“Holding Me Back”: Living With Arthritis While Recovering From Stroke

Wood JP, Connelly DM, Maly MR. “Holding me back”: living with arthritis while recovering from stroke.

Objective

To describe the experience of living with arthritis while recovering from stroke.

Design

Qualitative, phenomenological study. During the first three months post-stroke, 14 one-on-one semi-structured interviews were conducted. Analysis was guided by the modified van Kaam method.

Setting

General community.

Participants

Three men and two women with self-reported pre-existing knee arthritis who were recovering from a first stroke.

Intervention

Not applicable.

Main Outcome Measures

Not applicable.

Results

“Holding me back” was central to the experience of living with knee arthritis while recovering from stroke, due to pain, mobility limitations, frustration, and additional coping demands. Experiencing arthritic pain occurred during daily physical activity. As a result, arthritis interfered with participants' ability to fully engage in stroke rehabilitation. The resulting mobility limitations due to arthritis were frustrating experiences that required additional coping strategies by all participants.

Conclusions

From the perspective of the participants, the slowed recovery from stroke due to arthritis illustrated the need to consider the influence of knee arthritis on stroke recovery during inpatient rehabilitation and after discharge. Stroke rehabilitation interventions that emphasize weight-bearing exercise may not be tolerated by those with arthritis. Alternate pharmacological treatments and physical rehabilitation should be considered for people with pre-existing knee arthritis post-stroke.     

Psychometric Properties of the Community Integration Questionnaire Adjusted for People With Aphasia

Dalemans RJ, de Witte LP, Beurskens AJ, van den Heuvel WJ, Wade DT. Psychometric properties of the community integration questionnaire adjusted for people with aphasia.

Objectives

To describe the feasibility of the Community Integration Questionnaire (CIQ) adjusted for use in people with aphasia and to report its psychometric properties in people with aphasia (internal consistency, factor analysis, test-retest reliability, convergent validity).

Design

A cross-sectional, interview-based psychometric study. Test-retest reliability was evaluated in 20 people (minimal to severe aphasia) by 2 different interviewers within a 2-week period.

Setting

Community.

Participants

In total 490 stroke survivors with (minimal to severe) aphasia were approached, of which 165 (34%) participants returned the answering letter. Participants (N=150) agreed to take part and were interviewed using a structured interview format.

Interventions

Not applicable.

Main Outcome Measures

Community Integration Questionnaire (CIQ), Frenchay Aphasia Screening Test, Barthel Index, Dartmouth Coop Functional Health Assessment Charts (COOP)-World Organisation of Family Doctors (WONCA) Charts, Life Satisfaction Questionnaire.

Results

A total of 150 stroke survivors with aphasia completed the CIQ adjusted for people with aphasia. The CIQ adjusted for people with aphasia was a feasible instrument. Results showed good internal consistency for the CIQ total (standardized Cronbach α=.75), excellent test-retest reliability (intraclass correlation coefficient=.96), moderate correlations with the Barthel Index, the COOP-WONCA, and the Life Satisfaction Questionnaire with regard to construct validity. Significant relations were found with regard to age and aphasia severity.

Conclusions

The CIQ adjusted for people with aphasia seems to be an adequate instrument to assess participation in people with aphasia.     

Impact of comorbidities on stroke rehabilitation outcomes: does the method matter?

Berlowitz DR, Hoenig H, Cowper DC, Duncan PW, Vogel WB. Impact of comorbidities on stroke rehabilitation outcomes: does the method matter?

Objectives

To examine the impact of comorbidities in predicting stroke rehabilitation outcomes and to examine differences among 3 commonly used comorbidity measures—the Charlson Index, adjusted clinical groups (ACGs), and diagnosis cost groups (DCGs)—in how well they predict these outcomes.

Design

Inception cohort of patients followed for 6 months.

Setting

Department of Veterans Affairs (VA) hospitals.

Participants

A total of 2402 patients beginning stroke rehabilitation at a VA facility in 2001 and included in the Integrated Stroke Outcomes Database.

Interventions

Not applicable.

Main Outcome Measures

Three outcomes were evaluated: 6-month mortality, 6-month rehospitalization, and change in FIM score.

Results

During 6 months of follow-up, 27.6% of patients were rehospitalized and 8.6% died. The mean FIM score increased an average of 20 points during rehabilitation. Addition of comorbidities to the age and sex models improved their performance in predicting these outcomes based on changes in c statistics for logistic and R² values for linear regression models. While ACG and DCG models performed similarly, the best models, based on DCGs, had a c statistic of .74 for 6-month mortality and .63 for 6-month rehospitalization, and an R² of .111 for change in FIM score.

Conclusions

Comorbidities are important predictors of stroke rehabilitation outcomes. How they are classified has important implications for models that may be used in assessing quality of care.     

Alcohol Misuse and Multiple Sclerosis

Turner AP, Hawkins EJ, Haselkorn JK, Kivlahan DR. Alcohol misuse and multiple sclerosis.

Objective

To describe the prevalence of alcohol misuse and medical advice to reduce drinking in a national sample of veterans with multiple sclerosis (MS).

Design

Cross-sectional cohort study linking computerized medical record information to mailed survey data from 2004 through 2006.

Setting

Veterans Health Administration (VHA).

Participants

Two thousand six hundred fifty-five of 4929 veterans with MS who received services in VHA between 2004 and 2006 and also a survey questionnaire (53.9% response rate).

Interventions

Not applicable.

Main Outcome Measures

Demographic information, Short-Form 12-Item Health Survey Mental Component Summary and Physical Component Summary, Alcohol Use Disorders Identification Test Consumption questions, and questions assessing depressive symptoms and the receipt of alcohol-related advice from a medical professional.

Results

Among all survey respondents with MS, the prevalence of alcohol misuse for the sample was 13.9% (confidence interval [CI], 12.5-15.2), with 11.9% (CI, 10.6-13.2) and 2.0% (CI, 1.4-2.5) of participants scoring in the mild/moderate and severe range of alcohol misuse, respectively. In contrast to community samples there was no difference in prevalence by sex. In multivariate logistic regression, age younger than 60 years (<50y; adjusted odds ratio [AOR]=1.66; CI, 1.17-2.37, and 50-59; AOR=1.64; CI, 1.19-2.27), employment (AOR=1.54; CI, 1.06-2.24) and better physical health (AOR=1.02; CI, 1.01-1.04) were associated with a higher likelihood of alcohol misuse. Among persons who screened positive for alcohol misuse, only 26.2% (CI, 21.5-30.9) reported they had received advice from a medical provider in the past year to decrease or abstain from drinking. Self-report of advice was more likely among those endorsing severe misuse (AOR=3.65; CI, 1.85-7.17) and less likely among those with better mental health (AOR=0.97; CI, 0.94-1.00).

Conclusions

Despite the numerous health and social consequences of alcohol misuse, routine screening and intervention for people with MS remain uncommon. Brief screening and advice to reduce or refrain from alcohol use can be accomplished in as little as 5 minutes and can be incorporated into the regular course of medical care.     

Hemispatial Neglect and Rehabilitation in Acute Stroke

Cumming TB, Plummer-D'Amato P, Linden T, Bernhardt J. Hemispatial neglect and rehabilitation in acute stroke.

Objectives

To compare 2 methods for determining neglect in patients within 2 days of stroke, and to investigate whether early neglect was related to rehabilitation practice, and whether this relationship was affected by an early, intensive mobilization intervention.

Design

Data were collected from patients participating in a phase II randomized controlled trial of early rehabilitation after stroke.

Setting

Acute hospital stroke unit.

Participants

Stroke patients (N=71).

Intervention

The 2 arms of the trial were very early mobilization (VEM) and standard care (SC).

Main Outcome Measures

Neglect was assessed using the Star Cancellation Test and the National Institutes of Health Stroke Scale (NIHSS) inattention item within 48 hours of stroke onset, and therapy details were recorded during the hospital stay.

Results

Assessing neglect so acutely after stroke was difficult: 29 of the 71 patients were unable to complete the Star Cancellation Test, and agreement between this test and the NIHSS measure was only .42. Presence of neglect did not preclude early mobilization. SC group patients with neglect had longer hospital stays (median, 11d) than those without neglect (median, 4d); there was no difference in length of stay between patients with and without neglect in the VEM group (median, 6d in both).

Conclusion

Early mobilization of patients with neglect was feasible and may contribute to a shorter acute hospital stay.     

The validity of the lag signs in diagnosing full-thickness tears of the rotator cuff: a preliminary investigation

Miller CA, Forrester GA, Lewis JS. The validity of the lag signs in diagnosing full-thickness tears of the rotator cuff: a preliminary investigation.

Objective

To investigate whether the lag signs were valid tools in diagnosing full-thickness tears of the rotator cuff.

Design

A same-subject, correlation, double-blinded design was used. The results of the external rotation lag sign, drop sign, and internal rotation lag sign were compared with the criterion standard of diagnostic ultrasound to establish their accuracy.

Setting

A regional orthopedic hospital.

Participants

Consecutive subjects (N=37), 21 women and 16 men, with shoulder pain referred to a consultant orthopedic surgeon specializing in shoulder conditions were recruited for this investigation.

Interventions

Not applicable.

Main Outcome Measures

Sensitivity, specificity, and positive and negative likelihood ratios of the lag signs when using ultrasound as the reference test.

Results

The specificities of the drop sign and internal rotation lag sign were 77% and 84%, respectively, which, together with low positive likelihood ratios 3.2 (95% confidence interval [CI], 1.5-6.7) and 6.2 (95% CI, 1.9-12.0), indicate that a positive result was poor at recognizing the presence of full-thickness tears. The drop sign had a sensitivity of 73% with a negative likelihood ratio of .34 (95% CI, 0.2-0.8), suggesting that a negative test was fair at ruling out the presence of full-thickness tears. The sensitivity of the internal rotation lag sign (100%) supported by the negative likelihood ratio of 0 (95% CI, 0.0-2.5) suggests that a negative test will effectively rule out the presence of full-thickness tears of the subscapularis. A positive external rotation lag sign is the clinical test most likely to indicate that full-thickness tears of the supraspinatus and infraspinatus are present (specificity, 94%). However, the external rotation lag sign did demonstrate a low sensitivity score of 46% and negative likelihood ratio of .57 (95% CI, 0.4-0.9), which means that a negative test will not rule out the presence of full-thickness tears.

Conclusions

The findings of this investigation suggest that a clinical diagnosis of a full-thickness tear of the rotator cuff cannot be conclusively reached using one or more of the lag signs.     

Factors Predicting Inpatient Rehabilitation Length of Stay of Acute Stroke Patients in Singapore

Tan WS, Heng BH, Chua KS, Chan KF. Factors predicting inpatient rehabilitation length of stay of acute stroke patients in Singapore.

Objective

To determine the predictors of hospital length of stay (LOS) of stroke patients at the point of admission.

Design

A retrospective cohort study.

Setting

An acute hospital rehabilitation center in Singapore.

Participants

Stroke patients (N=491) admitted between March 2005 and December 2006.

Interventions

None.

Main Outcome Measures

Rehabilitation LOS was calculated as the total number of rehabilitation days before discharge. We measured the functional status of patients by using the Functional Independence Measure (FIM).

Results

The median LOS was 29 days (mean = 30.8d). Independent clinical and sociodemographic characteristics found to significantly predict rehabilitation LOS were FIM motor score at admission, the presence of more than 3 comorbid conditions at admission, living with nonimmediate relatives before admission, and the hospital subsidy status of the patient. In particular, the admission FIM motor score explained 43% of the variation in LOS and decreased the LOS by approximately 1.1 days for each 1-point increase in score.

Conclusion

Patients' socioeconomic status and family structure was found to influence LOS and should be considered in allocating resources and determining treatment need. The extent of motor function of patients at admission is an important factor influencing rehabilitation LOS and is a useful tool for facilitating rehabilitation resource planning for stroke patients.     

Comparison of the Responsiveness of the FIM and the interRAI Post Acute Care Assessment Instrument in Rehabilitation of Older Adults

Glenny C, Stolee P, Husted J, Thompson M, Berg K. Comparison of the responsiveness of the FIM and the interRAI Post Acute Care Assessment Instrument in rehabilitation of older adults.

Objective

To compare the responsiveness of 2 major systems developed for rehabilitation settings—the FIM and the interRAI Post Acute Care (PAC) assessment—in older patients.

Design

Trained raters assessed patients with both tools at admission and discharge.

Setting

Musculoskeletal (MSK) and geriatric rehabilitation units (GRUs) in 2 rehabilitation hospitals.

Participants

Older adults receiving rehabilitation (N=208; mean age ± SD, 78.5±9.3; 67% women).

Interventions

Not applicable.

Main Outcome Measures

Responsiveness was evaluated using effect size (ES) and standardized response mean (SRM).

Results

ES and SRM were somewhat higher for the FIM motor (GRU ES=1.68, SRM=1.31; MSK ES=2.12, SRM=2.25) than the PAC (GRU ES=1.64, SRM=1.29; MSK ES=1.57, SRM=1.89) in both patient groups. Both tools were more responsive in MSKs than GRUs. This may reflect the greater frailty and clinical complexity of GRU patients.

Conclusions

Both the FIM motor and the PAC were able to detect clinically relevant improvement in functional ability in older rehabilitation inpatients.     

Estimating minimal clinically important differences of upper-extremity measures early after stroke

Lang CE, Edwards DF, Birkenmeier RL, Dromerick AW. Estimating minimal clinically important differences of upper-extremity measures early after stroke.

Objective

To estimate minimal clinically important difference (MCID) values of several upper-extremity measures early after stroke.

Design

Data in this report were collected during the Very Early Constraint-induced Therapy for Recovery of Stroke trial, an acute, single-blind randomized controlled trial of constraint-induced movement therapy. Subjects were tested at the prerandomization baseline assessment (average days poststroke, 9.5d) and the first posttreatment assessment (average days poststroke, 25.9d). At each time point, the affected upper extremity was evaluated with a battery of 6 tests. At the second assessment, subjects were also asked to provide a global rating of perceived changes in their affected upper extremity. Anchor-based MCID values were calculated separately for the affected dominant upper extremities and the affected nondominant upper extremities for each of the 6 tests.

Setting

Inpatient rehabilitation hospital.

Participants

Fifty-two people with hemiparesis poststroke.

Interventions

Not applicable.

Main Outcome Measures

Estimated MCID values for grip strength, composite upper-extremity strength, Action Research Arm Test (ARAT), Wolf Motor Function Test (WMFT), Motor Activity Log (MAL), and duration of upper-extremity use as measured with accelerometry.

Results

MCID values for grip strength were 5.0 and 6.2kg for the affected dominant and nondominant sides, respectively. MCID values for the ARAT were 12 and 17 points, for the WMFT function score were 1.0 and 1.2 points, and for the MAL quality of movement score were 1.0 and 1.1 points for the 2 sides, respectively. MCID values were indeterminate for the dominant (composite strength), the nondominant (WMFT time score), and both affected sides (duration of use) for the other measures.

Conclusions

Our data provide some of the first estimates of MCID values for upper-extremity standardized measures early after stroke. Future studies with larger sample sizes are needed to refine these estimates and to determine whether MCID values are modified by time poststroke.     

Racial disparities in the development of dysphagia after stroke: analysis of the California (MIRCal) and New York (SPARCS) inpatient databases

Gonzalez-Fernandez M, Kuhlemeier KV, Palmer JB. Racial disparities in the development of dysphagia after stroke: analysis of the California (MIRCal) and New York (SPARCS) inpatient databases.

Objectives

To determine whether the proportion of patients with stroke experiencing dysphagia differs among racial groups and whether this relation can be explained by stroke type or severity.

Design

Case-control study using California's Medical Information Reporting and New York's Statewide Planning and Research Cooperative System databases for 2002. Cases had primary diagnosis of cerebrovascular disease (International Classification of Disease, 9th Revision [ICD-9] codes 430-438.9, excluding transient [435-435.9] and late-effects [438-438.9]), and self-identified race was white, black, or Asian. Two comparison groups were selected: (1) Parkinson's disease (ICD-9 codes 332-332.1) and (2) oral cancer (ICD-9 codes 141-149).

Setting

Inpatient admissions in the respective states.

Participants

Cases with primary diagnosis of cerebrovascular disease whose self-identified race was white, black, or Asian.

Interventions

Not applicable.

Main Outcome Measure

Dysphagia, defined by ICD-9 codes 787.2 (dysphagia), 507.0 (aspiration pneumonia), or presence of a feeding tube in the absence of a diagnosis of coma (Current Procedural Terminology codes 432.46 or 437.50 without ICD-9 code 780.01).

Results

In the stroke group, the adjusted odds ratio (OR) with 95% confidence interval (CI) for dysphagia was significantly higher for Asians than whites in New York (OR=1.64; 95% CI, 1.50-1.79) and California (OR=1.69; 95% CI, 1.34-2.13). The adjusted OR was slightly but significantly higher for blacks than whites in New York (OR=1.15; 95% CI, 1.03-1.28), but not in California (OR=1.08; 95% CI, 0.97-1.19). No statistically significant differences among racial groups were found in patients with Parkinson's disease or oral cancer. Other factors strongly associated with dysphagia included hemiplegia (OR=2.19; 95% CI, 2.07-2.32) and aphasia (OR=1.97; 95% CI, 1.83-2.11).

Conclusions

Asians were more likely to have dysphagia after stroke. This association was statistically significant after adjusting for age, sex, stroke severity indicators, comorbidities, and stroke type.     

Serum highly selective C-reactive protein concentration is associated with the volume of ischemic tissue in acute ischemic stroke

Background

There is growing evidence that inflammation plays an important role in atherogenesis. Previous studies have shown that the concentration of peripheral inflammatory markers, particularly C-reactive protein (CRP), strongly correlates with stroke severity and independently predicts mortality and recurrent vascular events in patients with acute ischemic stroke. The aim of this study was to clarify the relationship between inflammatory markers and stroke severity by means of volumetric measurement of infarct size.

Methods

From March 1, 2008, to February 28, 2009, 96 patients who had laboratory investigations and magnetic resonance imaging scans were included retrospectively in this study. Diffusion-weighted imaging (DWI) lesions were outlined using a semiautomatic threshold technique. Diffusion-weighted imaging lesion volumes were measured with MIPAV software (Medical Image Processing, Analysis and Visualization, version 4.1.1; National Institutes of Health, Bethesda, MD). The relationship between highly selective CRP (hs-CRP) levels and DWI infarct volume quartiles was examined.

Results

The mean age of patients was 66.9 years, and 50 patients (51.2%) were male. There was a significant correlation between hs-CRP and DWI volumes (Spearman ρ = 0.239, P = .010). The median hs-CRP values for successive volumes of DWI lesion quartiles (lowest to highest quartile) were as follows: 1.17, 1.14, 1.63, and 3.76 (P = .029).

Conclusions

Higher hs-CRP levels were associated with larger infarct volumes in patients with acute ischemic stroke. These results suggest that elevated hs-CRP levels, reflecting a large volume of infarct, may serve as a helpful serologic marker in the evaluation of severity of acute ischemic stroke.     

Hospital disposition after stroke in a national survey of acute cerebrovascular diseases in Israel

Treger I, Ring H, Schwartz R, Tsabari R, Bornstein NM, Tanne D; for the National Acute Stroke Israeli Survey Group. Hospital disposition after stroke in a national survey of acute cerebrovascular diseases in Israel.

Objective

To investigate predictive factors for disposition after acute stroke.

Design

A nationwide survey (2004 National Acute Stroke Israeli Survey).

Setting

All 28 primary general medical centers operating in Israel.

Participants

Acute stroke patients (n=1583) admitted during February and March 2004 and discharged from the primary hospital.

Interventions

Data collected on baseline characteristics, stroke presentation, type and severity, in-hospital investigation and complications, discharge disability, acute hospital disposition, and mortality follow-up.

Main Outcome Measure

Hospital disposition to home, acute rehabilitation, or nursing facility.

Results

Among patients, 58.9% (n=932) were discharged home, 33.7% (n=534) to rehabilitation departments, and only 7.4% (n=117) to nursing facilities. Admission neurologic status was a good predictor of hospital disposition. Patients with severe strokes were mostly discharged to rehabilitation facilities. Patients with significant functional decline before the index stroke, resulting from a previous stroke or another cause, were sent to inpatient rehabilitation less frequently. Disability level at discharge from acute hospitalization had high predictive value in hospital disposition after stroke. In the northern region of Israel, a higher proportion of patients were sent home and a lower proportion to rehabilitation and nursing facilities, probably because of lower availability of rehabilitation care in this region of Israel.

Conclusions

This nationwide survey shows that most stroke survivors in Israel are discharged home from the acute primary hospital. Good functional status before the index stroke is an important predictor for being sent to acute inpatient rehabilitation. Severity of neurologic impairment and level of disability after the stroke at discharge from the primary hospital are strong predictors for disposition after stroke in Israel. Our data may be useful in discharge planning for stroke patients by policy-makers and health care providers in Israel.     

Team training and stroke rehabilitation outcomes: a cluster randomized trial

Strasser DC, Falconer JA, Stevens AB, Uomoto JM, Herrin J, Bowen SE, Burridge AB. Team training and stroke rehabilitation outcomes: a cluster randomized trial.

Objective

To test whether a team training intervention in stroke rehabilitation is associated with improved patient outcomes.

Design

A cluster randomized trial of 31 rehabilitation units comparing stroke outcomes between intervention and control groups.

Setting

Thirty-one Veterans Affairs medical centers.

Participants

A total of 237 clinical staff on 16 control teams and 227 staff on 15 intervention teams. Stroke patients (N=487) treated by these teams before and after the intervention.

Intervention

The intervention consisted of a multiphase, staff training program delivered over 6 months, including: an off-site workshop emphasizing team dynamics, problem solving, and the use of performance feedback data; and action plans for process improvement; and telephone and videoconference consultations. Control and intervention teams received site-specific team performance profiles with recommendations to use this information to modify team process.

Main Outcome Measures

Three patient outcomes: functional improvement as measured by the change in motor items of the FIM instrument, community discharge, and length of stay (LOS).

Results

For both the primary (stroke only) and secondary analyses (all patients), there was a significant difference in improvement of functional outcome between the 2 groups, with the percentage of stroke patients gaining more than a median FIM gain of 23 points increasing significantly more in the intervention group (difference in increase, 13.6%; P=.032). There was no significant difference in LOS or rates of community discharge.

Conclusions

Stroke patients treated by staff who participated in a team training program were more likely to make functional gains than those treated by staff receiving information only. Team based clinicians are encouraged to examine their own team. (ClinicalTrials.gov identifier NCT00237757).     

Mean flow velocity in the middle cerebral artery is associated with rehabilitation success in ischemic stroke patients

Treger I, Aidinof L, Lutsky L, Kalichman L. Mean flow velocity in the middle cerebral artery is associated with rehabilitation success in ischemic stroke patients.

Objective

To evaluate the association between mean flow velocity (MFV) in the middle cerebral artery (MCA) measured by using transcranial Doppler (TCD) and functional and neurologic impairment change during rehabilitation after acute stroke.

Design

Cross-sectional observational study.

Setting

Acute neurologic rehabilitation department.

Participants

Consecutive patients (N=67; 53 men, 14 women; mean ± SD age, 61.54±8.92y) referred to the rehabilitation center during the first 6 months of 2006 for a first ischemic stroke in the MCA area.

Interventions

Not applicable.

Main Outcome Measures

All subjects were evaluated on admission and at discharge by using the National Institutes of Health Stroke Scale (NIHSS) and the FIM. TCD measurements of MFV of the ipsilateral and contralateral MCA were performed on admission (during the first 20 days after stroke) and a few days before discharge.

Results

Contralateral MFV at admission was associated significantly with all indexes of functional rehabilitation success (FIM score at discharge [β=.169; P=.010], change in FIM score [β=.554; P=.010], relative improvement in FIM score [β=.783; P=.003]). No significant association was found between indexes of NIHSS change and ipsilateral or contralateral MFV.

Conclusions

Ipsilateral or contralateral MFV measured at admission did not change during the 2-month rehabilitation period. Our data showed a significant association between blood flow velocity in the contralateral MCA and functional rehabilitation parameters of patients after first ischemic stroke in the MCA area.     

Ability of laypersons to use the cincinnati prehospital stroke scale

Objective

Early stroke recognition optimizes patients' opportunities to benefit from therapeutic options. Prehospital stroke recognition is suboptimal. If 9-1-1 dispatchers used stroke-identification tools, prehospital stroke recognition might occur more rapidly and accurately. The Cincinnati Prehospital Stroke Scale (CPSS) is a brief, effective tool used by emergency medical services and hospital personnel to identify stroke. The study's goal was to determine whether laypersons could be instructed to use the CPSS over the telephone.

Methods

Adult visitors (laypersons) to a tertiary care emergency department were enrolled. Using a mock patient, laypersons were instructed to use the CPSS via telephone by an investigator simulating a 9-1-1 dispatcher. The patient randomly portrayed clinically normal and abnormal patient types. The layperson's ability to convey CPSS instructions to the patient and relay findings to the investigator was scored.

Results

Seventy laypersons were enrolled (35 each for normal and abnormal patient types). Average age was 48 years, 63% were female, and 40% never attended college. Facial droop and speech instructions were administered with 100% accuracy. Arm drift instructions were administered with 99% accuracy. Layperson accuracies for interpreting findings were 93% for facial droop, 93% for arm drift, and 97% for speech. Overall, stroke symptoms were detected with 94% sensitivity (95% CI 87, 100) and 83% specificity (95% CI 70, 95).

Conclusion

Laypersons correctly administered and interpreted the CPSS when directed to do so over the telephone by a trained investigator. These findings suggest that the CPSS may be a useful tool in early prehospital detection of stroke by dispatchers.     

Reproducibility of the ABILOCO Questionnaire and Comparison Between Self-Reported and Observed Locomotion Ability in Adult Patients With Stroke

Caty GD, Theunissen E, Lejeune TM. Reproducibility of the ABILOCO questionnaire and comparison between self-reported and observed locomotion ability in adult patients with stroke.

Objectives

To test the reproducibility of the ABILOCO questionnaire. To validate the patient self-reporting method and the third-party assessment of the stroke patients' locomotion ability by a treating physical therapist.

Design

Prospective study.

Setting

University hospital.

Participants

Adult stroke patients (N=28; 59±13y). The time since stroke ranged from 3 to 253 weeks.

Interventions

Not applicable.

Main Outcome Measure

The ABILOCO questionnaire.

Results

The results of patient self-assessment and the results of the third-party assessments by the physiotherapists at a 2-week interval were highly correlated (intraclass correlation coefficient [ICC]=.77 and ICC=.89, respectively). The results of the patient self-assessment and the third-party assessment by the physical therapist were both well correlated to assessment by an independent medical examiner who observed the patient during the 13 ABILOCO activities (ICC=.69 and ICC=.87, respectively).

Conclusions

The use of ABILOCO as a self-reporting questionnaire is a valid and reproducible method for assessing locomotion ability in patients with stroke in daily clinical practice and research.     

Somatosensory stimulation enhances the effects of training functional hand tasks in patients with chronic stroke

Celnik P, Hummel F, Harris-Love M, Wolk R, Cohen LG. Somatosensory stimulation enhances the effects of training functional hand tasks in patients with chronic stroke.

Objective

To test the hypothesis that somatosensory stimulation would enhance the effects of training functional hand tasks immediately after practice and 1 day later in chronic subcortical stroke patients.

Design

Single-blinded and randomized, crossover study.

Setting

Human research laboratory.

Participants

Nine chronic subcortical stroke patients.

Interventions

Three separate sessions of motor training preceded by (1) synchronous peripheral nerve stimulation (PNS), (2) no stimulation, or (3) asynchronous PNS.

Main Outcome Measures

Time to complete the Jebsen-Taylor Hand Function Test (JTHFT time) and corticomotor excitability tested with transcranial magnetic stimulation.

Results

After familiarization practice, during which all patients reached a performance plateau, training under the effects of PNS reduced JTHFT time by 10% beyond the post-familiarization plateau. This behavioral gain was accompanied by a specific reduction in GABAergically mediated intracortical inhibition in the motor cortex. These findings were not observed after similar practice under the influence of no stimulation or asynchronous PNS sessions.

Conclusions

Somatosensory stimulation may enhance the training of functional hand tasks in patients with chronic stroke, possibly through modulation of intracortical GABAergic pathways.     

Changes in Passive Mechanical Properties of the Gastrocnemius Muscle at the Muscle Fascicle and Joint Levels in Stroke Survivors

Gao F, Grant TH, Roth EJ, Zhang L-Q. Changes in passive mechanical properties of the gastrocnemius muscle at the muscle fascicle and joint levels in stroke survivors.

Objectives

To investigate the ankle joint-level and muscle fascicle-level changes and their correlations in stroke survivors with spasticity, contracture, and/or muscle weakness at the ankle.

Design

To investigate the fascicular changes of the medial gastrocnemius muscle using ultrasonography and the biomechanical changes at the ankle joint across 0°, 30°, 60°, and 90° knee flexion in a case-control manner.

Setting

Research laboratory in a rehabilitation hospital.

Participants

Stroke survivors (n=10) with ankle spasticity/contracture and healthy control subjects (n=10).

Interventions

Not applicable.

Main Outcome Measurements

At the muscle fascicle level, medial gastrocnemius muscle architecture including the fascicular length, pennation angle, and thickness were evaluated in vivo with the knee and ankle flexion changed systematically. At the joint level, the ankle range of motion (ROM) and stiffness were determined across the range of 0° to 90° knee flexion.

Results

At comparable joint positions, stroke survivors showed reduced muscle fascicle length, especially in ankle dorsiflexion (P≤.048) and smaller pennation angle, especially for more extended knee positions (P≤.049) than those of healthy control subjects. At comparable passive gastrocnemius force, stroke survivors showed higher fascicular stiffness (P≤.044) and shorter fascicle length (P≤.025) than controls. The fascicle-level changes of decreased muscle fascicle length and pennation angle and increased medial gastrocnemius fascicle stiffness in stroke were correlated with the joint level changes of increased joint stiffness and decreased ROM (P<.05).

Conclusions

This study evaluated specific muscle fascicular changes as mechanisms underlying spasticity, contracture, and joint-level impairments, which may help improve stroke rehabilitation and outcome evaluation.     

Physical function and properties of quadriceps femoris muscle in men with knee osteoarthritis

Liikavainio T, Lyytinen T, Tyrväinen E, Sipilä S, Arokoski JP. Physical function and properties of quadriceps femoris muscle in men with knee osteoarthritis.

Objectives

To examine the objective physical function of the lower extremities, to measure the properties of quadriceps femoris muscle (QFM), and to assess subjective disabilities in men with knee osteoarthritis (OA) and to compare the results with those obtained from age- and sex-matched control subjects.

Design

Cross-sectional study.

Setting

Rehabilitation clinic in a university hospital.

Participants

Male volunteers (n=54) (age range, 50-69y) with knee OA and randomly selected healthy, age- and sex-matched control subjects (n=53).

Interventions

Not applicable.

Main Outcome Measures

Physical function evaluated with a test battery including the QFM composition measurement, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and the RAND 36-Item Short-Form Health Survey, version 1.0.

Results

Knee OA patients had 13% to 26% poorer (P range, .050-.001) physical function and muscle strength compared with the controls. There were also significant differences in QFM composition. WOMAC (P range, .050-.001) and muscle strength (P<.001) associated with physical function tests, but subjective pain correlated with neither physical function nor muscle strength in knee OA patients. The radiographic knee OA grade did not have any significant effect on physical function, but passive knee motion, knee extension strength, and WOMAC were related to the severity of the disease (P<.05).

Conclusions

The patients with knee OA exhibited impaired physical function and muscle strength and QFM composition compared with healthy controls. The severity of radiographic knee OA clearly had adverse effects on functional ability at the later stages of the disease. The results highlight the effect of QFM strength on physical function as well as the importance of patient's subjective and objective physical function when deciding on knee OA treatment policy.     

‘My brain couldn’t move from planning a birth to planning a funeral’: A qualitative study of parents’ experiences of decisions after ending a pregnancy for fetal abnormality

Background

With increasing technology for screening and diagnostic testing for fetal abnormality in pregnancy, many more pregnant women and couples are faced with the decision to terminate a pregnancy often after receiving diagnostic test results in the second or third trimester of pregnancy. Whilst there is extensive research on people's experience of diagnostic testing and decision-making, there has been less research on people's experiences of decisions they face immediately following their termination.

Objectives

To describe the experiences of (often unanticipated) decisions that people face in the immediate aftermath of ending a pregnancy following diagnosis of serious fetal abnormality.

Design

Secondary analysis of narrative qualitative interview data.

Settings

Participants were recruited throughout the United Kingdom (UK) and interviewed between 2004 and 2006.

Participants

38 individual mothers, 10 individual fathers and 10 couples who ended a pregnancy following diagnosis of fetal abnormality.

Results

Parents who had experienced the ending of a pregnancy following diagnosis of fetal abnormality described their experiences, and often distress, of facing painful decisions consequent upon their decision to terminate the pregnancy. What was striking from their accounts was their sense of being unprepared for these decisions. Often they suggested that they had received no information or forewarning of the ‘choices’ they would have to make, although information designed specifically for people in this situation is available in the UK.

Conclusions

Many of the decisions that people face in the immediate aftermath of a termination for fetal abnormality are upsetting, and in some circumstances more so because they are not anticipated. Often parents report not receiving information which could be helpful until after these decisions have been made. Health professionals face difficult choices about what issues to raise with patients at this sensitive time, and the optimum time to inform patients of the extra decisions they will face. More research is needed on whether these decisions subsequent to a termination for fetal abnormality have long term implications for people's mental health and their ability to come to terms with their loss.