Racial disparities in the development of dysphagia after stroke: further evidence from the Medicare database

Bussell SA, González-Fernández M. Racial disparities in the development of dysphagia after stroke: further evidence from the Medicare database.

Objective

To describe the relationship between minority race/ethnicity and dysphagia after stroke in a national sample. Unlike the multiple studies that have examined racial disparities in stroke incidence, risk factors, outcomes, and quality of care, the influence of race or ethnicity on dysphagia after stroke has been understudied. We hypothesized that the odds of dysphagia would be higher for Asians compared with Caucasians in the United States given the results of a previous study in the U.S.

Design

Observational study.

Setting

Conducted using the U.S. National Medicare Medical Provider Analysis and Review Data.

Participants

Medicare beneficiaries admitted in 2007 with a stroke diagnosis.

Intervention

We selected 382,959 cases with cerebrovascular disease codes with self-identified race/ethnicity of Caucasian, African American, Asian, Hispanic, Native American, or other/unknown. Cases had a diagnosis of cerebrovascular disease, defined as International Classification of Disease, Ninth Revision codes 430 to 438.9. Self-reported race/ethnicity was recorded in the following categories: Caucasian, African American, Asian, Hispanic, Native American, and other/unknown.

Main Outcome Measure

Dysphagia after stroke as coded in the data.

Results

The adjusted odds ratio (OR) for poststroke dysphagia was higher for Asians and other minority groups compared with Caucasians (Asian: OR, 1.73; 95% confidence interval [CI], 1.60–1.88; Hispanic: OR, 1.50; 95% CI, 1.39–1.63; African American: OR, 1.42; 95% CI, 1.37–1.47; unknown/other: OR, 1.27; 95% CI, 1.16–1.38; Native American; OR, 1.44; 95% CI, 1.22–1.69).

Conclusions

Our findings confirm previous research suggesting an association between Asian race and dysphagia after stroke while adding evidence for increased odds in other racial/ethnic minority groups.     

Racial disparities in outcomes of inpatient stroke rehabilitation

OBJECTIVE: To determine whether race is associated with outcomes of inpatient stroke rehabilitation. DESIGN: Retrospective cohort study. SETTING: A community-based inpatient rehabilitation facility. PARTICIPANTS: Poststroke patients (N=1002) admitted to a community-based inpatient rehabilitation facility between 1995 and 2001. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Functional improvement at discharge from the rehabilitation facility, discharge disposition, and functional improvement at 3 months after discharge. Inpatient and follow-up data were collected from the facility's electronic patient database. We used the FIM instrument to assess functional status at admission, discharge, and follow-up. RESULTS: In multivariable models, blacks achieved less functional improvement at discharge (-1.9 FIM points, P=.02) compared with whites and, despite worse FIM scores, were more likely to be discharged to home (adjusted odds ratio=1.7; 95% confidence interval, 1.1-2.5). Although Asian-American patients did not differ from whites in terms of functional improvement at discharge or disposition, they had less improvement at 3 months following discharge (-6.3 FIM points, P=.005). CONCLUSIONS: We identified racial disparities in poststroke outcomes in a community-based inpatient rehabilitation facility. Future research in stroke rehabilitation should explore the consistency of these findings across settings and if they are confirmed, identify explanatory mediators to better inform efforts to eliminate racial disparities.     

Disparities in postacute rehabilitation care for stroke: an analysis of the state inpatient databases

Freburger JK, Holmes GM, Ku L-JE, Cutchin MP, Heatwole-Shank K, Edwards LJ. Disparities in postacute rehabilitation care for stroke: an analysis of the state inpatient databases.

Objective

To determine the extent to which sociodemographic and geographic disparities exist in the use of postacute rehabilitation care (PARC) after stroke.

Design

Cross-sectional analysis of data for 2 years (2005–2006) from the State Inpatient Databases.

Setting

All short-term acute-care hospitals in 4 demographically and geographically diverse states.

Participants

Individuals (age, ≥45y; mean age, 72.6y) with a primary diagnosis of stroke who survived their inpatient stay (N=187,188). The sample was 52.4% women, 79.5% white, 11.4% black, and 9.1% Hispanic.

Interventions

Not applicable.

Main Outcome Measures

(1) Discharge to an institution versus home. (2) For those discharged to home, receipt of home health (HH) versus no HH care. (3) For those discharged to an institution, receipt of inpatient rehabilitation facility (IRF) or skilled nursing facility (SNF) care. Multilevel logistic regression analyses were conducted to identify sociodemographic and geographic disparities in PARC use, controlling for illness severity/comorbid conditions, hospital characteristics, and PARC supply.

Results

Blacks, women, older individuals, and those with lower incomes were more likely to receive institutional care; Hispanics and the uninsured were less likely. Racial minorities, women, older individuals, and those with lower incomes were more likely to receive HH care; uninsured individuals were less likely. Blacks, women, older individuals, the uninsured, and those with lower incomes were more likely to receive SNF versus IRF care. PARC use varied significantly by hospital and geographic location.

Conclusions

Several sociodemographic and geographic disparities in PARC use were identified.     

Arm motor control as predictor for hypertonia after stroke: a prospective cohort study

de Jong LD, Hoonhorst MH, Stuive I, Dijkstra PU. Arm motor control as predictor for hypertonia after stroke: a prospective cohort study.

Objectives

To analyze the development of hypertonia in the hemiparetic elbow flexors, and to explore the predictive value of arm motor control on hypertonia in a cohort of first-ever stroke survivors in the first 6 months poststroke.

Design

A prospective cohort study.

Setting

A cohort of stroke survivors from a large, university-affilliated hospital in The Netherlands.

Participants

Patients (N=50) with first-time ischemic strokes and initial arm paralysis who were admitted to a stroke unit.

Interventions

Not applicable.

Main Outcome Measures

At 48 hours, 10 to 12 days, 3 and 6 months poststroke, hypertonia and arm motor control were assessed using the Modified Ashworth Scale and the Fugl-Meyer Assessment arm score.

Results

The incidence rate of hypertonia reached its maximum before the third month poststroke (30%). Prevalence was 42% at 3 and 6 months. Participants with poor arm motor control at 48 hours poststroke were 13 times more likely to develop hypertonia in the first 6 months poststroke than those with moderate to good arm motor control. These results were not confounded by the amount of arm function training received.

Conclusions

Hypertonia develops in a large proportion of patients with stroke, predominantly within the first 3 months poststroke. Poor arm motor control is a risk factor for the development of hypertonia.     

Clinical analysis of risk factors for falls in home-living stroke patients using functional evaluation tools

Wada N, Sohmiya M, Shimizu T, Okamoto K, Shirakura K. Clinical analysis of risk factors for falls in home-living stroke patients using functional evaluation tools.

Objectives

To identify risk factors associated with falls in home-living stroke patients and to predict falls using patient information and functional evaluation tools.

Design

Cohort study.

Setting

Community.

Participants

We recruited 101 home-living stroke patients who had hemiparesis and could walk independently with or without supporting devices. Disease duration ranged from 1 to 22 years (mean, 6.1y).

Interventions

Not applicable.

Main Outcome Measures

The score of each item of the Stroke Impairment Assessment Set (SIAS), and the FIM instrument, sex, age, duration of disease, stroke type, affected side of the body, frequency of rehabilitation, use of sedatives, and Mini-Mental State Examination score were evaluated and the occurrence of falls was observed prospectively for 12 months.

Results

Forty-five (44.6%) participants fell, 20 of whom fell repeatedly. A logistic model for predicting falls was refined until it included 4 predictors: memory score on the FIM, range of motion of the lower extremities on the SIAS, duration of disease, and affected side. The predictive value of the logistic model was 86.7%.

Conclusions

Evaluation tools were useful for predicting falls and devising preventive strategies in the high-risk group of home-living stroke patients.     

Selection for inpatient rehabilitation after acute stroke: a systematic review of the literature

Hakkennes SJ, Brock K, Hill KD. Selection for inpatient rehabilitation after acute stroke: a systematic review of the literature.

Objective

To identify patient-related factors that have been found to correlate with functional outcomes post acute stroke to guide clinical decision making with regard to rehabilitation admission after acute stroke.

Data Sources

We systematically searched the scientific literature between 1966 and January 2010. The primary source of studies was the electronic databases Medline, CINAHL, and Embase. The search was supplemented with citation tracking.

Study Selection

Two reviewers independently applied the inclusion criteria to identify relevant articles from the citations obtained through the literature search. Eligible studies included systematic reviews of prognostic indicators, studies of prognostic indicators of acute discharge disposition, and studies of rehabilitation admission criteria after acute stroke. Of the 8895 studies identified, 83 articles, representing 79 studies, were included in the review.

Data Extraction

One reviewer extracted the data relating to the participants, prognostic indicators, and outcomes. A second reviewer independently checked data extracted with disagreement resolved by a third reviewer. Quality of included studies was assessed for internal and external validity.

Data Synthesis

Of the 79 studies, 26 were systematic reviews of prognostic indicators of functional level and/or discharge disposition, 48 were studies of prognostic indicators of acute discharge disposition, and 6 were studies of rehabilitation selection criteria. The methodologic quality of the included studies was generally poor. Age, cognition, functional level after stroke, and, to a lesser extent, continence were found to have a consistent association with outcome across all 3 research areas. In addition, stroke severity was also associated with acute discharge disposition, final discharge disposition, and functional level. Sex and side of stroke appeared to have no association across all 3 of the research areas.

Conclusions

This review highlights a number of important prognostic indicators and rehabilitation selection criteria that may assist clinicians in improving selection procedures and standardizing access to inpatient rehabilitation after stroke, although the quality of many studies is low. Further high quality studies and reviews of prognostic indicators and clinician decision making with regards to rehabilitation acceptance are required.     

Self-reported urinary incontinence in noninstitutionalized long-term stroke survivors: A population-based study

OBJECTIVES: To compare the prevalence of self-reported incontinence among noninstitutionalized long-term stroke survivors with population controls without stroke and to identify risk factors associated with urinary incontinence in the stroke survivors. DESIGN: Community-based, cross-sectional study. SETTING: Municipality of Tronso. PARTICIPANTS: A total of 213 noninstitutionalized stroke survivors (mean time poststroke, 9y) and 242 control subjects. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Self-reported presence of urinary incontinence. RESULTS: Urinary incontinence was present in 17% of the stroke survivors and in 7% of the control subjects (odds ratio [OR]=2.8; 95% confidence interval [CI], 1.5-5.2) and more prevalent among the stroke survivors than among the control subjects until 10 years poststroke. In the stroke survivors, urinary incontinence was associated with signs of depression (OR=3.0; 95% CI, 1.3-7.1) and tended to be associated with motor function of the leg (OR=3.1; 95% CI, 0.9-10.4) and cognitive function (OR=2.8; 95% CI, 0.9-8.6). Urinary incontinence was strongly related to the number of these risk factors present ( P trend, <.001; OR=7.2; 95% CI, 2.1-24.6) in subjects having 2 or more of the risk factors, compared with subjects with none of these risk factors). CONCLUSIONS: The prevalence of urinary incontinence is high among long-term stroke survivors, especially in subjects in whom paresis, depressive symptoms, and impaired cognition cluster.     

脑卒中偏瘫患者早期康复护理研究进展

康复训练的早期介入可促进脑卒中偏瘫患者肢体运动功能的恢复,降低致残率。对脑卒中所致偏瘫早期康复的机制、意义,训练介入的时间以及护理具体内容等方面进行综述。     

脑卒中患者吞咽功能障碍的超声检查与评估

目的通过B/M型超声研究颏舌骨肌的运动变化规律,评估其在脑卒中患者吞咽功能障碍康复治疗中的应用价值。 方法选取2017年2月至2018年12月在同济大学附属杨浦医院就诊的经综合康复治疗3个月后吞咽功能恢复正常的30例患者（病例组）为研究对象,应用B/M型超声分别于康复治疗前、治疗3周、痊愈后观察患者吞咽5 ml矿物质水过程中颏舌骨肌的运动时间、运动距离及平均运动速度。招募20例无吞咽功能障碍的健康老年人作为对照组,超声观察颏舌骨肌的运动。 结果健康老年人颏舌骨肌的运动距离、运动时间、平均运动速度分别为（7.798±0.996）mm、（0.897±0.113）s、（8.696±0.915）mm/s。脑卒中伴吞咽功能障碍患者治疗前：颏舌骨肌的运动距离、运动时间、平均运动速度分别为（6.178±0.847）mm、（1.672±0.195）s、（3.719±0.885）mm/s。脑卒中伴吞咽功能障碍患者治疗3周：颏舌骨肌的运动距离、运动时间、平均运动速度分别为（6.833±0.805）mm、（1.331±0.151）s、（5.735±0.684）mm/s。脑卒中伴吞咽功能障碍患者痊愈后：颏舌骨肌的运动距离、运动时间、平均运动速度分别为（7.693±0.422）mm、（0.848±0.294）s、（8.591±0.984）mm/s。 结论B/M型超声能准确定量评估脑卒中伴吞咽功能障碍患者颏舌骨肌功能改善情况,为康复治疗提供依据。     

球囊扩张术对脑卒中后吞咽障碍康复疗效及不良并发症研究

目的:研究球囊扩张术对脑卒中后吞咽障碍的康复疗效及不良并发症的影响。方法:选取我院经吞咽造影检查确诊为脑卒中后环咽肌失弛缓导致的吞咽障碍患者50例,随机分为2组各25例。对照组接受常规吞咽功能训练、Vitalstim神经肌肉低频电刺激,观察组另外给予球囊扩张术治疗。比较2组患者的总有效率、吞咽功能、并发症发生率,同时比较治疗前和治疗后的咽通过时间、吞咽造影检查(VFSS)评分及功能性经口摄食评估(FOIS)评分。结果:观察组的可进水、可进食流质物、可进食糊状物、可进食固体食物比例均明显高于对照组(均P0.01);观察组的吸入性肺炎发生率明显低于对照组(P0.05);治疗后,观察组的咽通过时间明显低于对照组(P0.01),VFSS和FOIS评分均明显高于对照组(均P0.01);观察组的康复总有效率明显高于对照组(96.0%,72.0%,P0.05)。结论:球囊扩张术对脑卒中后吞咽障碍具有显著疗效,缩短患者康复时间,降低误吸等并发症的发生。     

首发脑卒中患者吞咽障碍居家饮食护理方案的制订及应用

目的 制订首发脑卒中患者吞咽障碍居家饮食护理方案,并探讨其应用效果。方法 2017年7月—2018年6月,便利选取某三级甲等医院神经内科收治的3~4级吞咽障碍的首发脑卒中患者,一病区的30例患者纳入试验组,二病区的30例患者纳入对照组。试验组接受居家饮食护理方案,对照组接受常规饮食指导。出院3个月后,观察两组吸入性肺炎的发生情况、吞咽功能和生活质量的变化。结果 出院后3个月,两组吸入性肺炎发生率的比较,差异有统计学意义（P<0.05）。出院后1个月、3个月,试验组的吞咽功能优于对照组,差异均有统计学意义（P<0.05）。出院后1个月,试验组的生活质量在进食时间、症状频率、选择食物、恐惧、心理健康、疲劳程度、心理负担、进食欲望、社会交往维度得分高于对照组,差异有统计学意义（P<0.05）,两组在语言交流、睡眠维度得分的比较,差异无统计学意义（P>0.05）;出院后3个月,试验组进食时间、症状频率、选择食物、恐惧、心理健康、疲劳程度、心理负担、进食欲望、社会交往及睡眠维度得分高于对照组,差异有统计学意义（P<0.05）,两组语言交流维度得分比较,差异无统计学意义（P>0.05）。结论 首发脑卒中患者吞咽障碍居家饮食护理方案能有效预防吸入性肺炎的发生,提高患者的吞咽功能和生活质量。     

脑卒中患者的摄食-吞咽障碍

目的：研究脑卒中患者进食－吞咽障碍的发展情况和有关因素。方法：应用日本洼田俊夫的饮水试验对连续入住神经内科和康复科的100例脑卒中患者，在病情稳定后进行评价。结果：100例脑卒中患者进食－吞咽障碍的发生率达33％。相关因素分析显示，吞咽功能障碍的发展与患者的性别、年龄、病变所在侧别和有无伴发疾病无关，与患者的意识程度、认知功能、病变的性质、部位、病程、运动功能、日常生活活动和颜面失用、言语失用、失语症有关。     

脂蛋白(a)与缺血性脑卒中的相关性分析

目的分析血清脂蛋白(a)[Lp(a)]与缺血性脑卒中发病的相关性。方法选取127例缺血性脑卒中患者作为研究组,并选择同期住院的非脑卒中患者307例作为对照组,比较两组患者的Lp(a)水平,分析Lp(a)在缺血性脑卒中发病中的作用。结果脑卒中患者的Lp(a)水平[(317.11±252.32)mg/L]明显高于非脑卒中患者[(264.34±197.55)mg/L],差异有统计学意义(P0.05);LP(a)300 mg/L患者脑卒中患病率(35.12%)明显高于LP(a)≤300 mg/L的患者(25.56%),差异有统计学意义(P0.05),高水平LP(a)组患脑卒中的风险是正常组的1.38倍;经多因素Logostic回归分析揭示,Lp(a)与年龄是缺血性脑卒中的独立危险因素。结论 Lp(a)是缺血性脑卒中的独立危险因素。     

脑卒中患者与健康老年人的心理社会因素对比

目的：调查心理社会因素和人格特征在脑卒中患者康复过程中的影响。方法：采用症状自评量表（SCL－90）、艾森克个性评定量表（EPQ）和社会支持量表（SSRS）调查了78例脑卒中患者（脑卒中组），并与无神经缺陷的老年人52例（对照组）进行对照。结果：脑卒中组SCL－90总分、抑郁、焦虑、强迫、恐怖等因子分明显高于对照组（P＜0．01）；EPQ中N分及P分明显高于对照组（P＜0．01）；SSRS主观支持分及支持利用度明显低于对照组（P＜0．05）。结论：脑卒中患者除有抑郁、焦虑及恐怖等精神症状外，不良的个性特征以及缺乏对社会支持的认识和利用，也是影响其康复的重要因素。     

1000例脑卒中病例回顾性分析——对脑卒中发病和预警价值的研究

目的探讨脑卒中发病的相关危险性因素,对脑卒中发病及预警价值进行研究。方法对1000例确诊为脑卒中患者的临床及超声资料进行回顾性分析,并与正常组对照。结果卒中组有高血压、糖尿病、高脂血症病史及吸烟、饮酒史者明显多于对照组,卒中组患者血压、血脂及生化指标显著高于正常组;卒中组颈动脉彩色超声检查提示颅外段颈动脉内径增宽、内中膜厚度增加,斑块发生率增高,血流阻力指数升高：心脏超声心动图显示病变组左室肌增厚。结论高血压、糖尿病、高脂血症、吸烟为脑卒中的相关危险因素,它们共同导致卒中发生并加速病变进展。彩色多普勒超声是预测卒中发生及发展的重要检查手段之一。     

Lateral pelvic displacement during gait: abnormalities after stroke and changes during the first month of rehabilitation

OBJECTIVES: To measure the amplitude and symmetry of lateral pelvic displacement (LPD) in patients with acute hemiparetic stroke; to assess the relationship between LPD and walking speed; and to quantify changes in LPD during 1- and 4-week intervals in the early stages of gait rehabilitation. DESIGN: LPD amplitude and symmetry were measured in stroke patients on admission to acute rehabilitation, 1 week later, and at 4-week follow-up. Performance was compared with sex-, height-, and age-matched control subjects. SETTING: Urban geriatric inpatient rehabilitation facility in Australia. PARTICIPANTS: Fifteen patients with a single-hemisphere stroke, confirmed by computed tomography, were compared with the data from 12 control subjects. Patients' FIM trade mark instrument scores ranged from 54 to 124. INTERVENTION: Gait rehabilitation involved twice-daily individual physical therapy sessions of 45 to 60 minutes, 5 days a week, incorporating whole and part practice, mental rehearsal, verbal feedback on performance, manual guidance, and strengthening techniques. MAIN OUTCOME MEASURES: Three-dimensional motion analysis of LPD amplitude and symmetry; and preferred walking speed over 10m. RESULTS: Compared with controls, stroke patients initially showed increased amplitude of LPD, with no difference in LPD symmetry. A statistically significant linear relationship existed between walking speed and amplitude of LPD (r=-.53; P=.04), yet not between walking speed and symmetry (r=-.41, P=.13). Amplitude and symmetry values remained consistent during the 4-week period of rehabilitation. CONCLUSIONS: These results provide baseline LPD values for patients with acute hemiparetic stroke and demonstrate the relationship between LPD and walking speed. Change in LPD during inpatient rehabilitation was not uniform or predictable, particularly during longer periods. This highlights the need for therapists to regularly reassess each patient during the early rehabilitation phase after stroke, especially given that individual differences can be marked.     

卒中单元加强家属健康教育对合并吞咽困难患者康复的影响

目的：观察卒中单元病房加强陪护家属的康复知识教育对脑卒中合并吞咽困难患者康复的影响，并通过随访了解其远期康复疗效。方法：于卒中单元病房选取426例确诊为脑卒中合并吞咽困难患者，将其陪护家属按照同年龄（土3岁）、同性别、同文化程度、与患者关系相同、所陪护患者洼田饮水试验同级别等条件配对，筛选出152例（76对）符合条件者，采用随机数字表法分成试验组（76例）和对照组（76例）。两组患者均进行药物及常规康复干预，试验组的陪护家属在给与常规健康教育的基础上加强康复知识培训，对照组仅进行常规教育，分别于入院24h、出院前24h、随访6个月时对患者行吞咽功能障碍评价和BI指数评定。结果：入院24h两组患者的吞咽功能评价及Barthel指数评估患者的日常生活能力评分均无统计学意义（P〉0．05）；教育后，试验组患者吞咽功恢复情况明显优于对照组，BI评分高于对照组（P〈0．05），两组差异有统计学意义。结论：卒中单元病房加强陪护家属的康复知识教育有助于促进脑卒中合并吞咽困难患者的康复。