Pre-stroke socioeconomic status predicts upper limb motor recovery after inpatient neurorehabilitation

BACKGROUND

Lower socioeconomic status (SES) is associated with higher mortality rates and the likelihood of receiving less evidence-based treatment after stroke. In contrast, little is known about the impact of SES on recovery after discharge from inpatient rehabilitation. The aim of this study was to investigate the influence of SES on long-term recovery after stroke.

PATIENTS AND METHODS

In a prospective, observational, multicentre study, inpatients were recruited towards the end of rehabilitation. The 12-month follow-up focussed on upper limb motor recovery, measured by the Fugl-Meyer score. A clinically relevant improvement of ≥5.25 points was considered recovery. Patient-centric measures such as the Patient-reported Outcomes Measurement Information System-Physical Health (PROMIS-10 PH) provided secondary outcomes. Information on schooling, vocational training, income and occupational status pre-stroke entered a multidimensional SES index. Multivariate logistic regression models calculating odds ratios (ORs) and corresponding confidence intervals (CIs) were applied. SES was added to an initial model including age, sex and baseline neurological deficit. Additional exploratory analyses examined the association between SES and outpatient treatment.

RESULTS

One hundred and seventy-six patients were enrolled of whom 98 had SES and long-term recovery data. Model comparisons showed the SES-model superior to the initial model (Akaike information criterion (AIC): 123 vs. 120, Pseudo R²: 0.09 vs. 0.13). The likelihood of motor recovery (OR = 17.12, 95%CI = 1.31; 224.18) and PROMIS-10 PH improvement (OR = 20.76, 95%CI = 1.28; 337.11) were significantly increased with higher SES, along with more frequent use of outpatient therapy (p = .02).

CONCLUSIONS

Higher pre-stroke SES is associated with better long-term recovery after discharge from rehabilitation. Understanding these factors can improve outpatient long-term stroke care and lead to better recovery.KEY MESSAGEHigher pre-stroke socioeconomic status (SES) is associated with better long-term recovery after discharge from rehabilitation both in terms of motor function and self-reported health status.Higher SES is associated with significantly higher utilization of outpatient therapies.Discharge management of rehabilitation clinics should identify and address socioeconomic factors in order to detect individual needs and to improve outpatient recovery. Article registration: clinicaltrials.gov NCT04119479.

Long-term recovery of upper limb motor function and self-reported health: results from a multicenter observational study 1 year after discharge from rehabilitation

Background

Impaired motor functions after stroke are common and negatively affect patients' activities of daily living and quality of life. In particular, hand motor function is essential for daily activities, but often returns slowly and incompletely after stroke. However, few data are available on the long-term dynamics of motor recovery and self-reported health status after stroke. The Interdisciplinary Platform for Rehabilitation Research and Innovative Care of Stroke Patients (IMPROVE) project aims to address this knowledge gap by studying the clinical course of recovery after inpatient rehabilitation.

Methods

In this prospective observational longitudinal multicenter study, patients were included towards the end of inpatient rehabilitation after ischemic or hemorrhagic stroke. Follow-up examination was performed at three, six, and twelve months after enrollment. Motor function was assessed by the Upper Extremity Fugl-Meyer Assessment (FMA), grip and pinch strength, and the nine-hole peg test. In addition, Patient-Reported Outcomes Measurement Information System 10-Question Short Form (PROMIS-10) was included. Linear mixed effect models were fitted to analyze change over time. To study determinants of hand motor function, patients with impaired hand function at baseline were grouped into improvers and non-improvers according to hand motor function after twelve months.

Results

A total of 176 patients were included in the analysis. Improvement in all motor function scores and PROMIS-10 was shown up to 1 year after inpatient rehabilitation. FMA scores improved by an estimate of 5.0 (3.7–6.4) points per year. In addition, patient-reported outcome measures increased by 2.5 (1.4–3.6) and 2.4 (1.4–3.4) per year in the physical and mental domain of PROMIS-10. In the subgroup analysis non-improvers showed to be more often female (15% vs. 55%, p = 0.0155) and scored lower in the Montreal Cognitive Assessment (25 [23–27] vs. 22 [20.5–24], p = 0.0252).

Conclusions

Continuous improvement in motor function and self-reported health status is observed up to 1 year after inpatient stroke rehabilitation. Demographic and clinical parameters associated with these improvements need further investigation. These results may contribute to the further development of the post-inpatient phase of stroke rehabilitation.

Trial registration: The trial is registered at ClinicalTrials.gov (NCT04119479).

Protocol for a multicenter observational prospective study of functional recovery from stroke beyond inpatient rehabilitation - The Interdisciplinary Platform for Rehabilitation Research and Innovative Care of Stroke Patients (IMPROVE)

Introduction

Stroke and its long-term consequences pose major challenges for the lives of those affected and healthcare systems. Neurological rehabilitation therefore primarily attempts to improve function in order to increase independence in activities of daily living, and to enable social participation. There is only scarce data on dynamics of functional recovery after patients discharge from inpatient neurological rehabilitation. Even less is known about the patient's perspective on long-term recovery from stroke. The Interdisciplinary Platform for Rehabilitation Research and Innovative Care of Stroke Patients (IMPROVE) aims to address this knowledge gap by providing new insights into the dynamics and extent of functional recovery from stroke beyond inpatient rehabilitation treatment.

Methods

We provide the protocol for an observational, longitudinal, multicenter study conducted in an Universitary Stroke Center in cooperation with five Neurological Rehabilitation Centers in Northern Germany. Patients who suffered from ischemic or hemorrhagic stroke will be enrolled by the end of inpatient rehabilitation and followed up to 1 year. In addition, a group of chronic stroke patients and a group of craniocerebral trauma patients will be enrolled as a comparison group. Data on stroke characteristics, vascular risk factors, co-morbidities, social support, and demographics will be recorded. Comprehensive clinical evaluation will be performed at baseline, three, six, and twelve months after enrollment. The assessments and scores used reflect the three components of the International Classification of Functioning, Disability and Health (ICF), some of them are tests regularly used in rehabilitation settings. Tests of motor function, cognition, and mood are included, as are tests of self-reported health-related quality of life. Primary outcome measure is a hand motor score, built by the sum of the hand items of the Fugl-Meyer Assessment as an objective measurement of hand function at 12 months after enrollment. Predictors of the primary outcome will be analyzed using linear regression analysis.

Perspective

The results of IMPROVE will inform about the long-term dynamics of functional stroke recovery after patients' discharge from inpatient rehabilitation and will provide insights into the association of clinical and demographic factors with recovery of function.

Trial registration

The protocol is registered at ClinicalTrials.gov (NCT04119479).

The Posterior Cerebral Artery and its Main Cortical Branches Identified with Noninvasive Transcranial Color-Coded Duplex Sonography

PURPOSE

To differentiate PCA segments and cortical branches by means of transcranial color-coded duplex sonography (TCCD) and to measure flow parameters at rest and during visual stimulation.

MATERIALS AND METHODS

60 healthy subjects with a good acoustic temporal bone window were examined. The main stem of the PCA (P1, P2 and P3) and 4 main cortical branches - the anterior temporal artery (ATA), the occipital temporal artery (OTA), the parietooccipital artery (POA) and the calcarine artery (CA) - were assessed using an axial transtemporal approach. Systolic and diastolic blood flow velocities (BFVs) were recorded at rest and during visual stimulation.

RESULTS

Identification of the P1 segment of the PCA was successful in 97.5% (117/120) of cases. The P2 and P3 segments were visualized in all cases. The 4 main cortical branches could be identified to varying degrees: ATA in 88%, OTA in 96%, POA in 69% and CA in 62%. There was an evoked flow response in the P2 main stem and in all cortical branches. The most pronounced increase in diastolic/systolic BFV after visual stimulation test was seen in the CA (42%/35%), followed by P2 (30%/24%), the POA (27%/27%), the OTA (16%/13%) and the ATA (9%/8%).

CONCLUSION

Insonation through the temporal bone window with TCCD confidently allows the assessment of the P1 to P3 segments of the PCA as well as the 2 proximal branches, the ATA and the OTA. An ultrasound-based classification of PCA anatomy and its cortical branches may be used as a noninvasive method for the evaluation of posterior circulation pathology.

Complete basilar artery assessment by transcranial color-coded duplex sonography using the combined transforaminal and transtemporal approach

PURPOSE

Visualization of the basilar artery (BA) by transcranial color-coded duplex sonography (TCCD) can be challenging. The detection of stenosis or occlusion of the BA often has to rely on indirect signs like a highly pulsatile flow in the vertebral arteries. In case of a distal BA occlusion, however, the flow of the VAs can even be normal. The aim of our TCCD study was to visualize a maximum length of the BA combining the customarily used transforaminal appraoch for the proximal part and the less well known transtemporal coronal approach for the distal BA segment.

MATERIALS AND METHODS

TCCD was performed in 60 subjects with a good temporal bone window. Detectable extracranial or intracranial pathology was previously excluded. The BA was insonated using the transforaminal and transtemporal insonation plane and the visible length was measured. In one subject MRA was performed to substantiate our findings.

RESULTS

The BA was visualized in all subjects via both approaches. The maximal detectable BA length via the transforaminal and transtemporal approach was 26 ± 8 mm and 18 ± 5 mm, respectively. Assuming a previously reported average anatomical total BA length of 33 ± 6 mm, we supposed complete vessel visualization in 44 subjects (73 %).

CONCLUSION

The combined transforaminal and transtemporal insonation approach may permit total BA insonation, thus facilitating the evaluation of BA pathology.

Superior cerebellar artery - a potential pitfall in transcranial posterior cerebral artery insonation

PURPOSE

Transcranial color-coded duplexsonography (TCCD) of the posterior cerebral artery (PCA) is commonly performed in an axial midbrain insonation plane. The proximal PCA is easily identified as a vessel, originating from the top of the basilar artery (BA). However, the initial segment of the superior cerebellar artery (SCA) also originates from the top segment of the BA and runs in parallel. Therefore, it is possible to confuse the two vessels. The aim of our study is to anatomically differentiate the proximal PCA and SCA by means of TCCD in the coronal plane using a transtemporal approach and to analyze and compare their flow responses during a visual stimulus paradigm.

MATERIALS AND METHODS

60 subjects without a relevant vascular pathology and with a good temporal bone window were examined. The distal BA, the proximal PCA and the SCA were insonated using a coronal insonation plane and identified by their anatomical relationship. The visible length was measured and the blood flow velocities were recorded at rest and during visual stimulation.

RESULTS

The identification and differentiation of both vessels was successful in 101 of 120 hemispheres (84.2 %). The PCA systolic flow velocities at rest and during visual stimulation were 58.4 +/- 11 and 71.8 +/- 13 cm/sec (23.6 % increase), while the SCA velocities were 50.7 +/- 12 and 53.5 +/- 13 cm/sec, respectively (5.8 % increase). The difference was significant (p < 0.001).

CONCLUSION

Using the coronal transtemporal insonation approach, TCCD makes it possible to identify and distinguish the proximal PCA and SCA. Our study is the first to provide a systematic ultrasound assessment of the SCA and includes data on normal flow velocities and reactivity to a visual stimulus.

Transcranial color-coded sonography successfully visualizes all intracranial parts of the internal carotid artery using the combined transtemporal axial and coronal approach

BACKGROUND AND PURPOSE

Visualization of the intracranial internal carotid artery (ICA) with transcranial color-coded sonography (TCCS) by using the transtemporal coronal plane has been described previously. Because this approach is limited to the vertical running ICA segments, we investigated the feasibility of using TCCS to visualize all intracranial ICA segments by adding the transtemporal axial approach to the coronal plane.

MATERIALS AND METHODS

Subjects with excellent transtemporal acoustic windows were examined by TCCS by using standardized axial and coronal planes. Identification rate, flow velocities, pulsatility and resistance indices, and length (as visible in color-coded power mode) were determined.

RESULTS

A total of 120 intracranial ICAs from 60 subjects were investigated. By switching between the axial and coronal insonation planes, all intracranial segments of the ICA could be investigated in 100% of subjects-with the exception of the horizontal part of the petrosal ICA, which was identified in 96.7% of subjects.

CONCLUSIONS

TCCS becomes a reliable tool in investigating all parts of the intracranial ICA by adding the transtemporal axial approach to the coronal plane.