Factors Influencing Receipt of Early Rehabilitation After Stroke

Objective

To identify patient-level characteristics associated with rehabilitation during the acute poststroke phase.

Design

Retrospective cohort. Generalized estimating equations modeled the likelihood of rehabilitation during the index hospitalization to account for patient clusters.

Setting

Rehabilitation facilities.

Participants

Sample included veterans (N=9681; average age, 68.7y; 97.4% men) diagnosed with new stroke discharged from Veterans Affairs hospitals between October 1, 2006, and September 30, 2008.

Interventions

Not applicable.

Main Outcome Measure

Receipt of rehabilitation services.

Results

Of the total cohort, 73% received some type of rehabilitation. After adjustment, stroke patients with cerebral arteries occlusion were most likely to receive rehabilitation compared with other stroke types (P<.001). Patients with prestroke conditions of metastatic cancer (odds ratio [OR]=.68, P<.001) and psychosis (OR=.90, P=.045) were less likely to have rehabilitation, whereas those with hypertension (OR=1.26, P<.001) and other neurologic disorders (OR=1.29, P<.001) were more likely. Compared with patients admitted from home, patients transferred from a non-Veterans Affairs hospital (OR=1.4, P<.004) were more likely to receive rehabilitation, whereas patients admitted from extended care (OR=.59, P<.001) were less likely. Married veterans were less likely to receive rehabilitation services (OR=.87, P<.001) than unmarried veterans.

Conclusions

Within the Veterans Health Administration, initiating rehabilitation in the acute phase poststroke appears to be influenced by patient clinical characteristics and living circumstances.     

Predicting Home and Community Walking Activity in People With Stroke

Fulk GD, Reynolds C, Mondal S, Deutsch JE. Predicting home and community walking activity in people with stroke.

Objective

To determine the ability of the 6-minute walk test (6MWT) and other commonly used clinical outcome measures to predict home and community walking activity in high-functioning people with stroke.

Design

Cross-sectional.

Setting

Outpatient physical therapy clinic.

Participants

Participants (N=32) with chronic stroke (n=19; >6mo poststroke) with self-selected gait speed (GS) faster than .40m/s and age-matched healthy participants (n=13).

Interventions

Not applicable.

Main Outcome Measures

Independent variables: 6MWT, self-selected GS, Berg Balance Scale (BBS), lower extremity motor section of the Fugl-Meyer Assessment, and Stroke Impact Scale. Dependent variable: average steps taken per day during a 7-day period, measured using an accelerometer.

Results

6MWT, self-selected GS, and BBS were moderately related to home and community walking activity. The 6MWT was the only predictor of average steps taken per day; it explained 46% of the variance in steps per day.

Conclusions

The 6MWT is a useful outcome measure in higher functioning people with stroke to guide intervention and assess community walking activity.     

Family Functioning Is Associated With Depressive Symptoms in Caregivers of Acute Stroke Survivors

Epstein-Lubow GP, Beevers CG, Bishop DS, Miller IW. Family functioning is associated with depressive symptoms in caregivers of acute stroke survivors.

Objective

To determine whether family functioning is uniquely associated with caregiver depressive symptoms in the immediate aftermath of stroke.

Design

Cross-sectional data from the baseline assessment of an intervention study for stroke survivors and their families.

Setting

Neurology inpatient service of a large urban hospital.

Participants

Stroke survivors (n=192), each with a primary caregiver. The mean age of stroke survivors was 66 years, and most, 57%, were men (n=110). The mean age of caregivers was 57 years, and 73% (n=140) of the caregivers were women. Eighty-five percent of caregivers were white.

Interventions

Not applicable.

Main Outcome Measures

Measures were chosen to assess caregivers' depressive symptoms (Centers for Epidemiologic Studies Depression Scale), family functioning (Family Assessment Device), and additional factors such as health status (Medical Outcomes Study 36-Item Short-Form Health Survey) and stroke survivors' cognitive abilities (modified Mini-Mental State Examination) and functional impairments (FIM and Frenchay Activities Index).

Results

Depressive symptoms were mild to moderate in 14% and severe in 27% of caregivers. Family functioning was assessed as unhealthy in 34% of caregiver-patient dyads. In statistical regression models, caregiver depression was associated with patients' sex, caregivers' general health, and family functioning.

Conclusions

Forty-one percent of caregivers experienced prominent depressive symptoms after their family member's stroke. Higher depression severity in caregivers was associated with caring for a man, and having worse health and poor family functioning. After stroke, the assessment of caregivers' health and family functioning may help determine which caregivers are most at risk for a depressive syndrome.     

Anxiety and Depression Associated With Caregiver Burden in Caregivers of Stroke Survivors With Spasticity

Objective

To investigate the relationship between anxiety/depression and caregiver burden in informal caregivers of stroke survivors with spasticity.

Design

Data were collected via online surveys from informal caregivers 18 years or older who cared for stroke survivors.

Setting

Internet-based survey.

Participants

2007 through 2009 U.S. National Health and Wellness Survey database or Lightspeed Research general panel respondents (N=153).

Interventions

Not applicable.

Main Outcome Measures

Anxiety and depression were self-reported by the caregiver as a physician diagnosis. Depression severity was measured by the Patient Health Questionnaire-9 (PHQ-9). Caregiver burden was measured by the Oberst Caregiving Burden Scale (OCBS) and the Bakas Caregiving Outcomes Scale (BCOS). Logistic regression analyses were conducted with anxiety, depression, and the PHQ-9 depression severity categories as a result of each caregiver burden scale.

Results

Data were analyzed for 153 informal caregivers; they were mostly women (70.6%) and white (78.4%), with a mean age of 51.6 years. For every 1-point increase in the OCBS Difficulty Scale, the odds of anxiety or depression were 2.57 times as great (P<.001) and 1.88 times as great (P=.007), respectively. The odds of PHQ-9 severe depression versus all other categories combined were 2.48 times as great (P<.001). For every 1-point decrease in the BCOS, the odds of anxiety or depression were 2.43 times as great (P<.001) and 2.27 times as great (P=.002), respectively. The odds of PHQ-9 severe depression versus all other categories combined were 4.55 times as great (P<.001).

Conclusions

As caregiver burden increases, caregivers are more likely to have anxiety and depression. Depression severity also increases. Providing treatment to stroke survivors with spasticity that lessens the time and more importantly, the difficulty of caregiving may lead to a reduction in caregiver anxiety and depression.     

影响缺血性脑卒中患者ADL预后的多因素分析

目的:探讨影响缺血性脑卒中患者ADL能力恢复的相关因素,为临床针对性治疗提供依据。方法:对327例确诊的首发缺血性脑卒中患者建立CRF表并记录其各项基本情况。患者出院后随访记录其6个月末时ADL恢复情况。以修订的Barthel指数(MBI)为因变量,以各项可能因素为自变量,进行单因素分析和多元逐步回归分析,最终得出多元回归方程。结果:327例患者在6个月末时失访7例,复发10例,死亡7例,最终进入回归方程的变量为Fugl-Meyer运动功能评分、是否采取早期康复治疗、年龄及神经功能缺损程度评分等。结论:分析了解影响脑卒中患者ADL能力的因素,在发病早期即给予全速的康复干预,可更好改善其预后。     

Factors Associated With Posttraumatic Stress Disorder Among Veterans of Recent Wars Receiving Veterans Affairs Chiropractic Care

ObjectivesPost-traumatic stress disorder (PTSD) is thought to complicate pain management outcomes, which is consistent with the impact of other psychosocial factors in the biopsychosocial model of pain. This study aimed to identify patient sociodemographic and clinical characteristics associated with PTSD prevalence among veterans of Operations Enduring Freedom/Iraqi Freedom/New Dawn (OEF/OIF/OND) who received Veterans Affairs (VA) chiropractic care.MethodsA cross-sectional analysis of electronic health record data from a national cohort study of OEF/OIF/OND veterans with at least 1 visit to a VA chiropractic clinic from 2001 to 2014 was performed. The primary outcome measure was a prior PTSD diagnosis. Variables including sex, race, age, body mass index, pain intensity, alcohol and substance use disorders, and smoking status were examined in association with PTSD diagnosis using logistic regression.ResultsWe identified 14,025 OEF/OIF/OND veterans with at least 1 VA chiropractic visit, with a mean age of 38 years and 54.2% having a diagnosis of PTSD. Male sex (adjusted odds ratio [OR] = 1.23, 95% CI = 1.11-1.37), younger age (OR = 0.99, CI = 0.98-0.99), moderate-to-severe pain intensity (numerical rating scale ≥ 4) (OR = 1.72, CI = 1.59-1.87), body mass index ≥ 30 (OR = 1.34, CI = 1.24-1.45), current smoking (OR = 1.32, CI = 1.20-1.44), and having an alcohol or substance use disorder (OR = 4.51, CI = 4.01-5.08) were significantly associated with a higher likelihood of PTSD diagnosis.ConclusionPost-traumatic stress disorder is a common comorbidity among OEF/OIF/OND veterans receiving VA chiropractic care and is significantly associated with several patient characteristics. Recognition of these factors is important for the appropriate diagnosis and management of veterans with PTSD seeking chiropractic treatment for pain conditions.     

Rehabilitation Outcomes of Stroke Patients With and Without Diabetes

Objective

To investigate the relation of diabetes comorbidity and the rehabilitation outcomes of patients with stroke.

Design

Secondary data analysis.

Setting

Inpatient rehabilitation facilities.

Participants

Patients with stroke (N=35,243) who received inpatient rehabilitation in 2004 through 2008.

Interventions

None.

Main Outcome Measures

FIM, length of stay, and discharge destination.

Results

Mean age ± SD of the sample was 71.0±13.2 years. The percent of the sample of Medicare beneficiaries was 53.8%, whereas 46.2% had other sources of funding. Of the patients in the sample, 34.5% had a comorbidity of diabetes, with 17.2% classified as tier-eligible and 82.8% as nontier eligible. Findings included that patients in this sample with diabetes were admitted for rehabilitation services at a younger age than those without diabetes and support previous studies in which tier-eligible diabetes comorbidities moderated by patient age were found to be significant predictors of stroke rehabilitation outcomes. Furthermore, similar findings remained regardless of payer source.

Conclusions

This study provides additional evidence that diabetes as a comorbidity is significantly related to stroke rehabilitation outcome, but the relation is moderated by patient age.     

Patient Factors Associated With Return to Driving Poststroke: Findings From a Multicenter Cohort Study

Perrier M-J, Korner-Bitensky N, Mayo NE. Patient factors associated with return to driving poststroke: findings from a multicenter cohort study.

Objective

To estimate the extent to which body structure, function, activity, and context explain driving resumption at 1 year.

Design

Cohort study with relationships modeled in a path analysis.

Setting

Three urban Canadian communities.

Participants

Patients admitted to hospital with acute stroke who had driven before their stroke (n=290) who participated in a longitudinal study of stroke outcomes.

Main Outcome Measures

Driving resumption 1 year after the initial stroke diagnosis.

Results

One hundred seventy-seven patients (61%) returned to driving after 1 year. Direct relationships were found between measures of strength and motor activity (Stroke Impact Scale), cognition (Mini-Mental State Examination), type of stroke (hemorrhagic vs ischemic), and driving resumption at 1 year. The effects of stroke severity, fatigue, and sex on driving resumption were mediated through strength and motor activity shown by a model that had excellent fit (comparative fit index=.985, Tucker-Lewis Index=.952, root mean square error of approximation=.046).

Conclusions

There are multiple direct and indirect influences on driving resumption at 1 year, from the type of stroke, physical strength and motor activity, cognition, sex, and fatigue measured at 3 months. The paths outlined by this model highlight how stroke sequelae influence community mobility, as well as factors related to driving resumption that are amenable to intervention.     

Cortical Reorganization Induced by Body Weight-Supported Treadmill Training in Patients With Hemiparesis of Different Stroke Durations

Yang Y-R, Chen I-H, Liao K-K, Huang C-C, Wang R-Y. Cortical reorganization induced by body weight-supported treadmill training in patients with hemiparesis of different stroke durations.

Objective

To investigate corticomotor changes induced by body weight-supported treadmill training (BWSTT) in patients with short or long poststroke duration.

Design

Single-blinded and randomized controlled trial.

Setting

Neurologic physical therapy research laboratory.

Participants

Hemiparesis patients (N=18) whose motor-evoked potentials could be induced participated in this study. Subjects in each hemiparesis postonset of short (<6mo) or long (>12mo) duration group were randomly assigned to either the control or experimental group.

Interventions

Subjects in the experimental groups participated in BWSTT for 4 weeks. Those in the control groups received the general exercise program.

Main Outcome Measures

The primary outcomes were motor threshold and map size of the abductor hallucis muscle in the ipsilesional hemisphere. The secondary outcome was Fugl-Meyer Assessment. Outcome measures were blindly assessed before and after completing the 4 weeks of training.

Results

The 4-week BWSTT resulted in a decrease of motor threshold and an increase of map size in subjects with hemiparesis of short duration, whereas only the expansion of the map size was noted in subjects with hemiparesis of long duration. Improvement of motor control occurred in subjects with hemiparesis of both short and long duration after BWSTT.

Conclusions

The BWSTT results in similar improvement in motor control but different patterns of treatment-induced cortical reorganization in subjects with different poststroke durations.     

Timed Walking Tests Correlate With Daily Step Activity In Persons With Stroke

Mudge S, Stott NS. Timed walking tests correlate with daily step activity in persons with stroke.

Objectives

To examine the relationship among 4 clinical measures of walking ability and the outputs of the StepWatch Activity Monitor in participants with stroke.

Design

Correlational study.

Setting

Clinic and participants' usual environments.

Participants

Fifty participants more than 6 months after stroke were recruited. All participants were able to walk independently, but with some residual difficulty.

Interventions

Not applicable.

Main Outcome Measures

Rivermead Mobility Index (RMI), Rivermead Motor Assessment (RMA), six-minute walk test (6MWT), ten-meter walk test (10MWT), StepWatch outputs (based on daily step counts and stepping rates).

Results

The correlations between the RMA and all StepWatch outputs were low (ρ=0.36-0.48; P<.05), as were most for the RMI (ρ=0.31-0.52; P<.05). The 10MWT and 6MWT had moderate to high correlations (ρ=0.51-0.73; P<.01) with most StepWatch outputs. Multiple regression showed that the 6MWT was the only significant predictor for most StepWatch outputs, accounting for between 38% and 54% of the variance. Age and the RMI were further significant predictors of 1 and 2 outputs, respectively.

Conclusions

The 6MWT has the strongest relationship with the StepWatch outputs and may be a better test than the 10MWT to predict usual walking performance. However, it should be remembered that the 6MWT explains only half the variability in usual walking performance. Thus, activity monitoring captures aspects of walking performance not captured by other clinical tests and should be considered as an additional outcome measure in stroke rehabilitation.     

Gravity-Supported Exercise With Computer Gaming Improves Arm Function in Chronic Stroke

Objective

To investigate the effect of 4 to 6 weeks of exergaming with a computer mouse embedded within an arm skate on upper limb function in survivors of chronic stroke.

Design

Intervention study with a 4-week postintervention follow-up.

Setting

In home.

Participants

Survivors (N=13) of chronic (≥6mo) stroke with hemiparesis of the upper limb with stable baseline Fugl-Meyer assessment scores received the intervention. One participant withdrew, and 2 participants were not reassessed at the 4-week follow-up. No participants withdrew as a result of adverse effects.

Intervention

Four to 6 weeks of exergaming using the arm skate where participants received either 9 (n=5) or 16 (n=7) hours of game play.

Main Outcome Measure

Upper limb component of the Fugl-Meyer assessment.

Results

There was an average increase in the Fugl-Meyer upper limb assessment score from the beginning to end of the intervention of 4.9 points. At the end of the 4-week period after the intervention, the increase was 4.4 points.

Conclusions

A 4- to 6-week intervention using the arm skate significantly improved arm function in survivors of chronic stroke by an average of 4.9 Fugl-Meyer upper limb assessment points. This research shows that a larger-scale randomized trial of this device is warranted and highlights the potential value of using virtual reality technology (eg, computer games) in a rehabilitation setting.     

Effectiveness of Supported Employment for Veterans With Spinal Cord Injury: 2-Year Results

Objective

To examine if supported employment (SE) remains more effective than treatment as usual (TAU) in returning veterans to competitive employment after spinal cord injury (SCI) at 2-year follow-up.

Design

Prospective, randomized, controlled, multisite trial of SE versus TAU with 24 months of follow-up.

Setting

SCI centers.

Participants

Subjects (N=201) were enrolled and completed baseline interviews. At interventional sites, subjects were randomized to SE (n=81) or TAU (n=76). At observational sites, 44 subjects were enrolled in a nonrandomized TAU condition.

Intervention

The intervention was a SE program called the SCI Vocational Integration Program, which followed the principles of the individual placement and support model of SE for persons with mental illness.

Main Outcome Measures

Competitive employment in the community within 2 years.

Results

For the entire 2-year follow-up period, SE subjects were significantly more likely to achieve employment (30.8%; 95% confidence interval [CI], 21.8–41.6) than either the TAU subjects at the intervention sites (10.5%; 95% CI, 5.2–19.7; P<.001) or the TAU subjects at the observational sites (2.3%; 95% CI, 0.0–12.9; P<.002). Most subjects who obtained competitive employment did so in year 1, and the average time to first employment was about 17 weeks.

Conclusions

SE was better than usual practices in improving employment outcomes for veterans with SCI across a 2-year follow-up period. Although SE continued to be superior to traditional practices over the entire study, the first year of participation in SE may represent a critical window for achieving employment after SCI.     

Factors Associated With Interest in Subspecialty Training Among Neurology Residents

Phenomenon: Previous studies have not explored factors associated with decisions among neurology residents to pursue subspecialty training within neurology. Understanding career choices among neurology residents, particularly decisions regarding subspecialty training, is critical, as neurologists with specialized knowledge can help meet the needs of patients with specific disease conditions. This study addresses the knowledge gap about subspecialty training decisions by examining factors associated with neurology residents' interest in pursuing subspecialty training and the types of subspecialty training neurology residents consider. Approach: We surveyed a geographically stratified sample of neurology residents in U.S. training programs using a two-stage survey design. In Stage 1, we randomly sampled half of the accredited neurology residency programs stratified by U.S. census region; Stage 2 involved a survey of neurology residents within these programs. Findings: The majority (approximately 81%) of residents expressed interest in subspecialty training. Resident demographic characteristics and educational debt did not influence interest in pursuing subspecialty training. Residents were more likely to express interest in subspecialty training when they participated in any neurology research (odds ratio [OR] = 2.39), 95% confidence interval (CI) [1.13, 5.07], p = .02, and indicated more interest in careers involving teaching (OR = 8.33), 95% CI [1.64, 42.19], p = .01. Considering the “medical content of subspecialty” as a more important factor approached but did not reach statistical significance (OR = 3.12), 95% CI [0.97, 10.06], p = .06. Insights: Participation in any neurology research and interest in careers involving teaching are associated with interest in subspecialty training among neurology residents. Further research is needed to determine whether exposure to research and teaching stimulates interest in subspecialty training and whether residents believe that subspecialty training is instrumental in pursuing an academic career.     

5-Repetition Sit-to-Stand Test in Subjects With Chronic Stroke: Reliability and Validity

Mong Y, Teo TW, Ng SS. 5-repetition sit-to-stand test in subjects with chronic stroke: reliability and validity.

Objectives

To examine the (1) intrarater, interrater, and test-retest reliability of the 5-repetition sit-to-stand test (5-repetition STS test) scores, (2) correlation of 5-repetition STS test scores with lower-limb muscle strength and balance performance, and (3) cut-off scores among the 3 groups of subjects: the young, the healthy elderly, and subjects with stroke.

Design

Cross-sectional study.

Setting

University-based rehabilitation center.

Participants

A convenience sample of 36 subjects: 12 subjects with chronic stroke, 12 healthy elderly subjects, and 12 young subjects.

Interventions

Not applicable.

Main Outcome Measures

5-Repetition STS test time scores; hand-held dynamometer measurements of hip flexors, and knee flexors and extensors; ankle dorsiflexors and plantarflexors muscle strength; Berg Balance Scale (BBS); and limits of stability (LOS) test using dynamic posturography.

Results

Excellent intrarater reliability of intraclass correlation coefficient (ICC) (range, .970-.976), interrater reliability (ICC=.999), and test-retest reliability (ICC range, .989-.999) were found. Five-repetition STS test scores were also found to be significantly associated with the muscle strength of affected and unaffected knee flexors (ρ=-.753 to -.830; P<.00556) of the subjects with stroke. No significant associations were found between 5-repetition STS test and BBS and LOS tests in subjects with stroke. Cut-off scores of 12 seconds were found to be discriminatory between healthy elderly and subjects with stroke at a sensitivity of 83% and specificity of 75%.

Conclusions

The 5-repetition STS test is a reliable measurement tool that correlates with knee flexors muscle strength but not balance ability in subjects with stroke.