Granulocyte Colony Stimulating Factor and Physiotherapy after Stroke: Results of a Feasibility Randomised Controlled Trial: Stem Cell Trial of Recovery EnhanceMent after Stroke-3 (STEMS-3 ISRCTN16714730)

Background

Granulocyte-colony stimulating factor (G-CSF) mobilises endogenous haematopoietic stem cells and enhances recovery in experimental stroke. Recovery may also be dependent on an enriched environment and physical activity. G-CSF may have the potential to enhance recovery when used in combination with physiotherapy, in patients with disability late after stroke.

Methods

A pilot 2 x 2 factorial randomised (1:1) placebo-controlled trial of G-CSF (double-blind), and/or a 6 week course of physiotherapy, in 60 participants with disability (mRS >1), at least 3 months after stroke. Primary outcome was feasibility, acceptability and tolerability. Secondary outcomes included death, dependency, motor function and quality of life measured 90 and 365 days after enrolment.

Results

Recruitment to the trial was feasible and acceptable; of 118 screened patients, 92 were eligible and 32 declined to participate. 60 patients were recruited between November 2011 and July 2013. All participants received some allocated treatment. Although 29 out of 30 participants received all 5 G-CSF/placebo injections, only 7 of 30 participants received all 18 therapy sessions. G-CSF was well tolerated but associated with a tendency to more adverse events than placebo (16 vs 10 patients, p = 0.12) and serious adverse events (SAE) (9 vs 3, p = 0.10). On average, patients received 14 (out of 18 planned) therapy sessions, interquartile range [12, 17]. Only a minority (23%) of participants completed all physiotherapy sessions, a large proportion of sessions (114 of 540, 21%) were cancelled due to patient (94, 17%) and therapist factors (20, 4%). No significant differences in functional outcomes were detected in either the G-CSF or physiotherapy group at day 90 or 365.

Conclusions

Delivery of G-CSF is feasible in chronic stroke. However, the study failed to demonstrate feasibility for delivering additional physiotherapy sessions late after stroke therefore a definitive study using this trial design is not supported. Future work should occur earlier after stroke, alongside on-going clinical rehabilitation.

Trial Registration

ISRCTN.com ISRCTN16714730

Very early mobilization after stroke fast-tracks return to walking: further results from the phase II AVERT randomized controlled trial

BACKGROUND AND PURPOSE

regaining functional independence is an important goal for people who have experienced stroke. We hypothesized that introducing earlier and more intensive out-of-bed activity after stroke would reduce time to unassisted walking and improve independence in activities of daily living.

METHODS

a Very Early Rehabilitation Trial (AVERT) was a phase II randomized controlled trial. Patients with confirmed stroke (infarct or hemorrhage) admitted <24 hours after stroke and who met physiological safety criteria were eligible. Patients randomized to the very early and intensive mobilization group were mobilized within 24 hours of stroke and at regular intervals thereafter. Control patients received standard stroke unit care. The primary outcome for this analysis was the number of days required to return to walking 50 m unassisted. Secondary outcomes were the Barthel Index and Rivermead Motor Assessment at 3 and 12 months after stroke.

RESULTS

seventy-one stroke patients with a mean age of 74.7 years were recruited from 2 hospitals. Adjusted Cox regression indicated that very early and intensive mobilization group patients returned to walking significantly faster than did standard stroke unit care controls (P=0.032; median 3.5 vs 7.0 days). Multivariable regression revealed that exposure to very early and intensive mobilization was independently associated with good functional outcome on the Barthel Index at 3 months (P=0.008) and on the Rivermead Motor Assessment at 3 (P=0.050) and 12 (P=0.024) months.

CONCLUSIONS

earlier and more intensive mobilization after stroke may fast-track return to unassisted walking and improve functional recovery. Clinical Trial Registration- This trial was not registered because enrollment began before July 2005.

The Stroke Activity Scale: Results of a validity study

PURPOSE

To establish the concurrent validity and time to complete of the Stroke Activity Scale (SAS) a recently developed stroke motor disability scale designed for use in a busy clinical setting.

METHOD

Forty-one stroke patients with residual hemiplegia were recruited and assessed on a single occasion using both the SAS (five items) and modified Motor Assessment Scale (MMAS) (eight items) by a research physiotherapist. Performance was videotaped and assessed subsequently by a second physiotherapist.

RESULTS

Pearson's correlation coefficient between the two measures was 0.91. The SAS was significantly quicker to complete than the MMAS (2.8 vs. 10.4 min, p < 0.0001).

CONCLUSION

The SAS had high concurrent validity with the MMAS but was much quicker to complete and therefore more suitable for use in clinical environments where time is at a premium.

Issues for selection of outcome measures in stroke rehabilitation: ICF activity

PURPOSE

To evaluate the psychometric and administrative properties of outcome measures in the WHO International Classification of Functioning, Disability and Health (ICF) Activity category used in stroke rehabilitation research and reported in the published literature.

METHOD

Critical review and synthesis of measurement properties for nine commonly reported instruments in the stroke rehabilitation literature. Each instrument was rated using the eight evaluation criteria proposed by the UK Health Technology Assessment (HTA) programme. The instruments were also assessed for the rigour with which their reliability, validity and responsiveness were reported in the published literature.

RESULTS

The reporting of specific measurement qualities for outcome instruments was relatively consistent across measures located within the same general ICF category. There was evidence to suggest that the measures were responsive to change as well as being valid and reliable tools. The best available instruments were associated with the assessment of activities of daily living, balance (static and dynamic), functional independence, and functional mobility.

CONCLUSIONS

Given the diversity that exists among available measures, the reader is encouraged to examine carefully the nature and scope of outcome measurement used in reporting the strength of evidence for improved functional activity in stroke rehabilitation. However, there appears to be good consensus regarding the most important indicators of successful rehabilitation outcome, especially in the case of functional mobility.

The Relationship Between Balance, Disability, and Recovery After Stroke: Predictive Validity of the Brunel Balance Assessment

Objective. To examine the influence of balance disability on function and the recovery of function after stroke and consequently to assess the predictive validity of the Brunel Balance Assessment (BBA). Methods. Cross-sectional study of 102 patients admitted consecutively to 6 National Health Service hospitals with weakness 2 to 4 weeks after their first anterior circulation stroke; 75 of whom completed follow-up assessment at 3 months. The BBA was assessed during admission and compared to the Barthel Index and Rivermead Mobility Index at 3 months. Results. Balance disability was the strongest predictor of function (in terms of activities of daily living [ADLs] and mobility disability) in the acute stages. Weakness was also an independent predictor. Recovery of ADLs was independently predicted by balance disability, weakness, age, and premorbid disability, whereas recovery of mobility disability was predicted by balance and age alone. At 3 months, a minority of people with limited sitting balance (0%-22%) and standing balance (25%-50%) recovered independent functional mobility. Most people who could walk initially recovered independent functional mobility (66%-84%), but 16% suffered a decline in their mobility and 44% had enduring limitations in everyday mobility activities. Conclusion. Initial balance disability is a strong predictor of function and recovery after stroke. These results demonstrate the predictive validity of the BBA.

The support taken through walking aids during hemiplegic gait

OBJECTIVE

To assess the effect of different aids on the amount of support hemiplegic subjects took from them. The relationship between the amount of support, severity of hemiplegia and walking ability were also assessed.

DESIGN

Hemiplegic subjects' gait and the amount of support they took from the aid were measured as they walked with a normal height stick, a high stick and a tripod.

SUBJECTS

Fifteen subjects with a hemiplegia of more than three months' duration who could walk independently were recruited.

OUTCOME MEASURES

Velocity, the gross function section of the Rivermead Motor Assessment, percentage bodyweight taken through the aid, the aid contact time, the placement of the aid, and the lateral shift of the pelvis when weight bearing were assessed.

RESULTS

No differences in the amount of support or walking ability were found with the different aids. There was a significant relationship between severity of hemiplegia and the percentage of bodyweight taken through the aid (r= -0.67), between aid contact time and severity of hemiplegia (-0.53) and between aid contact time and walking ability (-0.53). No relationship between walking ability and other measures of the amount of support was found.

CONCLUSIONS

Different types of aid did not influence the amount of support taken by hemiplegic subjects. These results contradict the beliefs of many neurological physiotherapists in Britain and the clinical implications are discussed.

Single blind randomized controlled trial of visual feedback after stroke: effects on stance symmetry and function

A number of before and after and single case design studies of visual feedback have shown improvements in stance symmetry after stroke, an associated improvement in function has been demonstrated. This study examines this promising technique further using a single-blind controlled trial. Twenty-six patients were recruited from a register of consecutive admissions and randomized into treatment and control groups. Both groups received additional therapy, only the treatment group received visual feedback. Assessments were carried out independently. Significant improvements were seen in the treatment group in measures of stance symmetry and sway and motor and ADL function. Between group differences had disappeared at three months. The results indicate that feedback training incorporated into functional physiotherapy treatment can improve stance symmetry and sway. Transfer of training was indicated by improvements in ADL and gross motor function. Three months later the improvement was maintained, but did not automatically continue without treatment.

The scalability of the Rivermead Motor Assessment in acute stroke patients

OBJECTIVE

To examine the scalability of the Rivermead Motor Assessment with hospitalized acute stroke patients.

DESIGN

This was a prospective study of hospitalized stroke patients.

SUBJECTS

Fifty-one selected stroke patients, including those over the age of 65, were assessed at one, three and six weeks post-stroke using the Rivermead Motor Assessment. Coefficients of scalability and reproducibility were calculated for each of the three sections of the Rivermead Motor Assessment at each assessment.

RESULTS

The items in the gross function and arm sections met scaling criteria at all three assessments which meant that they were in appropriate order of difficulty. There was an overall increase in the proportion of subjects passing each item at successive assessments, suggesting that patients in the study were recovering. The leg and trunk section did not meet scale criteria with these acute stroke patients.

CONCLUSIONS

We recommend that only the gross function and arm sections should be used as hierarchical scales with selected acute stroke patients. The leg and trunk section should only be used as an assessment checklist.

The Rivermead Mobility Index: a further development of the Rivermead Motor Assessment

This paper reports on a development of the Rivermead Motor Assessment Gross Function scale, the Rivermead Mobility Index (RMI), a new measure of mobility disability which concentrates on body mobility. An early development included a second scale concentrating on elective mobility, but the results showed this to be unreliable. The RMI comprises a series of 14 questions and one direct observation, and covers a range of activities from turning over in bed to running. Its inter-observer reliability was tested on two groups of patients (n = 23 and 20 respectively) and it is reliable to a limit of 2 points (out of 15). Its validity as a measure of mobility after head injury and stroke was tested by concurrent measurement of mobility using gait speed and endurance, and by standing balance. The RMI does form a scale. It is short, simple, and clinically relevant, and can be used in hospital or at home.