Inability to self-report pain after a stroke: A population-based study

The frequency of not being able to self-report pain after a stroke has not been previously assessed in a population-based sample. We studied the epidemiology of this problem using a cohort of patients hospitalized after a stroke in Olmsted County, Minnesota, from June 1, 2008, to June 1, 2012. Overall, 52 of 388 (13.4%) individuals were unable to provide a meaningful response to either a Faces Pain Scale or Numerical Rating Scale on admission. Inability to self-report pain was associated with measures of stroke severity (P < .0001), aphasia severity (P < .0001), and level of consciousness (P < .0001). Inability to self-report pain on admission was further associated with either subsequent death during the hospitalization (P < .0001) or an inability to provide self-report on dismissal (P < .0001). Our study further defines the epidemiology of the inability to self-report pain after a stroke as being less common than previously thought. Attempts to validate observational pain scales for poststroke patients should focus on those individuals with aphasia and/or depressed levels of consciousness.     

Visual dependence after recent stroke]

INTRODUCTION: After chronic stroke, inability to use pertinent somatosensory or vestibular information have been described. The aim of the study was to determine whether visual dependence occurred early after stroke before rehabilitation. METHOD: Thirty patients with recent hemiplegia (16 right and 14 left hemispheric stroke) performed the rod and frame test (RFT). Patients were asked to adjust the rod to the vertical position under 3 conditions: basically, with a frame tilted 18 degrees to the right and then with the frame tilted to the left. Bias in each condition (mean, SD) was recorded and compared to adjustments of the rod by 23 controls. Motor control, sensibility, functional level (functional independence measure), age, neglect, and then balance by the postural assessment scale for stroke were assessed. RESULTS: Fifty-six per cent (17/30) of patients but only 26% of controls were influenced by the tilt of the frame on the 2 sides (visual dependence). No correlation was found between visual dependence and the characteristics of the patients. DISCUSSION: Many patients with recent hemiplegia seem to rely on visual input. The mechanisms of such visual dependence are discussed. Rehabilitation programs should take into account the possible impairment of sensory organisation and should include exercises to be performed under visual disturbances.     

Occupational categories and return to work after traumatic brain injury: a multicenter study

OBJECTIVE: To further evaluate determinants of return to work (RTW) after traumatic brain injury (TBI), with focus on the relation between preinjury occupational category and RTW outcome. DESIGN: Prospective collaborative cohort study. SETTING: Seventeen National Institute on Disability and Rehabilitation Research-designated Traumatic Brain Injury Model Systems. PARTICIPANTS: Consecutive sample of 1341 patients (age range, 18-62y) who were hospitalized with a TBI diagnosis, received both acute neurotrauma services and inpatient rehabilitation services, consented to participate, were employed before injury, and completed a 1-year follow-up assessment. INTERVENTION: An inpatient interdisciplinary brain injury rehabilitation program. MAIN OUTCOME MEASURE: Competitive employment at 1 year postinjury. RESULTS: Participants were categorized into 1 of 3 groups depending on preinjury occupational title: professional/managerial (n=192), skilled (n=751), or manual labor (n=398). Chi-square analyses were computed to examine changes across occupation groups between preinjury occupation group and postinjury RTW. The rate of successful RTW was greatest for professional/managerial (56%), lower for skilled (40%), and lowest for manual labor (32%), yielding an odds ratio of 2.959 between the highest and lowest groups. Of those with successful RTW, most did so within the same occupational category grouping. A multiple logistic regression showed that preinjury occupation, education level, discharge FIM score, age, sex, marital status, and hospital length of stay each influenced RTW. CONCLUSIONS: Prior research has shown that preinjury employment status (employed vs unemployed) greatly influences the odds of successful RTW after TBI. A related hypothesis, that occupational classification also influences RTW outcome, has been understudied and has yielded conflicting results. The current study shows convincingly that the type of occupation influences RTW outcome, with the best prospect for RTW among people with professional/managerial jobs. Occupational category should be examined in the future development of predictive models for RTW after TBI.     

Learning readiness for patient teaching in stroke rehabilitation

Motivation and ability are attributes of learning readiness for patient teaching. Achievement motivation theory includes the assumption that the tendency to succeed in regaining functional losses due to stroke is related to patients' perceptions of how difficult activities will be to accomplish. Ability is assessed using the Functional Independence Measure. A framework is applied to a patient situation demonstrating that the tendency to succeed is greater when striving to achieve goals with an uncertain level of difficulty than when goals are either easy or hard. Implications for nursing and research are described.     

Gender differences in emergency stroke care and hospital outcome in acute ischemic stroke: a multicenter observational study

Background

We aimed to investigate the effect of gender difference on the accessibility to emergency care, hospital mortality and disability in acute stroke care.

Methods

This study was performed on a single-tiered basic emergency medical service with a comprehensive national health insurance. Demographic variables, risk factors, elapsed time intervals, performing diagnosis and treatment options, hospital mortality, and modified Rankin Scale of acute ischemic stroke during 2008 were collected. We modeled the multivariate regression analysis for gender differences on the accessibility, hospital mortality, and disability. The adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were calculated adjusting for potential risk factors.

Results

The total number of patients was 6635. The time from symptom onset to emergency department (ED) arrival and to computed tomography or magnetic resonance imaging scan and from ED arrival to computed tomography or magnetic resonance imaging scan was significantly longer in women. No significant difference was found in either the time to intravenous thrombolysis or in the number of patients who received intravenous thrombolysis, anti-platelet therapy, anti-coagulation, or operation. The hospital mortality rate was higher in women (3.9%) than in men (2.9%) (P = .03). The increased disability was significantly higher in women (67.8%) than in men (65.1%) (P = .02). The hospital mortality and increased disability showed a non-significant difference between the 2 genders in the adjusted model (OR, 1.10; 95% CI, 0.74-1.64) and (OR, 1.11; 95% CI, 0.96-1.28), respectively.

Conclusion

The adjusted model for risk factors showed no significant difference on hospital mortality and disability between the 2 genders for stroke patients.     

Functional independence measure scores predict level of long-term care required by patients after stroke: a multicenter retrospective cohort study

Abstract

Purpose: To examine whether Functional Independence Measure (FIM) scores on admission can predict the future care levels of patients after acute stroke. Methods: In this multicenter retrospective cohort study, we enrolled post-acute stroke patients and assessed stroke subtypes, self-care abilities using FIM scores, and discharge destination. Patients’ care levels were assessed according to the Long-Term Care Insurance (LTCI) system (0–5: slight impairment to bedridden), the national insurance plan for care in Japan, at discharge. We divided patients into two groups according to LTCI care levels (0–2 versus 3–5) to compare their clinical characteristics using multivariate logistic regression analysis. The trial was registered with the UMIN Clinical Trials Registry (UMIN000012653). Results: Of the 1261 patients (47% female, mean age 75 years), 492 (39%) fulfilled LTCI care levels 0–2. FIM scores on admission were significantly correlated with LTCI care levels (p?<?0.001). On multivariate analysis, age and FIM scores on admission were found to be independent predictors of LTCI care levels 0–2. Conclusions: FIM scores on admission after stroke can independently predict later care requirements. Early prediction of LTCI care levels may contribute to the early supported discharge and improve the efficiency of healthcare planning.

• Implications for Rehabilitation

• There is a clear relationship between Functional Independence Measure (FIM) scores and the care levels certified by the Long-Term Care Insurance (LTCI) system, a national healthcare and insurance system in Japan.

• FIM scores on admission can predict future LTCI care levels required for patients after acute stroke.

• Early prediction of LTCI care levels may contribute to early supported discharge, improve the efficiency of stroke management and assist healthcare planning.

     

Optimizing muscle power after stroke: a cross-sectional study

Background

Symmetry and regularity of gait are essential outcomes of gait retraining programs, especially in lower-limb amputees. This study aims presenting an algorithm to automatically compute symmetry and regularity indices, and assessing the minimum number of strides for appropriate evaluation of gait symmetry and regularity through autocorrelation of acceleration signals.

Methods

Ten transfemoral amputees (AMP) and ten control subjects (CTRL) were studied. Subjects wore an accelerometer and were asked to walk for 70 m at their natural speed (twice). Reference values of step and stride regularity indices (Ad1 and Ad2) were obtained by autocorrelation analysis of the vertical and antero-posterior acceleration signals, excluding initial and final strides. The Ad1 and Ad2 coefficients were then computed at different stages by analyzing increasing portions of the signals (considering both the signals cleaned by initial and final strides, and the whole signals). At each stage, the difference between Ad1 and Ad2 values and the corresponding reference values were compared with the minimum detectable difference, MDD, of the index. If that difference was less than MDD, it was assumed that the portion of signal used in the analysis was of sufficient length to allow reliable estimation of the autocorrelation coefficient.

Results

All Ad1 and Ad2 indices were lower in AMP than in CTRL (P < 0.0001). Excluding initial and final strides from the analysis, the minimum number of strides needed for reliable computation of step symmetry and stride regularity was about 2.2 and 3.5, respectively. Analyzing the whole signals, the minimum number of strides increased to about 15 and 20, respectively.

Conclusions

Without the need to identify and eliminate the phases of gait initiation and termination, twenty strides can provide a reasonable amount of information to reliably estimate gait regularity in transfemoral amputees.     

Feasibility of a home-based program to improve handwriting after stroke: a pilot study

Purpose: To test the feasibility of a handwriting retraining program with adults after stroke; specifically the feasibility of: (i) recruiting people with stroke to the study, (ii) delivering the handwriting retraining program and (iii) outcome measures of handwriting performance. Method: A quasi-experimental pre-test post-test design was used. A four-week, home-based handwriting retraining program was delivered by an occupational therapist using task-specific practice. Legibility, speed, pen control and self-perception of handwriting were measured at baseline and completion of the program. Legibility was scored by a blinded rater. Results: Seven adults with stroke were recruited (eligibility fraction 43% of those screened, and enrolment fraction 78% of those eligible). There were no dropouts. Although, recruitment was slow the intervention was feasible and acceptable to adults with stroke. No statistically or clinically significant changes in legibility were reported in this small sample, but a ceiling effect was evident for some outcome measures. The study was not powered to determine efficacy. Conclusions: Delivery of a four-week handwriting intervention with eight supervised sessions in the community was feasible; however, recruitment of an adequate sample size would require greater investment than the single site used in this pilot.

• Implications for Rehabilitation

• Handwriting difficulty is common following hemiparesis after stroke, however research addressing handwriting retraining for adults with stroke is lacking.

• A four-week home-based handwriting program using task-specific practice and feedback was feasible to deliver and appropriate for adults with stroke.

• Improving handwriting legibility and neatness across a range of tasks were important goals for adults with handwriting impairment.

     

Spouse's life situation after partner's stroke event: psychometric testing of a questionnaire

AIM: This paper reports a study to validate and test the reliability of a questionnaire constructed to evaluate the life situation of spouses after their partners have had a stroke. BACKGROUND: Stroke is a disease with great consequences for survivors and their families. Most survivors return home after the hospitalization and rehabilitation due to the stroke event. Relatives, primarily spouses, often feel obligated to care for the survivor at home, providing emotional support or assisting the person in activities of daily living. More specific information is needed about the spouse's life situation after the stroke event in order to develop effective supportive strategies. METHODS: Psychometric testing of the Life Situation Questionnaire was undertaken with 99 spouses of stroke survivors. The 13-item questionnaire consists of four subscales: 'Worries', 'Powerlessness', 'Personal adjustment' and 'Social isolation'. RESULTS: Item analysis showed that each item correlated with its own subscale (r = 0.63-0.78). The instrument had high internal consistency, with Cronbach's alphas of 0.80-0.86 and reasonable high congruent validity when correlated with a Wellbeing instrument, with a correlation of 0.59 (P = 0.001). Exploratory factor analysis confirmed the subscales, accounting for 77% of the variance. CONCLUSION: The Life Situation Questionnaire is a valid and reliable instrument, and could serve as an assessment tool after a stroke event to identify family caregivers who have problems in their life situations and need support from healthcare services.     

Evaluation of a single-item screening tool for depression after stroke: a cohort study

OBJECTIVES: To determine the accuracy and utility of a single-item screening tool for depression (the Yale, taken from the Yale-Brown Obsessive Compulsive Scale) in patients who have recently had a stroke. DESIGN: Comparison of a clinical classification of depression with a screening tool in a defined cohort. SETTING: A large teaching hospital in Liverpool, UK. SUBJECTS: One hundred and twenty-two consecutive people admitted with an acute stroke who did not have severe cognitive or communication problems, and who were still in hospital in the second week post stroke. MAIN MEASURES: Classification of depression using the Montgomery-Asberg Depression Rating Scale was compared with the Yale, a single-item screening tool. RESULTS: When comparing the classification of depression according to the Montgomery-Asberg Depression Rating Scale and the response to the Yale we found that at week 2 the Yale had a sensitivity of 86% (57/66), a specificity of 84% (46/55), a positive predictive value of 86% (57/66) and a negative predictive value of 84% (46/55), with an overall efficiency of 85% (103/121); prevalence of depression was 54% (according to the Montgomery-Asberg Depression Rating Scale). At month 3 the Yale had a sensitivity of 95% (52/55), a specificity of 89% (32/36), a positive predictive value of 93% (52/56) and a negative predictive value of 91% (32/35), with an overall efficiency of 92% (84/91); prevalence of depression was 60%. CONCLUSIONS: The Yale, which only requires a 'yes' or 'no' answer to a single question, may prove a useful screening tool in identifying possible depression in people with stroke both two weeks and three months post stroke.     

Predictive factors for walking in acute stroke patients: a multicenter study using classification and regression tree analysis

[Purpose] Walking ability should be predicted as early as possible in acute stroke patients. The purpose is to construct a prediction model for independent walking from bedside assessments using classification and regression tree analysis. [Participants and Methods] We conducted a multicenter case-control study with 240 stroke patients. Survey items included age, gender, injured hemisphere, the National Institute of Health Stroke Scale, the Brunnstrom Recovery Stage for lower extremities, and “turn over from a supine position” from the Ability for Basic Movement Scale. The National Institute of Health Stroke Scale items, such as language, extinction, and inattention, were grouped under higher brain dysfunction. We used the Functional Ambulation Categories to classify patients into independent (four or more the Functional Ambulation Categories; n=120) and dependent (three or fewer the Functional Ambulation Categories; n=120) walking groups. A classification and regression tree analysis was used to create a model to predict independent walking. [Results] The Brunnstrom Recovery Stage for lower extremities, “turn over from a supine position” from the Ability for Basic Movement Scale, and higher brain dysfunction were the splitting criteria for classifying patients into four categories: Category 1 (0%), severe motor paresis; Category 2 (10.0%), mild motor paresis and could not turn over; Category 3 (52.5%), with mild motor paresis, could turn over, and had higher brain dysfunction; and Category 4 (82.5%), with mild motor paresis, could turn over, and no higher brain dysfunction. [Conclusion] We constructed a useful prediction model for independent walking based on the three criteria.     

High-intensity cycling exercise after a stroke: a single case study

Aerobic exercise training has demonstrated positive effects after brain injury. However, therapists express concern regarding the use of effortful exercise in individuals presenting with spasticity or involuntary muscle activity. This study aimed to address this concern and to evaluate whether an intervention of maximal intensity cycling exercise impaired an individual's ability to actively extend his hemiparetic elbow. Using a single case design, it was shown that active elbow extension improved during the period of this investigation, and was not impaired immediately following maximal cycling exercise.     

Targeted temperature management after intraoperative cardiac arrest: a multicenter retrospective study

Purpose

Few outcome data are available about temperature management after intraoperative cardiac arrest (IOCA). We describe targeted temperature management (TTM) (32–34 °C) modalities, adverse events, and association with 1-year functional outcome in patients with IOCA.

Methods

Patients admitted to 11 ICUs after IOCA in 2008–2013 were studied retrospectively. The main outcome measure was 1-year functional outcome.

Results

Of the 101 patients [35 women and 66 men; median age, 62 years (interquartile range, 42–72)], 68 (67.3%) were ASA PS I to III and 57 (56.4%) had emergent surgery. First recorded rhythms were asystole in 44 (43.6%) patients, pulseless electrical activity in 36 (35.6%), and ventricular fibrillation/tachycardia in 20 (19.8%). Median times from collapse to cardiopulmonary resuscitation and return of spontaneous circulation (ROSC) were 0 min (0–0) and 10 min (4–20), respectively. The 30 (29.7%) patients who received TTM had an increased risk of infection (P = 0.005) but not of arrhythmia, bleeding, or metabolic/electrolyte disorders. By multivariate analysis, one or more defibrillation before ROSC was positively associated with a favorable functional outcome at 1-year (OR 3.06, 95% CI 1.05–8.95, P = 0.04) and emergency surgery was negatively associated with 1-year favorable functional outcome (OR 0.36; 95% CI 0.14–0.95, P = 0.038). TTM use was not independently associated with 1-year favorable outcome (OR 0.82; 95% CI 0.27–2.46, P = 0.72).

Conclusions

TTM was used in less than one-third of patients after IOCA. TTM was associated with infection but not with bleeding or coronary events in this setting. TTM did not independently predict 1-year favorable functional outcome after IOCA in this study.

     

脑卒中偏瘫患者心肺运动功能评估临床研究

目的:评估脑卒中后偏瘫患者心肺运动功能,了解偏瘫患者心肺功能储备能力,探寻脑卒中偏瘫患者有氧运动康复方案。方法:选取11例脑卒中后偏瘫患者(实验组)和11例健康志愿者(对照组)进行心肺运动实验测试,比较两组受试对象心肺运动实验各指标差异。结果:两组受试对象性别、年龄、体重指数等基础指标差异无显著性。实验组峰值摄氧量(13.1±3.2 vs 22.3±6.6ml/kg/min)、无氧阈(11.2±2.9 vs 15.5±3.6ml/kg/min)、能量代谢当量(3.7±0.9 vs 6.4±1.9)、峰值氧脉搏(7.7±2.0 vs11.2±2.5ml)、峰值呼吸交换率(0.98±0.08 vs 1.15±0.11)、峰值分钟通气量(30.9±8.5 vs 55.7±17.7L/min)、峰值功率(72.5±18.8 vs 118.8±46.8w)与最大心率(117.9±14.7 vs 135.1±20.4bpm)明显低于对照组(P0.05),静息心率(81.6±11.5 vs 72.5±4.9bpm)明显高于对照组(P0.05)。实验组静息血压与峰值血压与对照组比较无显著性差异(P0.05)。结论:脑卒中偏瘫患者心肺运动功能明显低于健康人,心肺储备功能下降,脑卒中偏瘫患者的康复过程中有必要给予一定强度的有氧运动,以改善心肺运动功能,预防卒中再发和提高运动功能。     

The smiley as a simple screening tool for depression after stroke: a preliminary study

In Hong Kong, there is a paucity of evidence to support which tool is superior in measuring depression after stroke (DAS). A simple, non-language-based, culturally neutral, non-verbal and easy to apply tool that is not highly dependent on training will be desirable. OBJECTIVES: The present study aimed to examine the clinical utility of three smiley pictures in detecting DAS for older Chinese patients at 1 month after first-ever ischemic stroke. METHODS: This was a cross-sectional study. A total of 253 stroke patients were interviewed by a research nurse at 1-month follow-up. RESULTS: Taking Diagnostic and Statistic Manual (DSM IV) as the gold standard, the measurement properties of emoticon (sad) in terms of sensitivity, specificity, positive and negative predictive values, as well as Kappa's value were found comparable to Geriatric Depression Scale (GDS). The emoticon (happy) demonstrated a highly significant inverse relationship with all depression assessment tools (p<0.001). It was also found that the emoticon (flat) could capture 98% of all depressed subjects identified by DSM IV, although its predictive values were less satisfactory. CONCLUSIONS: The smiley pictures seemed to fulfil the requirements for early and prompt screening among older patients. Cultural implication regarding emotions dissipation among Chinese patients should be further studied.