Managing urinary incontinence in stroke rehabilitation--a review

BACKGROUND: Urinary incontinence following stroke is an extensive problem for the patients and their relatives that influences the well-being and care in the future. There are a lot of therapeutic interventions available, their effectiveness, however, is not known in detail. For rehabilitation practice the ongoing question is how Urinary Incontinence (UI) can best be treated in a way that the patients daily life is not compromised. METHOD: The search for clinical trials was carried out in PubMed, CINAHL, and Cochrane Library, restricted to German and English papers published between 1989 and April 2005. Medical, nursing and physiotherapeutic interventions for treating UI after stroke were described and analysed. RESULTS: The clinical trials were divided into process-oriented trials and those looking at individual interventions. The process trials could be divided into three different groups with an overall success of 82-95 %, 50-56 % and 23-36 % respectively. Behavioral methods (caregiver-induced, patient-active and other interventions) and medical interventions are available. The studies of the most successful group include staff education and application of interventions based on an assessment procedure and a guideline. No clinical trial on individual interventions reached a result like the process-oriented studies. CONCLUSION: For treating urinary incontinence a multimodal approach is necessary: special education of the nurses, applying and acting in a problem-solving process, for example in the Rehabilitation Cycle and delivering care based on an assessment procedure and guidelines. Development of a guideline for treating urinary incontinence after stroke can be recommended. Further research in the efficacy of individual interventions is needed.     

Basic Body Awareness Therapy in patients suffering from fibromyalgia: A randomized clinical trial

ABSTRACT

Introduction: The aim of this study is to assess whether Basic Body Awareness Therapy (BBAT) improves musculoskeletal pain, movement quality, psychological function, and quality of life. Methods: The effects of BBAT in addition to treatment as usual (TAU) were studied in a randomized controlled trial. Forty-one patients were randomly assigned to a control group (n = 21) and an intervention group (n = 20). Both groups received TAU including pharmacological therapy. The intervention group took part in 10 BBAT sessions. Outcome variables were measured regarding pain, movement quality, psychological function, and quality of life. Outcome measures were assessed before intervention, in posttest, and in follow-ups at 12 and 24 weeks. Results: The BBAT group showed significant improvement in ‘pain’ at posttest (p = 0.037) and in ‘movement quality’ from baseline to 24 weeks (p = 0.000). Intragroup analysis showed significant improvements in the SF-36 body pain subscale at 12 and 24 weeks (p = 0.001, p = 0.014), Hospital Anxiety Depression scale in anxiety subscale at 12 weeks (p = 0.019), State-Trait Anxiety Inventory anxiety questionnaire at 12 and 24 weeks (p = 0.012, p = 0.002), and STAI state at 12 and 24 weeks (p = 0.042, p = 0.004). Conclusion: This study showed that BBAT might be an effective intervention in patients suffering from fibromyalgia in relation to pain, movement quality, and anxiety.     

Eating disabilities and dietary intake after stroke

Aim: to explore eating disabilities persisting at 6 months post stroke, and relationship with dietary intake.Design: prospective survey of a cohort of stroke survivors in South London.Participants: consecutive admissions to a District General Hospital in South London with a clinical diagnosis of acute stroke during the period March 1998 to February 1999 were interviewed at discharge from hospital. If the patient was English-speaking, with a Mental Status Questionnaire score ≥7 and Frenchay Aphasia Screening Test scores indicating adequate comprehension and communication skills, or a live-in carer met these conditions, follow up was sought via interview in their own home at 6 months post stroke.Main outcome measures: the Barthel Index, the Eating Disabilities Assessment Scale (EDAS) and a 24-hour recall of food intake.Results: a range of enduring stroke-related eating disabilities was revealed, most commonly arm movement, chewing and swallowing impairment, visual/perceptual and communication deficits. Substantial dietary inadequacy was also revealed, although in this group (which excluded the most disabled stroke survivors) there was no significant relationship between EDAS score and dietary intake.Conclusion: Further work is required to explore the relationship between eating disabilities and representative groups of stroke survivors, and to explore factors related to inadequate intake in less-disabled subjects.     

Public opinion of a stroke clinical trial using exception from informed consent

Background

Acute stroke is a leading cause of morbidity and mortality. Clinical trials in stroke are challenging because victims often do not have the capacity to provide informed consent, excluding those patients most likely to benefit from the research.

Aim

We evaluated patient willingness to participate in a hypothetical acute stroke trial using an exception from informed consent.

Methods

Consecutive patients presenting to four emergency departments (EDs) underwent structured interviews regarding a hypothetical stroke trial using an exception from informed consent.

Results

Of 461 (72% of eligible) participants, 55% (95% CI, 50%–59%) were willing to be enrolled in the hypothetical study without giving informed consent. After multivariable analysis, independent predictors of willingness to enroll included Catholic religion (OR 1.57, 95% CI 1.17–2.10) and belief that current therapy offers a >50% chance of full recovery (OR 1.29, 95% CI 1.05–1.57). There was no difference between the proportion willing to enroll in a cardiac arrest study vs. a stroke study (55% vs. 55%, p?=?0.83)

Conclusions

Fifty-five percent of ED patients would be willing to be enrolled in a stroke trial using exception from informed consent.     

Expanding the role of the stroke nurse: a pragmatic clinical trial

AIMS: This paper reports a study evaluating whether expanding a specialist nursing role to provide outreach education and support to stroke patients and carers after discharge from hospital is effective in promoting recovery. BACKGROUND: Building therapeutic relationships with patients and carers is a key component of the nursing role in stroke rehabilitation, although this is limited by the constraints of service organization. METHODS: A pragmatic randomized controlled trial was undertaken. Patients with a diagnosis of stroke were randomized to receive continued support from a stroke nurse (n = 87) or usual care and follow-up (n = 89) after discharge from hospital. Patients were recruited from two hospitals in the north-west of England from November 1999 to April 2001. Patient dependence (Barthel Index), general health (Nottingham Health Profile), activities of living (Frenchay Activity of Living Index), depression (Beck Depression Inventory) and carer strain (Carer Strain Index) were assessed at 3 and 12 months after stroke. RESULTS: The continued intervention of a stroke nurse after discharge was associated with improved patient perceptions of general health at 12 months (median difference 42.6, P = 0.012), and in particular reduced negative emotional reaction (P = 0.037) and perceived social isolation (P = 0.002). In addition, the intervention reduced carer strain at 3 months (P = 0.045), and reduced deterioration in physical dependence from 3 to 12 months (P = 0.049). CONCLUSION: The provision of continued intervention from a stroke nurse after discharge from hospital, focusing on education and support, has tangible benefits for patients and carers.     

Issues in recruiting community-dwelling stroke survivors to clinical trials: The AMBULATE trial

BackgroundRecruitment to clinical trials is often slow and difficult, with a growing body of research examining this issue. However there is very little work related to stroke.AimsThe aim of this study was to examine the success and efficiency of recruitment of community-dwelling stroke survivors over the first two years of a clinical trial aiming to improve community ambulation.MethodRecruitment strategies fell into 2 broad categories: (i) advertisement (such as newspaper advertising and media releases), and (ii) referral (via hospital and community physiotherapists, a stroke liaison officer and other researchers). Records were kept of the number of people who were screened, were eligible and were recruited for each strategy.ResultsThe recruitment target of 60 in the first two years was not met. 111 stroke survivors were screened and 57 were recruited (i.e., a recruitment rate of 51%). The most successful strategy was referral via hospital-based physiotherapists (47% of recruited participants) and the least successful were media release and local newspaper advertising. The referral strategies were all more efficient than any of the advertisement strategies.ConclusionsIn general, recruitment was inefficient and costly in terms of human resources. Given that stroke research is underfunded, it is important to find efficient ways of recruiting stroke survivors to clinical trials. An Australian national database similar to other disease-specific data bases (such as the National Cancer Database) is under development. In the interim, recruiting for several clinical trials at once may increase efficiency.     

悬吊训练治疗脑卒中患者平衡功能障碍的临床研究

目的: 观察悬吊训练（SET）对脑卒中患者平衡功能恢复的影响。方法: 脑卒中平衡功能障碍患者40例,随机分为对照组和观察组各20例,2组均接受常规康复训练,在此基础上,观察组加以悬吊训练。治疗前和治疗4周后采用Berg平衡量表（BBS）、Barthel指数（BI）以及采集竖脊肌表面肌电平均肌电值（AEMG）和中位频率值（MF）对2组患者进行评定。结果: 治疗4周后,2组BBS、BI评分均明显高于治疗前（均P<0.01）,且观察组以上评分均明显高于对照组（均P<0.05）。治疗前,2组患者AEMG、MF值组内比较健侧均明显高于患侧（均P<0.05）;治疗４周后,2组患者健患侧竖脊肌AEMG、MF值均较治疗前明显提高（均P<0.05）,观察组健患侧AEMG、MF值均较对照组明显提高（均P<0.05）,但观察组健患侧AEMG、MF值之间无统计学差异。结论: SET能够改善脑卒中患者的竖脊肌AEMG、MF值及BBS和BI评分,提高脑卒中患者躯干肌肉运动功能,从而提高平衡功能以及日常生活活动能力,值得在临床推广应用。     

Awareness and prevention of error in clinical decision-making

The risk of errors in the planning and delivery of health care is an inescapable feature of clinical practice for which health providers have developed sophisticated defences. However, errors still occur. This paper, the final in a four-part series on nurses' decision-making and judgement, illustrates some common pitfalls facing clinicians who have to make complex decisions and judgements, and suggests simple techniques to help combat some of the systematic errors people make when exercising judgement and making choices.     

Over-ground and robotic-assisted locomotor training in adults with chronic stroke: a blinded randomized clinical trial

Purpose: The purpose was to compare the effectiveness of robotic-assisted body weight supported treadmill training using the Lokomat^® to over-ground gait training (OGT) in adults with chronic stroke. Methods: Participants were randomly assigned to the Lokomat^® or OGT interventions. Both protocols included 40 sessions over 8 weeks. Primary outcome measures were the 10-meter walk test and 6-minute walk distance. Secondary measures included the Functional Independence Measure^TM locomotion score, Fugl-Meyer Lower Extremity Motor Score (FM-LE), Barthel Index, and Stroke Impact Scale. Blinded assessors tested the participants at baseline, post-intervention, and 3-month follow-up. Results: Eleven Lokomat^® and nine OGT participants completed the study. Within group differences in the FM-LE score and Barthel Index occurred over time from baseline to post-intervention and baseline to 3-month follow-up. No other within group differences and no between group differences were observed. Conclusions: Although walking measures did not show significant changes between groups, LE motor function and physical functional levels improved over time within both groups. The Lokomat^® may allow aggressive locomotor training, particularly for the lower functioning patients who wish to improve walking ability due to apparent eased therapist physical burden, when compared to OGT, although an increased risk of skin breakdown is present.

Implications for Rehabilitation

• Survivors of chronic stroke can continue to improve in motor recovery and functional ability after intensive over-ground or robotic-assisted locomotor training.

• Over-ground and robotic-assisted locomotor training appear to equivalently enhance motor recovery and functional ability in low functioning survivors of chronic stroke.

• Risk of skin breakdown is significant with roboticassisted locomotor training.

     

早期康复临床路径对缺血性脑卒中患者功能恢复影响的多中心、单盲、随机对照研究

目的:明确早期康复临床路径联合康复方案对缺血性脑卒中患者日常生活活动能力、运动功能的影响,为脑卒中早期康复临床路径的优化和推广提供数据支持。方法:符合纳入标准的缺血性脑卒中患者286例,随机分为临床路径组(n=143)和常规康复组(n=143)。临床路径组入组后进入脑卒中早期康复临床路径及相应的康复治疗方案,常规康复组采取一般康复治疗,不进入临床路径,对康复治疗内容及时间不做要求。分别于入组前和临床路径介入后第三周末(即出院时)采用改良Barthel指数(modified Barthel index,MBI)和Fugl-Meyer运动功能评分量表(Fugl-Meyer motor assessment scale,FMA)评估两组患者的日常活动能力和运动功能。结果:临床路径组康复治疗前后的MBI差值、MBI改善程度((MBI后-MBI前)(/100-MBI前)×100%)均显著高于常规康复组,差异有显著性意义(P0.05)。两组患者康复治疗前后FMA差值及FMA改善程度([FMA后-FMA前)/(100-FMA前)×100%]比较差异无显著性意义(P0.05)。结论:早期康复临床路径结合规范化的康复方案能提高缺血性脑卒中患者的日常活动能力的恢复。     

Telemedicine in cardiac rehabilitation--a literature review and critical appraisement

The propagation of telemedicine has influenced the development of cardiac rehabilitation as well. Especially on an outpatient basis, there is an increasing number of publications about exercise training at home controlled by telemedical ECG. These trials, however, are predominantly feasibility studies including only few patients. In addition, most of the patients were male, classified as uncomplicated low-risk patients, and the vast majority was not included until weeks and months after the acute event. So far, there is no randomized controlled trial about telemedicine in cardiac rehabilitation in a large representative population. Furthermore, in most of the studies, only telemedically conducted exercise training was evaluated, and education classes as well as psychosocial interaction with the multidisciplinary team were not considered. The argument most often cited for the further spread of telemedicine, i.e. that its use will reduce the costs of medical care, has been proven so far neither. In conclusion, telemedical supervision of exercise training at home is technically feasible. As controlled data are lacking, risks and benefits of telemedical interventions in cardiac rehabilitation are not well evaluated yet. By no means may the sole telemedically supervised exercise training at home replace the multidisciplinary cardiac rehabilitation on an in- or outpatient basis. However, as there is the great opportunity to facilitate access to cardiac rehabilitation programmes for patients living in rural areas as well, the application of telemedical techniques should be further evaluated scientifically in this setting giving special attention to cost-effectiveness in times of limited financial resources.     

Robot-assisted upper-limb therapy in acute rehabilitation setting following stroke: Department of Veterans Affairs multisite clinical trial

This randomized, controlled, multisite Department of Veterans Affairs clinical trial assessed robot-assisted (RA) upper-limb therapy with the Mirror Image Movement Enabler (MIME) in the acute stroke rehabilitation setting. Hemiparetic subjects (n = 54) received RA therapy using MIME for either up to 15 hours (low-dose) or 30 hours (high-dose) or received up to 15 hours of additional conventional therapy in addition to usual care (control). The primary outcome measure was the Fugl-Meyer Assessment (FMA). The secondary outcome measures were the Functional Independence Measure (FIM), Wolf Motor Function Test, Motor Power, and Ashworth scores at intake, discharge, and 6-month follow-up. Mean duration of study treatment was 8.6, 15.8, and 9.4 hours for the low-dose, high-dose, and control groups, respectively. Gains in the primary outcome measure were not significantly different between groups at follow-up. Significant correlations were found at discharge between FMA gains and the dose and intensity of RA. Intensity also correlated with FMA gain at 6 months. The high-dose group had greater FIM gains than controls at discharge and greater tone but no difference in FIM changes compared with low-dose subjects at 6 months. As used during acute rehabilitation, motor-control changes at follow-up were no less with MIME than with additional conventional therapy. Intensity of training with MIME was positively correlated with motor-control gains.     

Intensive blood pressure control in obese diabetic patients: clinical relevance of stroke prevention in the ACCORD trial

Evaluation of: Barzilay JI, Howard AG, Evans GW et al. Intensive blood pressure treatment does not improve cardiovascular outcomes in centrally obese hypertensive individuals with diabetes: the Action to Control Cardiovascular Risk in Diabetes (ACCORD) Blood Pressure Trial. Diabetes Care 35(7), 1401–1405 (2012).

In the ACCORD clinical trial, lowering blood pressure (BP) to normal levels, below currently recommended levels, did not significantly reduce the combined risk of fatal or nonfatal cardiovascular (CV) disease events in adults with Type 2 diabetes. A new post hoc analysis of the same trial also suggests that lowering BP in centrally obese diabetic patients is not a useful means for CV prevention. The authors discuss these findings in the light of accumulated evidence on the relationship between the degree of BP reduction and the risk of CV events in patients with diabetes. In particular, the authors focus on trial and systematic review findings, suggesting that a more intensive reduction of BP in Type 2 diabetes effectively protects from stroke.     

Constraint-Induced Movement Therapy: a new family of techniques with broad application to physical rehabilitation--a clinical review

A new family of rehabilitation techniques, termed Constraint-Induced Movement Therapy or CI Therapy, has been developed that controlled experiments have shown is effective in producing large improvements in limb use in the real-world environment after cerebrovascular accident (CVA). The signature therapy involves constraining movements of the less-affected arm with a sling for 90% of waking hours for 2 weeks, while intensively training use of the more-affected arm. The common therapeutic factor in all CI Therapy techniques would appear to be inducing concentrated, repetitive practice of use of the more-affected limb. A number of neuroimaging and transcranial magnetic stimulation studies have shown that the massed practice of CI Therapy produces a massive use-dependent cortical reorganization that increases the area of cortex involved in the innervation of movement of the more-affected limb. The CI Therapy approach has been used successfully to date for the upper limb of patients with chronic and subacute CVA and patients with chronic traumatic brain injury and for the lower limb of patients with CVA, incomplete spinal cord injury, and fractured hip. The approach has recently been extended to focal hand dystonia of musicians and possibly phantom limb pain.     

综合康复对重症脑卒中患者残疾功能改善的作用

目的：探讨综合康复对重症脑卒中患者残疾功能改善的作用。方法：选择重症脑卒中患者80例分为康复组50例和对照组30例。康复组患者入院后生命体征稳定48h起即给予早期综合康复，病情好转或出院后恢复期继续给予社区或家庭综合康复与指导；对照组仅给予简单康复与指导。两组分别于1周内、1，3，6，12个月时用GCS、NIHSS、FMA、ADL进行阶段量化评分，所得数据采用SPSS10．0软件统计。结果：两组间GCS在1个月时差异有统计学意义（P〈0．05）、3个月时NIHSS、FMA差异有统计学意义（P〈0．01），6个月时ADL差异有统计学意义（P〈0．05），12个月时ADL差异有统计学意义（P〈0．05）。结论：综合康复对重症脑卒中患者残疾功能改善有着重要作用。