Can lowering homocysteine levels reduce the incidence of stroke?

Hyperhomocysteinaemia has been identified as an independent risk factor for atherosclerotic and thromboembolic diseases such as cerebro-vascular diseases, coronary artery disease and venous thrombosis. This review will discuss the role of high levels of plasma homocysteine in stroke disease.     

What is the functional outcome for the upper limb after stroke?

The Motor Assessment Scale (MAS) and the Functional Independence Measure (FIM) are commonly used in Australian rehabilitation centres but there have been few systematic studies using them to measure recovery after stroke, especially with regard to upper limb function. The aims of this study were to provide a profile of upper limb recovery in a non-surgical stroke population using measures of impairment and disability. The records of 153 subjects were audited for upper limb MAS sub-scores, the FIM sub-score for upper body dressing, and the total FIM score at admission and discharge from rehabilitation. Significant improvement occurred for all outcome measures. There was no relationship between the MAS scores and the functional task of upper body dressing. The results emphasize the importance of using outcome measures that assess both impairment and disability, and indicate that substantial improvements in upper limb function frequently occur after stroke. Although the MAS has limitations, it is a valuable tool for measuring upper limb outcome after stroke because it provides a more accurate profile of true upper limb recovery than the FIM.     

Can non-contrast head CT and stroke severity be used for stroke triage? A population-based study

Background and PurposeAcute ischemic stroke (AIS) patients may benefit from endovascular thrombectomy (EVT) up to 24 h since last known normal (LKN). Advanced imaging is required for patient selection. Small or rural hospitals may not have sufficient CT technician and radiology support to rapidly acquire and interpret images. We estimated transfer rates using non-contrast head CT and stroke severity to select patients to be transferred to larger centers for evaluation.MethodsWe identified all AIS among residents of the study region in 2010. Only cases age ≥ 18 with baseline mRS 0–2 that presented to an ED were included. Among cases that presented between 6 and 24 h from LKN, those without evidence of acute infarct on head CT and with initial NIHSS ≥6 or ≥ 10 were identified.ResultsOf 1359 AIS cases, 448 (33.0%) presented between 6 and 24 h, of which 383 (85.5%) showed no evidence of acute infarct on CT. Of cases with no acute infarct on CT, 89/383 (23.2%) had NIHSS ≥6, of which 66 (74.2%) initially presented to a hospital without thrombectomy capabilities; and 51/383 (13.3%) had NIHSS ≥10, of which 40 (78.4%) presented to a non-thrombectomy hospital.ConclusionsIn our population, 40–66 AIS patients annually (0.8–1.3/week, or 3–5 patients/100,000 persons/year) may present to non-thrombectomy hospitals and need to be transferred using non-contrast CT and stroke severity as screening tools. Such an approach may sufficiently mitigate the impact of delays in treatment on outcomes, without overburdening the referring nor accepting hospitals.     

Can we exploit event-related potentials for retraining language after stroke?

Purpose: To ascertain the utility of event-related potentials in studying language processing in patients suffering from aphasia. Methods: Recent methods to evaluate event related potentials in response to spoken words were applied in two young patients suffering from a recent aphasia in whom expressive deficits were particularly marked. Recordings were made on three occasions for each patient at the same time of the day. The second recording session took place after six months and the final one after one year. Eighteen right-handed subjects in normal health (10 women, 8 men) were enrolled as controls. Results: Three kinds of potential were obtained over time, P300, P340 and N400. P300 was useful to monitor attention and discrimination. It improved over time. Both of our patients lacked a defined P340 potential, but longitudinal recordings could show a very slow reappearance over time although with a frequently inverted polarity. Apparently, the expressive aphasia did not improve over a one year interval. In contrast to P340, N400 was relatively preserved. This potential is linked to semantic judgement. The patients with relatively preserved comprehension were able to exhibit a N400 soon after stroke. The bilateral representation indicated that the right hemisphere was involved in some kind of language processing. Conclusion: The results indicate that digitized spoken words appear to be an appropriate tool because they permit the study of EEG changes on a millisecond-to-millisecond basis. Apparently, ERPs enable us to study receptive processes in patients with expressive aphasia. Moreover, they appear to be particularly suitable for monitoring the recovery of neural mechanisms responsible for language.     

Health education for stroke patient carers: Does it affect functional status improvement in patients after ischemic stroke?

AimThe aim of the prospective cohort study was to assess the impact of the conducted carer training on functional status improvement in patients after stroke.BackgroundIn recent years, the role of family in unprofessional care provision for patients in their home environment has been emphasized.MethodsThe cohort comprised 157 patients after ischemic stroke. The study group consisted of 81 patients and their carers who participated in the education program, and the control group included 76 patients. We used a repeated measures design: the patients' functional status was assessed on the day of hospital discharge and after 3 and 12 months at home.ResultsAfter 12 months the patients' functional status according to Barthel Index and Modified Rankin Scale significantly improved in both groups, but no difference between the groups was noted in the degree of improvement achieved.ConclusionsThe carers' participation in the education program did not significantly affect the patients' functional improvement.     

Can a functional postural exercise improve performance in the cranio-cervical flexion test? – A preliminary study

Deep cervical flexor (DCF) muscle impairment is common in patients with neck pain. Retraining function is often commenced with a motor relearning approach, requiring the patient to practice and hold a cranio-cervical flexion position in supine lying. Motor relearning requires multiple repetitions which is difficult to achieve if only exercising in supine. This preliminary study investigated the effects of training the DCF with a functional exercise: assumption of an upright lumbo-pelvic and spinal postural position, adding a neck lengthening manoeuvre. The exercise effect was evaluated by changes in sternocleidomastoid (SCM) muscle activity in the cranio-cervical flexion test (CCFT). Twenty subjects with neck pain were randomly assigned to an exercise or control group. The exercise group trained for two weeks. Pre and post-intervention, electromyographic (EMG) signals were recorded from the SCM muscles during the five stages of the CCFT. Results indicated that the exercise improved performance. SCM EMG signal amplitudes decreased across all CCFT stages, albeit significant only at the first and third stages of the test; 22 mmHg (p = 0.043) and 26 mmHg (p = 0.003). No differences were evident in the control group (all p > 0.05). There was no difference between groups for pain and disability measures. This initial study indicates that a postural exercise, convenient to perform during the working day, improves the pattern of SCM muscle activity in the CCFT. Whilst further research is necessary, these observations suggest the worth of such an exercise to augment other training in the rehabilitation of patients with neck pain.     

Accessing rehabilitation after stroke – a guessing game?

Aim: To explore the use, meaning and value of the term “rehabilitation potential”.

Method: The authors of this commentary met to discuss concerns relating to the pressure on health service staff created by reduced length of stay in acute settings of those who have suffered a stroke and the need to determine the potential of a patient for rehabilitation in order to inform discharge arrangements. Points raised at this meeting were shared with an email group who over a 12-month period contributed to this paper.

Results: The group agreed that: (a) Given that there is very limited evidence to guide judgements regarding rehabilitation potential following stroke at an early stage the need for rehabilitation needs to be reviewed on a regular basis over a long period and that this needs to be reflected in clinical guidelines. (b) Rehabilitation needs to be available in a broad range of care settings, in order that discharge from hospital is not equated with a lack of rehabilitation potential. (c) Research related to rehabilitation potential needs to be conducted. This should examine influences of decision-making and the algorithms associated with recovery and local policy on rehabilitation potential. (d) The economic benefits of rehabilitation needs further exploration. (e) Assessment of rehabilitation potential should be made more explicit and supported by appropriate evidence.

Conclusion: Whilst further research is required to assist in determining the right time for people to benefit from formal rehabilitation this gives the impression that one dose of rehabilitation at a specific time will meet all needs. It is likely that a rehabilitation pathway identifying features required in the early stages following stroke as well as that required over many years in order to prevent readmission, maintain fitness and prevent secondary sequelae such as depression and social isolation would be beneficial.

• Implications for Rehabilitation

• The potential of a patient to benefit from rehabilitation may be overlooked due to other pressures.

• Some patients following a stroke will demonstrate potential to benefit from rehabilitation later than the majority and this is not always easy to predict.

• Regular reassessment is required in order to identify whether an individual will benefit from rehabilitation at a particular time.

     

Can staff attitudes to team working in stroke care be improved?

BACKGROUND: Teamwork is regarded as the cornerstone of rehabilitation. It is recognized that the skills of a multiprofessional team are required to provide the care and interventions necessary to maximize the patient's potential to recover from his/her stroke. LITERATURE REVIEW: Critical evaluation of team working is lacking in the literature. Indeed, there is no consensus on a precise definition of teamwork or on the best way of implementing it, beyond a general exhortation to members to work to the same therapeutic plan in a cohesive manner. The literature has highlighted many problems in team working, including petty jealousies, ignorance and a perceived loss of autonomy and threat to professional status. AIM: To determine if the use of team co-ordinated approaches to stroke care and rehabilitation would improve staff attitudes to team working. METHOD: A pre-post design was adopted using 'The Team Climate Inventory' to explore attitudes to team working before and after introducing the interventions. Local Research Ethics Committee approval was obtained. RESULTS: Improvements in attitudes towards team working suggest that the introduction of team co-ordinated approaches (integrated care pathways and team notes) did not result in greater team working. LIMITATIONS: The introduction of an integrated care pathway and team notes is based on an assumption that they would enhance team working. CONCLUSIONS: The results suggest that the introduction of team co-ordinated approaches (team notes and care pathways) do not improve attitudes to team working, teams appear to take a long time to establish cohesion and develop shared values.     

Can there be a good death?

While some deaths are worse than others, there is no such thing as a ‘good death’ since the plausible desiderata of a ‘good death’ form an inconsistent set. Because death is of the greatest existential consequence to us, a ‘good’ death must be a self‐aware death in which we grasp the import of what is happening to us; however, such realization is incompatible with our achieving the tranquillity of mind which is another requirement for the ‘good’ death. Nevertheless, the welcome recognition in recent years by medical personnel, palliative care workers and hospice staff that dying is an existential predicament as well as a physiological condition has enabled more people to avoid a ‘soulless death in intensive care’, even if it pays insufficient regard to the personal virtues that we need if we are to mitigate the worst evils of dying.