may be beneficial for other rehabilitation programs interested in managing and improving program adherence.

Association of homocysteine and polymorphism of methylenetetrahydrofolate reductase with early-onset post stroke depression

Background

Homocysteine (Hcy) has been indicated to be involved in pathophysiology of post stroke depression (PSD). There is a lack of research to study the relationship between Hcy metabolism genes and PSD. Our study aims to investigate the relationship among Hcy metabolism genes, Hcy, and early-onset PSD.

Materials and methods

We recruited 212 patients with stroke and collected their peripheral blood sample, clinical data, and laboratory test on admission. 12 single nucleotide polymorphisms (SNPs) in methylenetetrahydrofolate reductase (MTHFR), methionine synthase reductase (MTRR), and methionine synthase (MTR) genes were genotyped by high-resolution melt analysis. PSD was diagnosed by DSM-V at 2 weeks after stroke. Binary logistic regression and haplotype analysis were used to examine the association between Hcy metabolism genes and PSD. Mediation analysis was performed to clarify whether the SNPs exerted their effect on PSD by affecting the Hcy level.

Results

81 patients were diagnosed with PSD, and the incidence rate was 38.2%. Hcy level in PSD group was significantly higher than it in non-PSD group (p = 0.019). MTHFR rs1801133 AA genotype an A allele were associated with an elevated risk of PSD after adjustment for some confounding factors (OR = 4.021, 95% CI: 1.459∼11.080, p = 0.007 for AA genotype; OR = 1.808, 95% CI: 1.172∼2.788, p = 0.007 for A allele). Furthermore, the effect of MTHFR rs1801133 AA genotype on PSD was mediated by Hcy (OR = 1.569, 95% CI: 0.013∼3.350, p < 0.05).

Conclusion

MTHFR rs1801133 and Hcy were associated with PSD, and MTHFR rs1801133 may exert an effect on PSD via mediating Hcy level. This offers a new perspective for treating PSD and understanding the mechanism of PSD.

A unilateral robotic knee exoskeleton to assess the role of natural gait assistance in hemiparetic patients

Background

Hemiparetic gait is characterized by strong asymmetries that can severely affect the quality of life of stroke survivors. This type of asymmetry is due to motor deficits in the paretic leg and the resulting compensations in the nonparetic limb. In this study, we aimed to evaluate the effect of actively promoting gait symmetry in hemiparetic patients by assessing the behavior of both paretic and nonparetic lower limbs. This paper introduces the design and validation of the REFLEX prototype, a unilateral active knee–ankle–foot orthosis designed and developed to naturally assist the paretic limbs of hemiparetic patients during gait.

Methods

REFLEX uses an adaptive frequency oscillator to estimate the continuous gait phase of the nonparetic limb. Based on this estimation, the device synchronically assists the paretic leg following two different control strategies: (1) replicating the movement of the nonparetic leg or (2) inducing a healthy gait pattern for the paretic leg. Technical validation of the system was implemented on three healthy subjects, while the effect of the generated assistance was assessed in three stroke patients. The effects of this assistance were evaluated in terms of interlimb symmetry with respect to spatiotemporal gait parameters such as step length or time, as well as the similarity between the joint’s motion in both legs.

Results

Preliminary results proved the feasibility of the REFLEX prototype to assist gait by reinforcing symmetry. They also pointed out that the assistance of the paretic leg resulted in a decrease in the compensatory strategies developed by the nonparetic limb to achieve a functional gait. Notably, better results were attained when the assistance was provided according to a standard healthy pattern, which initially might suppose a lower symmetry but enabled a healthier evolution of the motion of the nonparetic limb.

Conclusions

This work presents the preliminary validation of the REFLEX prototype, a unilateral knee exoskeleton for gait assistance in hemiparetic patients. The experimental results indicate that assisting the paretic leg of a hemiparetic patient based on the movement of their nonparetic leg is a valuable strategy for reducing the compensatory mechanisms developed by the nonparetic limb.

Vitamin D as therapeutic modulator in cerebrovascular diseases: a mechanistic perspectives

Vitamin D deficiency has been linked to several major chronic diseases, such as cardiovascular and neurodegenerative diseases, diabetes, and cancer, linked to oxidative stress, inflammation, and aging. Vitamin D deficiency appears to be particularly harmful to the cardiovascular system, as it can cause endothelial dysfunctioning and vascular abnormalities through the modulation of various downstream mechanisms. As a result, new research indicates that therapeutic approaches targeting vitamin D inadequacies or its significant downstream effects, such as impaired autophagy, abnormal pro-inflammatory and pro-oxidant reactions, may delay the onset and severity of major cerebrovascular disorders such as stroke and neurologic malformations. Vitamin D modulates the various molecular pathways, i.e., Nitric Oxide, PI3K-Akt Pathway, cAMP pathway, NF-kB Pathway, Sirtuin 1, Nrf2, FOXO, in cerebrovascular disorder. The current review shows evidence for vitamin D's mitigating or slowing the progression of these cerebrovascular disorders, which are significant causes of disability and death worldwide.

Towards universal health coverage for people with stroke in South Africa: a scoping review

OBJECTIVES

To explore the opportunities and challenges within the health system to facilitate the achievement of universal health coverage (UHC) for people with stroke (PWS) in South Africa (SA).

SETTING

SA.

DESIGN

Scoping review.

SEARCH METHODS

We conducted a scoping review of opportunities and challenges to achieve UHC for PWS in SA. Global and Africa-specific databases and grey literature were searched in July 2020. We included studies of all designs that described the healthcare system for PWS. Two frameworks, the Health Systems Dynamics Framework and WHO Framework, were used to map data on governance and regulation, resources, service delivery, context, reorientation of care and community engagement. A narrative approach was used to synthesise results.

RESULTS

Fifty-nine articles were included in the review. Over half (n=31, 52.5%) were conducted in Western Cape province and most (n=41, 69.4%) were conducted in urban areas. Studies evaluated a diverse range of health system categories and various outcomes. The most common reported component was service delivery (n=46, 77.9%), and only four studies (6.7%) evaluated governance and regulation. Service delivery factors for stroke care were frequently reported as poor and compounded by context-related limiting factors. Governance and regulations for stroke care in terms of government support, investment in policy, treatment guidelines, resource distribution and commitment to evidence-based solutions were limited. Promising supporting factors included adequately equipped and staffed urban tertiary facilities, the emergence of Stroke units, prompt assessment by health professionals, positive staff attitudes and care, two clinical care guidelines and educational and information resources being available.

CONCLUSION

This review fills a gap in the literature by providing the range of opportunities and challenges to achieve health for all PWS in SA. It highlights some health system areas that show encouraging trends to improve service delivery including comprehensiveness, quality and perceptions of care.

Long-term Functional Outcomes for World Federation of Neurosurgical Societies Grade V Aneurysmal Subarachnoid Hemorrhage after Active Treatment

This study investigated the long-term outcomes of patients with World Federation of Neurosurgical Societies (WFNS) grade V aneurysmal subarachnoid hemorrhage (SAH) who underwent early aneurysm repair. We evaluated consecutive patients with WFNS grade V aneurysmal SAH from April 2010 to March 2015 who underwent aneurysm repair within 72 h after onset. We assessed the functional outcomes at discharge and 3 years after onset using the modified Rankin Scale (mRS). The primary outcome was defined as a favorable functional outcome (mRS ≤2). We identified 145 patients with grade V SAH during the study period. Of these, 44 patients (19 males and 25 females; median age, 64 years; range, 24–79 years) met the inclusion criteria. For aneurysm repair, surgical clipping and coiling were performed in 40 (90.9%) and 4 (9.1%) patients, respectively. Although no patient had a favorable functional outcome at discharge, 11 (25.0%) patients had a favorable functional outcome at the end of follow-up. The number of patients with a favorable outcome significantly increased during the first year (P = 0.012) and during the follow-up period (P <0.001). Patients who underwent active rehabilitation had significant improvement. Our study showed that one-fourth of the patients who underwent early aneurysm repair with WFNS grade V SAH achieved a mRS score of ≤2 over a 3-year period. It might be important to consider age and rehabilitation for better clinical outcomes. Larger studies are required to adequately assess the long-term functional outcomes and other multi-faceted prognoses.

Adherence to a Rehabilitation Regimen in Stroke Patients: A Concept Analysis

BACKGROUND

Adherence to rehabilitation regimens is a major issue in the treatment of stroke. Despite the agreement on the importance of adherence, there is still no clear definition of this concept in rehabilitation. The aim of this study was the concept analysis of the concept of adherence to rehabilitation regimens in stroke patients.

MATERIALS AND METHODS

This qualitative concept analysis was performed using Walker and Avant's method. English and Persian articles were searched using keywords such as "adherence", "compliance", "rehabilitation", "stroke", and other related keywords among articles published from 1997 to 2018 in PubMed, Scopus, Web of Science, Google Scholar, Iranmedex, Magiran, and Scientific Information Database (SID). Related textbooks were also searched and all articles containing definitions, attributes, antecedents, and consequences of the concept were included in the study.

RESULTS

The attributes of the concept included complex, multidimensional, and dynamic behavior in the treatment process, personal experience, and adaptive behavior in patients, changeable, situational, voluntary, and collaborative behavior, and active communication between the patient and the healthcare provider. Common antecedents of the concept of adherence to the rehabilitation regimen were classified into patient-related and environmental-related categories and the consequences were classified into the three categories of patient-related, healthcare professional-related, and healthcare system-related.

CONCLUSIONS

This concept analysis can be useful in eliminating any ambiguity of the concept of adherence to rehabilitation regimens. It helps clarify the vague concepts used in nursing rehabilitation instead of adherence. The results of this study can be helpful for researchers for further studies in this context.

Quantitative Assessment of Upper Limb Motor Function in Ethiopian Acquired Brain Injured Patients Using a Low-Cost Wearable Sensor

Acquired brain injuries place a significant burden on sub-Saharan African rehabilitation clinicians and health care facilities. While wearable sensors have the potential to alleviate these issues, many are beyond the financial capabilities of the majority of African persons and clinics. To bridge this gap, we have developed a low-cost wrist-worn sensor (the outREACH sensor) capable of accurately measuring upper limb movement kinematics. In this study we evaluated the extent to which the outREACH sensor is sensitive to the hand performing the task (unimpaired, impaired) and level of impairment (mild, moderate) in 14 Ethiopian persons with acquired brain injury (mean age = 51.6 ± 12.2 years, 1 female, 13 male). Participants performed an object manipulation task with both the impaired and the unimpaired limb, and reaching performance was measured using standard kinematic measures (i.e., movement time, spectral arc length, peak velocity, peak acceleration, mean velocity, mean acceleration). Overall, movements were smoother and faster when performed by the patient's unimpaired limb. In contrast, maximum velocity did not differ between the two limbs. Moreover, the outREACH sensor was sensitive to differences in performance-based upper limb impairment. Fugl-Meyer assessment for upper extremity scores were significantly correlated with movement time, spectral arc length, and peak velocity. Upper limb movement kinematics can be accurately measured using the outREACH sensor. The outREACH sensor can be a valuable addition to standardized clinical measures that provides rehabilitation clinicians with information regarding initial upper limb impairment level and changes in function across the rehabilitation lifespan.

Factors affecting adherence to rehabilitation in Iranian stroke patients: A qualitative study

Adherence to rehabilitation has significant effects on patient outcomes. This study aimed to explore factors affecting adherence to rehabilitation in Iranian stroke patients. This is a descriptive, qualitative study. This study was conducted in 2018. Participants were stroke patients, family members, and rehabilitation team members-20 in total. They were purposively recruited from Rofaideh inpatient rehabilitation center in Tehran, and the outpatient physiotherapy center of Poursina hospital in Rasht. Data collection was performed through semistructured interviews and was continued up to data saturation. Data were analyzed by content analysis technique. Factors affecting adherence to rehabilitation in stroke patients were categorized into four main categories, namely patients-related, rehabilitation team, rehabilitation systems, and insurance and social support systems factors. Health care providers can promote patients' adherence to rehabilitation, involvement in the process of treatment, and their quality of life through broadening patients' knowledge about rehabilitation effectiveness, strengthening communication with health care providers, and adequate insurance and social support.

Relationships between Occupational Therapy Practitioner Characteristics and Home Exercise Program Prescription for Clients with Neurological Injuries

There are no guidelines for the prescription of home exercise programs (HEPs) for clients with neurological injuries. However, 95% of occupational therapy practitioners prescribe HEPs. Two thousand anonymous surveys were distributed to occupational therapy practitioners. Data from the 352 returned, usable surveys were analyzed to determine trends in HEP prescription across practice settings and provider demographics. Occupational therapy practitioners in community-based settings tended to use more functional activities and the number of years in practice did not influence HEP dosage. These findings suggest a need for clear guidelines for varying practice settings to guide HEP prescription.

Construct validity of the NIH Toolbox Cognition Battery in individuals with stroke

OBJECTIVE

The National Institutes of Health (NIH) Toolbox (NIHTB) for the Assessment of Behavior and Neurological Function Cognition Battery (NIHTB-CB) provides a brief assessment (approximately 30 min) of key components of cognition. This article examines construct validity to support the clinical utility of the NIHTB-CB in individuals with stroke.

RESEARCH METHOD

A total of 131 individuals with stroke (n = 71 mild stroke; n = 60 moderate/severe stroke) completed the NIHTB-CB. Univariate analyses were conducted to examine the cognitive profiles of the two different stroke groups (mild vs. moderate/severe stroke) on NIHTB-CB measures and composite scores. Pearson correlations were conducted between NIHTB-CB and established measures to examine convergent and discriminant validity. Effect sizes and clinical impairment rates for the different NIHTB-CB measures and composite scores were also examined.

RESULTS

Participants experiencing moderate to severe stroke had poorer performance than did individuals with mild stroke on several of the NIHTB cognition measures. Evidence of convergent validity was provided by moderate to strong correlations between the NIHTB measures and the corresponding standard neuropsychological test (Pearson rs ranged from 0.31 to 0.88; median = .60). Evidence of discriminant validity was provided by smaller correlations between different cognitive domains than correlations of measures within the same domain. Effect sizes for composite and subtest scores regarding stroke severity were generally moderate-to-large. In addition, 42% of the sample were exhibiting mild cognitive impairment (i.e., ≥2 low scores on fluid tests).

CONCLUSIONS

Findings provide support for the construct validity of the NIHTB-CB in individuals with stroke. (PsycINFO Database Record

Community-Based Rehabilitation to Improve Stroke Survivors' Rehabilitation Participation and Functional Recovery

OBJECTIVE

The aim of this study was to evaluate the effectiveness of a community-based rehabilitation appropriate technique (CRAT) intervention program in increasing rehabilitation participation and improving functional recovery of stroke survivors.

DESIGN

This study followed a quasi-experimental design. In each of 5 centers servicing approximately 50,000 individuals, 2 communities were designated as either the intervention or control community. A CRAT intervention program, including 2-year rehabilitation education and 3-month CRAT treatment, was regularly implemented in the intervention communities, whereas there was no special intervention in the control community. Two sampling surveys, at baseline and after intervention, were administered to evaluate the rehabilitation activity undertaken. In intervention communities, stroke survivor's motor function, daily activity, and social activity were evaluated pretreatment and posttreatment, using the Fugl-Meyer Motor Function Assessment, Barthel index, and Social Functional Activities Questionnaire.

RESULTS

The proportion of individuals participating in rehabilitation-related activity was increased significantly (P < 0.05) in intervention communities, as compared with control communities. In intervention communities, the patients' Fugl-Meyer Motor Function Assessment, Barthel index, and Social Functional Activities Questionnaire scores were significantly improved after rehabilitation (P < 0.05) across all ages and disease courses, except for the FAQ scores in patients younger than 50 years (P > 0.05).

CONCLUSIONS

Community-based rehabilitation appropriate technique increases rehabilitation participation rates and enhances motor function, daily activity, and social activity of stroke survivors.

Predictive validity of the functional independence and difficulty scale in community-dwelling Japanese older adults

[Purpose] The newly developed Functional Independence and Difficulty Scale is a tool for assessing the performance of basic activities of daily living in terms of both independence and difficulty. The aim of this study was to examine the predictive validity of the scale for decline of instrumental activities of daily living ability and multiple falls during a 24-month follow-up period. [Subjects and Methods] One-hundred forty older adults (median age 74.0, 60% women) completed baseline data collection and a follow-up postal survey. At baseline, background variables, the Functional Independence and Difficulty Scale, and instrumental activities of daily living ability assessed by the five sub-items of Tokyo Metropolitan Institute of Gerontology Index of Competence were recorded. At follow-up, data on instrumental activities of daily living ability and falls in the previous 12 months were obtained. [Results] Of the 140 participants, 15 (10.7%) declined in instrumental activities of daily living ability and 14 (10.0%) experienced multiple falls. The Functional Independence and Difficulty Scale at baseline independently predicted decline of instrumental activities of daily living ability and multiple falls. [Conclusion] The Functional Independence and Difficulty Scale predicts subsequent decline of instrumental activities of daily living ability and multiple falls.

Outcomes of Botulinum Toxin Type A for equinovarus deformity in patients with CVA: A case series

BACKGROUND

There is evidence that Botulinum Toxin-A (BTX-A) reduces focal spasticity associated with equinovarus to improve gait in patients poststroke. However, there is little research examining whether gait improvements are maintained after the effectiveness period of BTX-A injections. The purpose of this observational study was to determine whether there was a difference in gait parameters in three patients before BTX-A injection versus four and ten weeks after.

CASE SERIES

Three women, ages 63, 60, and 42 postischemic stroke with hemiparesis and equinovarus underwent measurements for: plantar flexor spasticity, ankle dorsiflexion ROM, temporal-spatial gait parameters, and gait endurance. All participants improved in ankle ROM. At week 10, spasticity had returned to initial measurement levels in participants A and C. Base of support and step length symmetry ratios did not improve following injections. Participants A and B, who received physical therapy during the study, showed modest gains in gait endurance and velocity.

CONCLUSION

Although BTX-A injections improved spasticity, this improvement did not translate to gait outcomes. Addition of physical therapy interventions appeared to improve gait outcomes in this case series. We suggest future randomized control studies to compare effects of physical therapy alone to BTX-A combined with physical therapy on gait outcomes.

Comparison of the measurement properties of the Functional Independence and Difficulty Scale with the Barthel Index in community-dwelling elderly people in Japan

BACKGROUND

The new Functional Independence and Difficulty Scale (FIDS) is a tool for assessing the performance of basic activities of daily living (BADL). Because many BADL measures already exist, it is important to know whether FIDS can offer added benefit over the existing measures.

AIMS

This study compared measurement properties between the FIDS and a representative BADL assessment tool, the Barthel Index (BI).

METHODS

Recruitment of the participants was done on the basis of convenience sampling. Participants were community-dwelling elderly Japanese subjects (n = 314; age ≥65 years) divided into a healthy elderly group [n = 225; subjects not using long-term care insurance (LTCI) services] and frail elderly group (n = 89; subjects using LTCI services). For each group, ceiling effect (percent participation with the maximum score) was calculated, and it was compared between the two scales. Associations between the FIDS, BI and Medical Outcomes Study Short Form 8 Health Survey (SF-8) were evaluated by Spearman correlation coefficient and partial correlations. Partial correlations coefficients to SF-8 were compared between the two scales.

RESULTS

FIDS showed a relatively small ceiling effect compared to the BI. Compared to the BI, FIDS showed a significant positive partial correlation with the broader aspect of the SF-8 subscales, but the strength of correlation between FIDS and SF-8 was weak to negligible.

CONCLUSIONS

The FIDS might be less affected by ceiling effect than the BI. Additional studies using a sufficient number of probability samples are needed to clarify whether FIDS has any benefit over BI in terms of correlations with the SF-8.

Regional variation in post-stroke multidisciplinary rehabilitation care among veteran residents in community nursing homes

INTRODUCTION

Effective post-acute multidisciplinary rehabilitation therapy improves stroke survivors' functional recovery and daily living activities. The US Department of Veterans Affairs (VA) places veterans needing post-acute institutional care in private community nursing homes (CNHs). These placements are made under the same rules and regulations across the VA health care system and through individual per diem contracts between local VA facilities and CNHs. However, there is limited information about utilization of these veterans' health services as well as the geographic variation of the service utilization.

AIM

The aims of this study were to determine rehabilitation therapy and restorative nursing care utilization by veterans with stroke in VA-contracted CNHs and to assess risk-adjusted regional variations in the utilization of rehabilitation therapy and restorative nursing care.

METHODS

This retrospective study included all veterans diagnosed with stroke residing in VA-contracted CNHs between 2006 and 2009. Minimum Dataset (a health status assessment tool for CNH residents) for the study CNHs was linked with veterans' inpatient and outpatient data within the VA health care system. CNHs were grouped into five VA-defined geographic regions: the North Atlantic, Southeast, Midwest, Continental, and Pacific regions. A two-part model was applied estimating risk-adjusted utilization probability and average weekly utilization days. Two dependent variables were rehabilitation therapy and restorative nursing care utilization by veterans during their CNH stays.

RESULTS

The study comprised 6,206 veterans at 2,511 CNHs. Rates for utilization of rehabilitation therapy and restorative nursing care were 75.7% and 30.1%, respectively. Veterans in North Atlantic and Southeast CNHs were significantly (p<0.001) more likely to receive rehabilitation therapies than veterans from other regions. However, veterans in Southeast CNHs were significantly (p<0.001) less likely to receive restorative nursing care compared with veterans in all other regions, before and after risk adjustment.

CONCLUSION

The majority of veterans with stroke received rehabilitation therapy, and about one-third had restorative nursing care during their stay at VA-contracted CNHs. Significant regional variations in weekly days for rehabilitation therapy and restorative nursing care utilization were observed even after adjusting for potential risk factors.

The Effect of Peripheral Nerve Stimulation on Shoulder Biomechanics: A Randomized Controlled Trial in Comparison to Physical Therapy

OBJECTIVE

To establish the effects on shoulder biomechanics from a peripheral nerve stimulation (PNS) treatment compared to physical therapy (PT) in stroke survivors with chronic hemiplegic shoulder pain.

DESIGN

Single-site, pilot, randomized controlled trial for adults with chronic shoulder pain after stroke. Participants were randomized to receive a 3-week treatment of single-lead PNS or physical therapy (PT). The outcomes included isometric shoulder abduction strength, pain-free shoulder external rotation range of motion (ROM), delay in initiation and termination of shoulder abduction electromyogram (EMG) activity, and the Fugl-Meyer Motor Assessment (upper extremity section). Outcomes were measured at baseline, and at weeks 1, 4, 12, and 16.

RESULTS

Twenty-five participants were recruited, 13 to PNS and 12 to PT. There were significant improvements for both PNS and PT in maximum isometric shoulder abduction strength, pain-free external rotation ROM, and Fugl-Meyer Motor Assessment. There were no significant changes in delay of initiation or termination of deltoid EMG with either treatment.

CONCLUSIONS

Both PNS and PT are capable of improving shoulder biomechanics in those with HSP, though changes in biomechanics alone do not account for the greater pain relief associated with PNS than PT.

Poststroke Rehabilitation and Restorative Care Utilization: A Comparison Between VA Community Living Centers and VA-contracted Community Nursing Homes

BACKGROUND

Effective poststroke rehabilitation care can speed patient recovery and minimize patient functional disabilities. Veterans affairs (VA) community living centers (CLCs) and VA-contracted community nursing homes (CNHs) are the 2 major sources of institutional long-term care for Veterans with stroke receiving care under VA auspices.

OBJECTIVES

This study compares rehabilitation therapy and restorative nursing care among Veterans residing in VA CLCs versus those Veterans in VA-contracted CNHs.

RESEARCH DESIGN

Retrospective observational.

SUBJECTS

All Veterans diagnosed with stroke, newly admitted to the CLCs or CNHs during the study period who completed at least 2 Minimum Data Set assessments postadmission.

MEASURES

The outcomes were numbers of days for rehabilitation therapy and restorative nursing care received by the Veterans during their stays in CLCs or CNHs as documented in the Minimum Data Set databases.

RESULTS

For rehabilitation therapy, the CLC Veterans had lower user rates (75.2% vs. 76.4%, P=0.078) and fewer observed therapy days (4.9 vs. 6.4, P<0.001) than CNH Veterans. However, the CLC Veterans had higher adjusted odds for therapy (odds ratio=1.16, P=0.033), although they had fewer average therapy days (coefficient=-1.53±0.11, P<0.001). For restorative nursing care, CLC Veterans had higher user rates (33.5% vs. 30.6%, P<0.001), more observed average care days (9.4 vs. 5.9, P<0.001), higher adjusted odds (odds ratio=2.28, P<0.001), and more adjusted days for restorative nursing care (coefficient=5.48±0.37, P<0.001).

CONCLUSION

Compared with their counterparts at VA-contracted CNHs, Veterans at VA CLCs had fewer average rehabilitation therapy days (both unadjusted and adjusted), but they were significantly more likely to receive restorative nursing care both before and after risk adjustment.

Early medical rehabilitation after neurosurgical treatment of malignant brain tumours in Slovenia

Background

The number of patients with malignant brain tumours is on the rise, but due to the novel treatment methods the survival rates are higher. Despite increased survival the consequences of tumour properties and treatment can have a significant negative effect on the patients’ quality of life. Providing timely and appropriate rehabilitation interventions is an important aspect of patient treatment and should be started immediately after surgery. The most important goal of rehabilitation is to prevent complications that could have a negative effect on the patients’ ability to function.

Conclusions

By using individually tailored early rehabilitation it is often possible to achieve the patients’ independence in mobility as well as in performing daily tasks before leaving the hospital. A more precise evaluation of the patients’ functional state after completing additional oncologic therapy should be performed to stratify the patients who should be directed to complex rehabilitation treatment. The chances of a good functional outcome in patients with malignant brain tumours could be increased with good early medical rehabilitation treatment.

A Design Methodology for Medical Processes

BACKGROUND

Healthcare processes, especially those belonging to the clinical domain, are acknowledged as complex and characterized by the dynamic nature of the diagnosis, the variability of the decisions made by experts driven by their experiences, the local constraints, the patient's needs, the uncertainty of the patient's response, and the indeterminacy of patient's compliance to treatment. Also, the multiple actors involved in patient's care need clear and transparent communication to ensure care coordination.

OBJECTIVES

In this paper, we propose a methodology to model healthcare processes in order to break out complexity and provide transparency.

METHODS

The model is grounded on a set of requirements that make the healthcare domain unique with respect to other knowledge domains. The modeling methodology is based on three main phases: the study of the environmental context, the conceptual modeling, and the logical modeling.

RESULTS

The proposed methodology was validated by applying it to the case study of the rehabilitation process of stroke patients in the specific setting of a specialized rehabilitation center. The resulting model was used to define the specifications of a software artifact for the digital administration and collection of assessment tests that was also implemented.

CONCLUSIONS

Despite being only an example, our case study showed the ability of process modeling to answer the actual needs in healthcare practices. Independently from the medical domain in which the modeling effort is done, the proposed methodology is useful to create high-quality models, and to detect and take into account relevant and tricky situations that can occur during process execution.

Association of Rehabilitation Intensity for Stroke and Risk of Hospital Readmission

BACKGROUND

Little is known about the use of rehabilitation in the acute care setting and its impact on hospital readmissions.

OBJECTIVE

The objective of this study was to examine the association between the intensity of rehabilitation services received during the acute care stay for stroke and the risk of 30-day and 90-day hospital readmission.

DESIGN

A retrospective cohort analysis of all acute care hospitals in Arkansas and Florida was conducted.

METHODS

Patients (N=64,065) who were admitted for an incident stroke in 2009 or 2010 were included. Rehabilitation intensity was categorized as none, low, medium-low, medium-high, or high based on the sum and distribution of physical therapy, occupational therapy, and speech therapy charges within each hospital. Cox proportional hazards regression was used to estimate hazard ratios, controlling for demographic characteristics, illness severity, comorbidities, hospital variables, and state.

RESULTS

Relative to participants who received the lowest intensity therapy, those who received higher-intensity therapy had a decreased risk of 30-day readmission. The risk was lowest for the highest-intensity group (hazard ratio=0.86; 95% confidence interval=0.79, 0.93). Individuals who received no therapy were at an increased risk of hospital readmission relative to those who received low-intensity therapy (hazard ratio=1.30; 95% confidence interval=1.22, 1.40). The findings were similar, but with smaller effects, for 90-day readmission. Furthermore, patients who received higher-intensity therapy had more comorbidities and greater illness severity relative to those who received lower-intensity therapy.

LIMITATIONS

The results of the study are limited in scope and generalizability. Also, the study may not have adequately accounted for all potentially important covariates.

CONCLUSIONS

Receipt of and intensity of rehabilitation therapy in the acute care of stroke is associated with a decreased risk of hospital readmission.

Warm Needling Therapy and Acupuncture at Meridian-Sinew Sites Based on the Meridian-Sinew Theory: Hemiplegic Shoulder Pain

This study was performed to evaluate the effectiveness and safety of warm needling acupuncture at meridian-sinew sites based on the meridian-sinew theory in the treatment of hemiplegic shoulder pain (HSP) after stroke. In total, 124 subjects were randomized into a treatment group and control group. In the treatment group, warm needling therapy and acupuncture at meridian-sinew sites based on the meridian-sinew theory were performed. In the control group, usual care therapy was applied. The visual analog scale (VAS) score, range of motion (ROM), and Barthel index (BI) were used to evaluate treatment effectiveness. At 2 weeks of treatment, the VAS score, ROM, and BI had obviously changed from baseline in the two groups (P < 0.01). The changes in the VAS score and ROM in the treatment group were significantly greater than those in the control group (P < 0.01). At the 3-month follow-up after treatment, the changes in the treatment group were significantly greater than those in the control group (P < 0.01). This study indicates that warm needling therapy with acupuncture at meridian-sinew sites based on the meridian-sinew theory is effective for HSP.

Fully implantable peripheral nerve stimulation for the treatment of hemiplegic shoulder pain: a case report

This case report describes the first participant treated with a fully implantable, single-lead peripheral nerve stimulation system for refractory hemiplegic shoulder pain. During the 6-wk trial stage, a temporary lead was placed percutaneously near the terminal branches of the axillary nerve to the deltoid. The primary outcome measure was the Brief Pain Inventory-Short Form Question 3, a 0-10 pain numeric rating scale. The participant experienced 75% pain reduction and proceeded to the implantation stage, where he received a single-lead, implantable pulse generator. After 3 wks, the participant became pain-free. However, 7 wks after implantation, the system was turned off because of an unrelated acute medical illness. Hemiplegic shoulder pain reemerged with a Brief Pain Inventory-Short Form Question 3 score of 9. After 11 wks of recovery, peripheral nerve stimulation was reinitiated and the participant became pain-free through the 9-mo follow-up. At 12 mos, Brief Pain Inventory-Short Form Question 3 score was 1. This case report demonstrates the feasibility of a single-lead, fully implantable peripheral nerve stimulation system for refractory hemiplegic shoulder pain.

Inpatient Stroke Care Quality for Veterans: Are There Differences between Veterans Affairs Medical Centers in the Stroke Belt and other Areas?

Background

Stroke mortality has been found to be much higher among residents in the stroke belt region than in the rest of United States, but it is not known whether differences exist in the quality of stroke care provided in Department of Veterans Affairs medical centers in states inside and outside this region.

Objective

We compared mortality and inpatient stroke care quality between Veterans Affairs medical centers inside and outside the stroke belt region.

Methods

Study patients were veterans hospitalized for ischemic stroke at 129 Veterans Affairs medical centers. Inpatient stroke care quality was assessed by 14 quality indicators. Multivariable logistic regression models were fit to examine differences in quality between facilities inside and outside the stroke belt, adjusting for patient characteristics and Veterans Affairs medical centers clustering effect.

Results

Among the 3909 patients, 28·1% received inpatient ischemic stroke care in 28 stroke belt Veterans Affairs medical centers, and 71·9% obtained care in 101 non-stroke belt Veterans Affairs medical centers. Patients cared for in stroke belt Veterans Affairs medical centers were more likely to be younger, Black, married, have a higher stroke severity, and less likely to be ambulatory pre-stroke. We found no statistically significant differences in short- and long-term post-admission mortality and inpatient care quality indicators between the patients cared for in stroke belt and non-stroke belt Veterans Affairs medical centers after risk adjustment.

Conclusions

These data suggest that a stroke belt does not exist within the Veterans Affairs health care system in terms of either post-admission mortality or inpatient care quality.

Post-Stroke Consultation Service: A Nurse-Managed Model for Care Delivery

In 1989, a multidisciplinary consultation service devoted to providing primary care and rehabilitative care services to stroke survivors in the home was developed and tested at the University of Pennsylvania. This nurse-managed service, Post-Stroke Consultation Service, used the expertise of a nurse practitioner, geriatrician, physiatrist, physical therapists, home health care nurses, specialty care providers, families, and stroke survivors to develop and implement a plan of care that optimized health and function and would be sustainable over time. The service and its impact are described.

Comprehensive versus consultative rehabilitation services postacute stroke: Outcomes differ

Comprehensive rehabilitation services postacute stroke have been shown efficacious in European trials; however, their effectiveness in everyday practices in the United States is unknown. We compared outcomes of veteran patients provided with comprehensive rehabilitation with those provided with consultative rehabilitation services postacute stroke using propensity scores. Outcomes included change in patients' physical and cognitive independence after rehabilitation, discharge to home as opposed to other settings, and 1-yr posthospital discharge survival. Of the 2,963 patients in the study, 683 (23.1%) received comprehensive rehabilitation while the remaining patients received consultative services. We found, after propensity adjustment, that those who received comprehensive rehabilitation compared with consultative gained on average 12.8 (95% confidence interval [CI]: 9.1 to 16.5) more points of physical independence on a 78-point scale and gained 1.5 (95% CI: 0.8 to 2.2) more points of cognitive independence on a 30-point scale. The likelihoods of discharge to home from the hospital (odds ratio [OR] = 1.61, 95% CI: 1.07 to 2.44) and 1-yr posthospital discharge survival (OR = 1.79, 95% CI: 1.25 to 2.56) were significantly higher among those who received comprehensive rehabilitation. Among patients hospitalized for acute stroke, comprehensive rehabilitation services are associated with greater recovery of physical and cognitive independence, improved home discharge likelihood, and improved 1-yr survival.

Serial treatments of primed low-frequency rTMS in stroke: characteristics of responders vs. nonresponders

PURPOSE

This study analyzed the characteristics of responders vs. nonresponders in people with stroke receiving a novel form of repetitive transcranial magnetic stimulation (rTMS) to improve hand function.

METHODS

Twelve people with stroke received five treatments of 6-Hz primed low-frequency rTMS to the contralesional primary motor area. We compared demographic factors, clinical features, and the ipsilesional/contralesional volume ratio of selected brain regions in those who improved hand performance (N = 7) on the single-hand component of the Test Évaluant la performance des Membres supérieurs des Personnes Âgées (TEMPA) and those who showed no improvement (N = 5).

RESULTS

Responders showed significantly greater baseline paretic hand function on the TEMPA, greater preservation volume of the ipsilesional posterior limb of the internal capsule (PLIC), and lower scores (i.e., less depression) on the Beck Depression Inventory than nonresponders. There were no differences in age, sex, stroke duration, paretic side, stroke hemisphere, baseline resting motor threshold for ipsilesional primary motor area (M1), NIH Stroke Scale, Upper Extremity Fugl-Meyer, Mini-Mental State Examination, or preservation volume of M1, primary somatosensory area, premotor cortex, or supplementary motor area.

CONCLUSION

Our results support that preserved PLIC volume is an important influential factor affecting responsiveness to rTMS.

Assessing and treating higher level somatosensory impairments post stroke

Poststroke somatosensory impairment is prevalent, yet commonly used clinical measures lack the sensitivity needed to quantify impairment and detect change due to intervention. This selective review, prepared and presented as a part of the I-Treat Conference (June 22, 2013, Columbus, Ohio), discusses the prevalence of somatosensory impairment after stroke, highlights measures of higher level somatosensory processing, and briefly reviews sensorimotor rehabilitation. The goal of this article is to encourage dialogue regarding the development and use of measures of higher level somatosensory function that will enable personalization of sensorimotor rehabilitation.

Predictors of Percutaneous Endoscopic Gastrostomy Tube Placement after Stroke

Aims:

the goal of this study was to identify important prognostic variables affecting placement of a percutaneous endoscopic gastrostomy (Peg) tube after acute stroke.

Methods:

We retrospectively reviewed our patient database to identify acute ischemic stroke patients who placed Peg or nasogastric tube (Ngt) tube, but were free of other confounding conditions affecting swallowing. A total of 340 patients were involved in our study. We assessed the influence of age, National Institutes of Health stroke scale (NIHss) score, infarct volume, stroke subtype based on the toAst criteria, swallowing disorders, bilateral lesions in cerebrum and length of stay (los) in a logistic regression analysis.

Results:

In univariate analysis, age (p=0.048), NIHss score (p<0.0001), lesion volume (p<0.0001), los (p<0.0001), stroke location (p=0.045), and swallowing disorders (p<0.0001) were found to be the primary predictors of placing Peg. the presence of lesions in bilateral cerebral was included in the final model based on clinical considerations. After multivariate adjustment, only NIHss score (odds ratio [oR], 4.055; 95% confidence interval [CI], 2.398-6.857; p=0.0001), lesion volume (oR, 1.69; 95%CI, 1.09–4.39; p=0.014), swallowing disorders (oR, 1.151; 95% CI, 1.02-1.294; p=0.047), los (oR, 0.955; 95% CI, 0.914-0.998; p=0.0415) and bilateral lesions (oR, 2.8; 95% CI, 1.666-4.705; p=0.0001) remained significant.

Conclusion:

our data shows that NIHss score, lesion volume, swallowing disorders, los and bilateral lesions in cerebrum can predict the requiring of Peg tube insertion in patients after stroke.

Identification of dysphagia using the Toronto Bedside Swallowing Screening Test (TOR-BSST©): are 10 teaspoons of water necessary?

Dysphagia screening often includes administration of water. This study assessed the accuracy in identifying dysphagia with each additional teaspoon of water. The original research of the TOR-BSST(©) permitted this assessment. Trained nurses from acute and rehabilitation facilities prospectively administered the TOR-BSST(©) to 311 eligible stroke inpatients. A sensitivity analysis was conducted for the water item using 10 teaspoons plus a sip as the standard. The proportion of positive screenings was 59.2% in acute and 38.5% in rehabilitation. Of all four items that form the TOR-BSST(©), the water swallow item contributed to the identification of dysphagia in 42.7% in acute and 29.0% in rehabilitation patients. Across all patients, dysphagia accuracy was that five teaspoons resulted in a sensitivity of 79% (95% confidence interval [CI] = 70-86), eight a sensitivity of 92% (95% CI = 85-96) and 10 a sensitivity of 96% (95% CI = 90-99). Although a primary contributor, the water swallow item alone does not identify all patients with dysphagia. For a water swallow to accurately identify dysphagia, it is critical to administer 10 teaspoons. The TOR-BSST(©) water swallow item contributes largely to the total TOR-BSST(©)'s screening score and in making the test highly accurate and reliable.

Peripheral nerve stimulation compared with usual care for pain relief of hemiplegic shoulder pain: a randomized controlled trial

OBJECTIVE

This study sought to establish the efficacy of single-lead, 3-wk peripheral nerve stimulation (PNS) therapy for pain reduction in stroke survivors with chronic hemiplegic shoulder pain.

DESIGN

This study is a single-site, pilot, randomized controlled trial of adults with chronic shoulder pain after stroke. Participants were randomized to receive a 3-wk treatment of single-lead PNS or usual care. The primary outcome was the worst pain in the last week (Brief Pain Inventory, Short Form, question 3) measured at baseline and weeks 1, 4, 12, and 16. The secondary outcomes included pain interference (Brief Pain Inventory, Short Form, question 9), pain measured by the ShoulderQ Visual Graphic Rating Scales, and health-related quality-of-life (Short-Form 36 version 2).

RESULTS

Twenty-five participants were recruited, 13 to PNS and 12 to usual care. There was a significantly greater reduction in pain for the PNS group compared with the controls, with significant differences at 6 and 12 wks after treatment. Both PNS and usual care were associated with significant improvements in pain interference and physical health-related quality-of-life.

CONCLUSIONS

Short-term PNS is a safe and efficacious treatment of shoulder pain. Pain reduction is greater compared with usual care and is maintained for at least 12 wks after treatment.

Tai Chi-based exercise program provided via telerehabilitation compared to home visits in a post-stroke population who have returned home without intensive rehabilitation: study protocol for a randomized, non-inferiority clinical trial

Background

The incidence of strokes in industrialized nations is on the rise, particularly in the older population. In Canada, a minority of individuals who have had a stroke actually receive intensive rehabilitation because most stroke patients do not have access to services or because their motor recovery was judged adequate to return home. Thus, there is a considerable need to organize home-based rehabilitation services for everyone who has had a stroke. To meet this demand, telerehabilitation, particularly from a service center to the patient’s home, is a promising alternative approach that can help improve access to rehabilitation services once patients are discharged home.

Methods/Design

This non-inferiority study will include patients who have returned home post-stroke without requiring intensive rehabilitation. To be included in the study, participants will: 1) not be referred to an Intensive Functional Rehabilitation Unit, 2) have a Rankin score of 2 or 3, and 3) have a balance problem (Berg Balance Scale score between 46 and 54). Participants will be randomly assigned to either the teletreatment group or the home visits group. Except for the delivery mode, the intervention will be the same for both groups, that is, a personalized Tai Chi-based exercise program conducted by a trained physiotherapist (45-minute session twice a week for eight consecutive weeks). The main objective of this research is to test the non-inferiority of a Tai Chi-based exercise program provided via telerehabilitation compared to the same program provided in person at home in terms of effectiveness for retraining balance in individuals who have had a stroke but do not require intensive functional rehabilitation. The main outcome of this study is balance and mobility measured with the Community Balance and Mobility Scale. Secondary outcomes include physical and psychological capacities related to balance and mobility, participants’ quality of life, satisfaction with services received, and cost-effectiveness associated with the provision of both types of services.

Study/trial registration

ClinicalTrials.gov: NCT01848080

Is motor-imagery brain-computer interface feasible in stroke rehabilitation?

In the past 3 decades, interest has increased in brain-computer interface (BCI) technology as a tool for assisting, augmenting, and rehabilitating sensorimotor functions in clinical populations. Initially designed as an assistive device for partial or total body impairments, BCI systems have since been explored as a possible adjuvant therapy in the rehabilitation of patients who have had a stroke. In particular, BCI systems incorporating a robotic manipulanda to passively manipulate affected limbs have been studied. These systems can use a range of invasive (ie, intracranial implanted electrodes) or noninvasive neurophysiologic recording techniques (ie, electroencephalography [EEG], near-infrared spectroscopy, and magnetoencephalography) to establish communication links between the brain and the BCI system. Trials are most commonly performed on EEG-based BCI in comparison with the other techniques because of its high temporal resolution, relatively low setup costs, portability, and noninvasive nature. EEG-based BCI detects event-related desynchronization/synchronization in sensorimotor oscillatory rhythms associated with motor imagery (MI), which in turn drives the BCI. Previous evidence suggests that the process of MI preferentially activates sensorimotor regions similar to actual task performance and that repeated practice of MI can induce plasticity changes in the brain. It is therefore postulated that the combination of MI and BCI may augment rehabilitation gains in patients who have had a stroke by activating corticomotor networks via MI and providing sensory feedback from the affected limb using end-effector robots. In this review we examine the current literature surrounding the feasibility of EEG-based MI-BCI systems in stroke rehabilitation. We also discuss the limitations of using EEG-based MI-BCI in patients who have had a stroke and suggest possible solutions to overcome these limitations.

Comparative kinematic and electromyographic assessment of clinician- and device-assisted sit-to-stand transfers in patients with stroke

BACKGROUND

Workplace injuries from patient handling are prevalent. With the adoption of no-lift policies, sit-to-stand transfer devices have emerged as one tool to combat injuries. However, the therapeutic value associated with sit-to-stand transfers with the use of an assistive apparatus cannot be determined due to a lack of evidence-based data.

OBJECTIVE

The aim of this study was to compare clinician-assisted, device-assisted, and the combination of clinician- and device-assisted sit-to-stand transfers in individuals who recently had a stroke.

DESIGN

This cross-sectional, controlled laboratory study used a repeated-measures design.

METHODS

The duration, joint kinematics, and muscle activity of 4 sit-to-stand transfer conditions were compared for 10 patients with stroke. Each patient performed 4 randomized sit-to-stand transfer conditions: clinician-assisted, device-assisted with no patient effort, device-assisted with the patient's best effort, and device- and clinician-assisted.

RESULTS

Device-assisted transfers took nearly twice as long as clinician-assisted transfers. Hip and knee joint movement patterns were similar across all conditions. Forward trunk flexion was lacking and ankle motion was restrained during device-assisted transfers. Encouragement and guidance from the clinician during device-assisted transfers led to increased lower extremity muscle activation levels.

LIMITATIONS

One lifting device and one clinician were evaluated. Clinician effort could not be controlled.

CONCLUSIONS

Lack of forward trunk flexion and restrained ankle movement during device-assisted transfers may dissuade clinicians from selecting this device for use as a dedicated rehabilitation tool. However, with clinician encouragement, muscle activation increased, which suggests that it is possible to safely practice transfers while challenging key leg muscles essential for standing. Future sit-to-stand devices should promote safety for the patient and clinician and encourage a movement pattern that more closely mimics normal sit-to-stand biomechanics.

Intrathecal Administration of Autologous CD34 Positive Cells in Patients with Past Cerebral Infarction: A Safety Study

Regenerative strategies in treatment of stroke have great potential. The goal of the current study was to investigate safety of intrathecal administration of autologous CD34 positive cells in treatment of patients with poststroke. A total of eight male patients with a history of stroke were enrolled. The patients were treated subcutaneously with 5 μg/kg body weight rhG-CSF for 5 consecutive days, and then leukapheresis was performed to concentrate cells for CD34 positive immunoselection. All patients underwent intrathecal administration of CD34 positive cells via lumbar puncture. The primary outcome was safety evaluation for 12-month followup. In addition, behavioral function was evaluated with NIH stroke scale and Barthel index 1, 6, and 12 months after the last treatment, respectively. There were no major adverse events, and abnormal changes of blood tests during the whole treatment process included intrathecal administration and 12-month followup. The main message from the current study was that administration of G-CSF-mobilized autologous CD34 positive cells in patients with poststroke was safe. Future studies with larger population and control group are needed to confirm the safety and investigate the efficacy.

Implementation of stroke Dysphagia screening in the emergency department

Early detection of dysphagia is critical in stroke as it improves health care outcomes. Administering a swallowing screening tool (SST) in the emergency department (ED) appears most logical as it is the first point of patient contact. However, feasibility of an ED nurse-administered SST, particularly one involving trial water swallow administration, is unknown. The aims of this pilot study were to (1) implement an SST with a water swallow component in the ED and track nurses' adherence, (2) identify barriers and facilitators to administering the SST through interviews, and (3) develop and implement a process improvement plan to address barriers. Two hundred seventy-eight individuals with stroke symptoms were screened from October 2009 to June 2010. The percentage of patients screened increased from 22.6 in October 2009 to a high of 80.8 in March 2010, followed by a decrease to 61.9% in June (Cochran-Armitage test z = −5.1042,  P < 0.0001). The odds of being screened were 4.0 times higher after implementation compared to two months before implementation. Results suggest that it is feasible for ED nurses to administer an SST with a water swallow component. Findings should facilitate improved quality of care for patients with suspected stroke and improve multidisciplinary collaboration in swallowing screening.

Stroke rehabilitation

Despite improvements in prevention and acute management, stroke remains a common condition and a major cause of permanent disability. For patients who have had a stroke, an effective rehabilitation program is critical to maximize functional recovery and quality of life. Rehabilitation can occur in a number of different physical settings and is often coordinated by a comprehensive interdisciplinary team of professionals. Rehabilitation includes retraining to regain loss of function and teaching compensatory strategies when that is not possible. A number of interesting training approaches have been developed in recent years to supplement more traditional rehabilitation programs. A variety of adaptive devices is available to improve mobility and performance of self-cares, and these devices should be prescribed for appropriate patients. Physicians caring for patients during stroke rehabilitation must be aware of potential medical complications, as well as a number of special problems that may complicate recovery, including dysphagia, urinary incontinence, shoulder pain, spasticity, falls, and poststroke depression. Involvement of the patient and caregivers in the rehabilitation process is essential. It is important to train and educate these individuals in the physical aspects of poststroke care, the expectations for recovery, and secondary stroke prevention. Issues related to community reintegration, including driving and vocational aspects, should be addressed in appropriate patients. Stroke rehabilitation is an important part of the "stroke continuum of care," which includes prevention, acute management, rehabilitation, and secondary prevention.