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Motor and Functional Recovery After Stroke A Comparison of 4 European Rehabilitation Centers
Abstract
Outcome after first stroke varies significantly across Europe. This study was designed to compare motor and functional recovery after stroke between four European rehabilitation centers.
Consecutive stroke patients (532 patients) were recruited. They were assessed on admission and at 2, 4, and 6 months after stroke with the Barthel Index, Rivermead Motor Assessment of Gross Function, Rivermead Motor Assessment of Leg/Trunk, Rivermead Motor Assessment of Arm, and Nottingham Extended Activities of Daily Living (except on admission). Data were analyzed using random effects ordinal logistic models adjusting for case-mix and multiple testing.
Patients in the UK center were more likely to stay in lower Rivermead Motor Assessment of Gross Function classes compared with patients in the German center (DeltaOR, 2.4; 95% CI, 1.3 to 4.3). In the Swiss center, patients were less likely to stay in lower Nottingham Extended Activities of Daily Living classes compared with patients in the UK center (DeltaOR, 0.7; 95% CI, 0.5 to 0.9). The latter were less likely to stay in lower Barthel Index classes compared with the patients in the German center (DeltaOR, 0.6; 95%CI, 0.4 to 0.8). Recovery patterns of Rivermead Motor Assessment of Leg/Trunk and Rivermead Motor Assessment of Arm were not significantly different between centers.
Gross motor and functional recovery were better in the German and Swiss centers compared with the UK center, respectively. Personal self-care recovery was better in the UK compared with the German center. Previous studies in the same centers indicated that German and Swiss patients received more therapy per day. This was not the result of more staff but of a more efficient use of human resources. This study indicates potential for improving rehabilitation outcomes in the UK and Belgian centers.
... 13,14 Research comparing stroke rehabilitation outcomes in four European countries showed that UK stroke patients received less therapy and had poorer outcomes than those in Germany and Switzerland, even when confounding variables (such as stroke severity) were controlled. 15 The differences in outcome were attributed to the amount, rather than the type, of therapy and the UK's low dose of therapy was due to poor organisation, rather than lower staffing levels. [16][17][18][19] For many years, stroke has been recognised as an NHS priority area, which led to a National Stroke Improvement Programme, including instigation of a national stroke register and audit programme called the Sentinel Stroke National Audit Programme (SSNAP). ...
... The level of consciousness scores (i.e. 0, 1, 2 and 3) were mapped on to stroke severity scores from the NIHSS as follows: l level of consciousness = 0 = mild stroke (NIHSS score < 5) l level of consciousness = 1 = moderate stroke (NIHSS score 5-14) l level of consciousness = 2 = severe stroke (NIHSS score [15][16][17][18][19][20] l level of consciousness = 3 = very severe stroke (NIHSS score > 20). If other items were recorded, they were added to the patient's score, thus the patient's corresponding severity category was defined as the total of the patient observed score plus the adjustment value for level of consciousness. ...
... Over a decade ago, the CERISE (Collaborative Evaluation of Rehabilitation in Stroke across Europe) study showed that low amounts of therapy in the UK were related to poorer outcomes and were due to the way therapists' workload was organised, with administration and non-direct contact often being given priority over face-to-face contact with patients. 9,15,17 Since then, NHS funding has fallen and staff shortages have risen, 84 such that staffing levels may have been 'cut to the bone' and that therapists struggle to provide sufficient therapy. A recent ethnographic study found that although staffing levels influenced the amount of therapy provided, the way in which therapy services were organised also played a part. ...
Background
Therapy is key to effective stroke care, but many patients receive little.
Objectives
To understand how stroke therapy is delivered in England, Wales and Northern Ireland, and which factors are associated with dose, outcome and resource use.
Design
Secondary analysis of the Sentinel Stroke National Audit Programme, using standard descriptive statistics and multilevel mixed-effects regression models, while adjusting for all known and measured confounders.
Setting
Stroke services in England, Wales and Northern Ireland.
Participants
A total of 94,905 adults admitted with stroke, who remained an inpatient for > 72 hours.
Results
Routes through stroke services were highly varied (> 800), but four common stroke pathways emerged. Seven distinct impairment-based patient subgroups were characterised. The average amount of therapy was very low. Modifiable factors associated with the average amount of inpatient therapy were type of stroke team, timely therapy assessments, staffing levels and model of therapy provision. More (of any type of) therapy was associated with shorter length of stay, less resource use and lower mortality. More occupational therapy, speech therapy and psychology were also associated with less disability and institutionalisation. Large amounts of physiotherapy were associated with greater disability and institutionalisation.
Limitations
Use of observational data does not infer causation. All efforts were made to adjust for all known and measured confounding factors but some may remain. We categorised participants using the National Institutes of Health Stroke Scale, which measures a limited number of impairments relatively crudely, so mild or rare impairments may have been missed.
Conclusions
Stroke patients receive very little therapy. Modifiable organisational factors associated with greater amounts of therapy were identified, and positive associations between amount of therapy and outcome were confirmed. The reason for the unexpected associations between large amounts of physiotherapy, disability and institutionalisation is unknown. Prospective work is urgently needed to investigate further. Future work needs to investigate (1) prospectively, the association between physiotherapy and outcome; (2) the optimal amount of therapy to provide for different patient groups; (3) the most effective way of organising stroke therapy/rehabilitation services, including service configuration, staffing levels and working hours; and (4) how to reduce unexplained variation in resource use.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research ; Vol. 8, No. 17. See the NIHR Journals Library website for further project information.
... Actual therapy time during a regular day at a rehabilitation hospital is generally very limited. This is mostly due to management decisions, lack of structured organization and inefficient use of resources [6,7]. In four European rehabilitation centers, individuals with stroke received between one and three hours of therapy per day, yet,over 72 % of the day was spent on non-therapeutic activities [6]. ...
... In four European rehabilitation centers, individuals with stroke received between one and three hours of therapy per day, yet,over 72 % of the day was spent on non-therapeutic activities [6]. This has consequences, as these authors were also able to show that patients in centers with less therapy time per day have less functional recovery than those who are treated in centers that provide more therapy time per day [7]. ...
... So, while it is certainly possible to intensify therapeutic treatments during inpatient rehabilitation [3,7], it is challenging for many reasons and often not done. ...
Evidence more and more supports the notion that higher intensity training also leads to better outcomes in neurorehabilitation. However, current practice shows that for many reasons, it is challenging for health care professionals to deliver such high intensity training. Rehabilitation technology can be one important factor to help overcome those barriers and to provide to our patients the intensive therapy they need and deserve. It is, however, crucial that those devices are well integrated into the clinical every day practice, well combined with traditional therapy and that reimbursement questions are solved. The work is cut out for us, let's all get to work, for the benefit of our patients!.
... However, there is no unified selection of patients for specialized inpatient rehabilitation. The existing inclusion criteria have a permissive nature and the availability and effectiveness of services in different countries vary depending on local policy and available resources (12)(13)(14). ...
... The CERISE study demonstrated diverse results when comparing four European rehabilitation centres with direct transfer from the acute setting (13). Even so, they state that comparison between countries could serve to guide optimization of stroke care (13). ...
... The CERISE study demonstrated diverse results when comparing four European rehabilitation centres with direct transfer from the acute setting (13). Even so, they state that comparison between countries could serve to guide optimization of stroke care (13). ...
Objectives:
Inpatient rehabilitation is a commonly used complex intervention to improve a person's independence after stroke. Evaluation and comparison of the effects of routine clinical practice could provide a contribution towards optimization of stroke care. The aim of this study is to describe results of inpatient rehabilitation as a complex intervention for persons after stroke and explore possible differences between two countries.
Methods:
Data from 1055 Latvian and 1748 Swedish adult patients after stroke receiving inpatient rehabilitation, during 2011-2013, were used for this retrospective cohort study. Qualitative description of systems, as well as information on basic medical and sociodemographic information, and organizational aspects were reported. Change in the Functional Independence Measure during rehabilitation was investigated. In six domains of the instrument, the shifts for three levels of dependence were analysed using ordinal regression analysis.
Results:
The components of stroke care seem to be similar in Latvia and Sweden. However, the median time since stroke onset until the start of rehabilitation was 13 weeks in Latvia and 2 weeks in Sweden. The median length of rehabilitation was 12 and 49 days, respectively. The level of dependency at start, time since stroke onset and length of the period had an impact on the results of the rehabilitation.
Conclusions:
Although components of the rehabilitation are reported as being the same, characteristics and the outcome of the inpatient rehabilitation are different. Therefore, comparison of stroke rehabilitation between countries requires caution.
... Langhamer et al. [15] compared nine specialized rehabilitation centers in seven different countries and found great disparities in length of stay, rehabilitation intensity, and therapeutic content, often with little reference to evidence-based practice. Even in developed countries in western Europe, among reputable rehabilitation facilities where evidence-based treatment is expected, variable therapeutic content and rehabilitation outcomes have been reported [16]. This wide variety in rehabilitation care practice also holds true in SN care. ...
... In addition, patients usually stay in the BIR Program for 10-12 weeks. As shown in the present study, the median length of stay was 74 days, which is considerably longer than the 23 days reported in Chen et al.'s study [14], reflecting the difference in length of rehabilitation stay between the United States (17-23 days [10,15,34]) and European countries (45-75 days [16,44]). However, a longer hospital stay may not necessarily lead to better functional outcomes [45,46]; thus, it is unknown whether the length of hospital stay plays an important role. ...
Spatial neglect (SN) impedes functional recovery after stroke, leading to reduced rehabilitation gains and slowed recovery. The objective of the present study was to investigate whether integrating prism adaptation treatment (PAT) into a highly intensive rehabilitation program eliminates the negative impact of spatial neglect on functional and motor recovery. We examined clinical data of the 355 consecutive first-time stroke patients admitted to a sub-acute inpatient neurorehabilitation program that integrated PAT. The 7-item Motor Functional Independence Measure, Berg Balance Scale, and Motor Activity Log were used as main outcome measures. We found that 84 patients (23.7%) had SN, as defined by a positive score on the Catherine Bergego Scale via the Kessler Foundation Neglect Assessment Process (KF-NAP®). Although 71 patients (85%) received PAT, the presence of SN at baseline, regardless of PAT completion, was associated with lower functional independence, higher risk of falls, and a lower functional level of the affected upper limb both at admission and at discharge. The severity of SN was associated with inferior rehabilitation outcomes. Nonetheless, patients with SN who received PAT had similar rehabilitation gains compared to patients without SN. Thus, the present study suggests that integrating PAT in an intensive rehabilitation program will result in improved responses to regular therapies in patients with SN.
... By undergoing a speci c stroke rehabilitation pathway, persons with stroke can achieve their best possible functional independence, which ultimately improves their quality of life (7). Good outcomes after stroke have been seen in patients undergoing rehabilitation in the conventional setting (9,(28)(29)(30)(31)(32). Stroke outcomes have also been shown to be better in cases managed at the stroke units with multi-disciplinary care (33). ...
Background
Conventional and complementary treatments are often used in rehabilitation for persons with stroke. Conventional treatment makes use of medications, physiotherapy, occupational, speech and diet therapies while complementary treatment makes use of homeopathy, naturopathy, massage and acupuncture. The structure, process and outcomes of stroke rehabilitation using conventional or complementary treatments have not been empirically investigated in Ghana.
Aim
To investigate the structure, process and outcomes of stroke rehabilitation at the Korle Bu Teaching Hospital (KBTH) in Accra and Kwayisi Christian Herbal Clinic (KCHC) in Nankese-Ayisaa, Ghana and to explore experiences of persons with stroke.
Methods
A mixed methods approach involving a cross sectional, hospital-based cohort and qualitative exploratory studies. The objectives of the study will be achieved using three phases: Phase one will recruit health professionals and gather information on the structure and process of stroke rehabilitation at conventional and complementary hospital using adapted questionnaires. Phase two will determine outcomes of persons with stroke attending a conventional and complementary hospital facility at baseline, two, three- and six-months follow-up using outcome measures based on the International Classification of Functioning, Disability and Health (ICF) model. Phase three will explore experiences of persons with stroke who use complementary or conventional treatment using an interview guide.
Data Analysis
IBM SPSS Statistics Version 27 will be used to analyse the data using descriptive and inferential statistics. Repeated measures of ANOVA analysis will be used to determine differences between varaibles at baseline, one, three- and six-months post stroke. The qualitative data will be transcribed and entered into Atlas Ti version 9.0. The data will be coded and analysed using thematic areas that will be generated from the codes.
Conclusion
The study protocol will provide a comprehensive overview of structure, process and outcomes of stroke rehabilitation in Ghana: incorporating both conventional and complementary treatment and rehabilitation into the stroke recovery journey. It will also inform clinical practice, with new insights on the experiences of persons with stroke based on their choice of rehabilitation pathway.
... We evaluated functional status related to stroke using the Korean version of modified Barthel index (K-MBI), Berg balance scale (BBS), functional ambulatory category (FAC), and manual function test (MFT), which have been well-established for patients with stroke. The K-MBI is used to assess performance in 10 basic activities related to self-care and mobility, with a score ranging from 0 to 100 and lower scores indicating greater dependency (23). The BBS is used to evaluate a patient's ability to safely balance during a series of predetermined tasks. ...
Background
Stroke-related sarcopenia is caused by various factors, such as brain damage, systemic catabolic state, skeletal muscle imbalance, and malnutrition. In the long-term care plan after stroke, appropriate rehabilitation strategies to achieve maximum functional improvement and prevent the development of sarcopenia are important. This study has investigated the effect of branched-chain amino acid (BCAA) supplementation on sarcopenia after stroke. We also evaluated the effect of BCAA on functional improvement during the intensive rehabilitation period.
Methods
Patients with subacute stroke with stroke-related disabilities were enrolled and given dietary supplement powder containing BCAAs for 1 month. These BCAAs were supplied through the nutrition team during feeding time. Patients whose age, sex, and stroke lesions were similar to those of the study group were enrolled in the control group through medical record review. Both groups received personalized intensive inpatient rehabilitation therapy in a single-unit rehabilitation center. All patients' target calories were calculated regularly by the nutritional support team in our institution. Sarcopenia status was evaluated using grip strength and the skeletal muscle index (SMI), which was assessed by dual-energy X-ray absorptiometry (DEXA). The functional status associated with stroke was evaluated every month, including activities of daily living, balance, gait, and swallowing.
Results
A total of 54 patients were enrolled, with 27 patients in each of the two groups. The study group showed significantly greater improvement in SMI after intervention than the control group. Both groups improved functionally over time, but the improvement in the study group was significantly greater than that in the control group. Univariate analysis revealed that patients with better functional status had a greater SMI with a combination of BCAA supplementation and intensive rehabilitation therapy.
Conclusion
Our results showed a positive effect of BCAA supplementation on sarcopenia after stroke. We also found that nutritional support helps functional improvement during neurological recovery. These results suggest that comprehensive rehabilitation intervention combined with BCAA supplementation could be a helpful option during the critical period of post-stroke neurological recovery.
... The findings of non-significant differences between 6 and 12 months post-stroke support hypothesis 2. Nonetheless, both the mean (online supplement, Table S1) and median ( Figure 2) values suggest further improvements in most temporospatial parameters. In aggregate, our results agree with other longitudinal studies reporting that the major recovery of motor function takes place within the first few months of stroke [35][36][37][38][39][40]. Less prominent improvements in gait past first 6 months may be due to a decreased capacity for neuroplasticity later in the course of recovery or no provision/less intense outpatient therapy between 6 and 12 months post-stroke. ...
Given the paucity of longitudinal data in gait recovery after stroke, we compared temporospatial gait characteristics of stroke patients during subacute (<2 months post-onset, T0) and at approximately 6 and 12 months post-onset (T1 and T2, respectively) and explored the relationship between gait characteristics at T0 and the changes in gait speed from T0 to T1. Forty-six participants were assessed at T0 and a subsample of 24 participants at T2. Outcome measures included Fugl-Meyer lower-extremity motor score, 14 temporospatial gait parameters and symmetry indices of 5 step parameters. Except for step width, all temporospatial parameters improved from T0 to T1 (p ≤ 0.0001). Additionally, significant improvements in symmetry were found for the initial double-support time and single-support time (p ≤ 0.0001). Although group results at T2 were not different from those at T1, the individual analysis revealed that 42% (10/24) of the subsample showed a significant increase in gait speed. The increase in gait speed from T0 to T1 was negatively correlated with gait speed and stride length, and positively correlated with the symmetry indices of stance and single-support times at T0 (p ≤ 0.002). Temporospatial gait parameters and stance time symmetry improve over the first 6 months after stroke with an apparent plateau thereafter. Approximately 40% of the subsample continue to increase gait speed from 6 to 12 months post-stroke. A greater increase in gait speed during the first 6 months post-stroke is associated with initially slower walking, shorter stride length, and more pronounced asymmetry in stance and single-support times. The improvement in lower-extremity motor function and bilateral improvements in step parameters collectively suggest that gait changes over the first 12 months after stroke are likely due to neurological recovery, although some compensation by the non-paretic side cannot be excluded.
... Similarly, when considering initial severe motor impairment, secondary A reported limitation of the study by Scrutinio et al. (also presented in Table 1) was in relation to LOS, quite longer than comparable populations in other countries. Mean or median LOS varies considerably, ranging from 17 days in the United States (Reistetter et al., 2010) to 35 in Canada (Grant et al., 2014), to 44-66 in Europe (De Wit et al., 2007). Therefore, as presented in Table 5, we conducted an additional analysis considering only participants with LOS ≤ 66 (48.2% of participants) in which model 3 yielded an AUC = 0.901 (0.849-0.952) for primary outcome and AUC = 0.844 (0.776-0.913) for secondary outcome. ...
Background:
Many efforts have been devoted to identify predictors of functional outcomes after stroke rehabilitation. Though extensively recommended, there are very few external validation studies.
Objective:
To externally validate two predictive models (Maugeri model 1 and model 2) and to develop a new model (model 3) that estimate the probability of achieving improvement in physical functioning (primary outcome) and a level of independence requiring no more than supervision (secondary outcome) after stroke rehabilitation.
Methods:
We used multivariable logistic regression analysis for validation and development. Main outcome measures were: Functional Independence Measure (FIM) (primary outcome), Functional Independence Staging (FIS) (secondary outcome) and Minimal Clinically Important Difference (MCID).
Results:
Patients with stroke admitted to a rehabilitation center from 2006 to 2019 were retrospectively studied (N = 710). Validation of Maugeri models confirmed very good discrimination: for model 1 AUC = 0.873 (0.833-0.915) and model 2 AUC = 0.803 (0.749-0.857). The Hosmer-Lemeshow χ 2 was 6.07(P = 0.63) and 8.91(P = 0.34) respectively. Model 3 yielded an AUC = 0.894 (0.857-0.929) (primary outcome) and an AUC = 0.769 (0.714-0.825) (MCID).
Conclusions:
Discriminative power of both Maugeri models was externally confirmed (in a 20 years younger population) and a new model (incorporating aphasia) was developed outperforming Maugeri models in primary outcome and MCID.
... 17 Moreover, some elements within the scope of the socioeconomic status (SES) paradigm have been associated with post-stroke recovery. 18 Lower income patients are less likely to access outpatient and ambulatory health care services. 19 In addition, these patients are presented with challenges regarding medication acquisition and proper nutrition optimal for recovery. ...
Background and purpose:
Blacks have a higher burden of post-stroke disability. Factors associated with racial differences in long-term post-stroke disability are not well-understood. Our aim was to assess the long-term racial differences in risk factors associated with stroke recovery.
Methods:
We examined Health and Retirement Study (HRS) longitudinal interview data collected from adults living with stroke who were aged >50 years during 2000-2014. Analysis of 1,002 first-time, non-Hispanic, Black (210) or White (792) stroke survivors with data on activities of daily living (ADL), fine motor skills (FMS) and gross motor skills (GMS) was conducted. Ordinal regression analysis was used to assess the impact of sex, race, household residents, household income, comorbidities, and the time since having a stroke on functional outcomes.
Results:
Black stroke survivors were younger compared with Whites (69 ± 10.4 vs 75 ± 11.9). The majority (~65%) of Black stroke survivors were female compared with about 54% White female stroke survivors (P=.007). Black stroke survivors had more household residents (P<.001) and comorbidities (P<.001). Aging, being female, being Black and a longer time since stroke were associated with a higher odds of having increased difficulty in ADL, FMS and/or GMS. Comorbidities were associated with increased difficulty with GMS. Black race increased the impact of comorbidities on ADL and FMS in comparison with Whites.
Conclusion:
Our data suggest that the effects of aging, sex and unique factors associated with race should be taken into consideration for future studies of post-stroke recovery and therapy.
... Hence, the tribution was ove-disperssed (variance > mean) and the expected CD4 cell count was linearly increased h corresponding follow-up times/visits(Refer to Figure1). This was supported by the Cochran-Armitage t (z =16.34, p-value < 0.0001) [24]. t the joint models of CD4 cell count and BMI data collected from the hospital, rst quasi-Poisson for CD4 count data and binary logistic model for BMI data were considered separately [29]. ...
Background: The rate of prevalence of HIV among adults has been increasing in Sub-Sahara African countries over the last decade. Currently, an estimated number of 722, 248 people are living with HIV, 23, 000 people are newly infected with HIV and 11,000 people are died because of AIDS related illness. The objective of this study was to identify the most significant variables associated with the variation of CD4 cell count and body mass index (BMI) of HIV positive adults who initiated HAART at Felege Hiwot Teaching and Specialized Hospital, North-West Ethiopia. This study also aimed to compared the precision of parameter estimates conducted by separate and joint models.
Methods: To analyze the long-term CD4 cells count and body mass index of HIV infected adults, a cohort longitudinal study of 792 HIV-infected patients was performed. A joint model was employed to identify the variables associated with the variation of CD4 cell count and body mass index of adults receiving treatment at Felege Hiwot Teaching and specialized Hospital. A random of 792 samples was taken among patients using individual charts in the hospital.
Results: Among the main effects, Socio-demographic variables (Level of education, level of disclosure of the disease to persons living together and Marital status ), individuals factors(age, weight and gender), economic factors (ownership of cell phone, level of income), clinical factors (baseline CD4 cell count) retention (food and medication adherence, follow-up time/visit) significantly affected the variables of interests. Similarly, the interaction effects of follow-up times/visits * cell phone ownership, follow-up times/visits * gender, age * gender of patients significantly affected both response variables in current investigation.
Conclusion: Socio-demographic, individual and Clinical variables had significant effect on CD4 cell count and BMI in HAART medication program. Follow-up time/visit in the HAART program had also direct and significant effect on the variables of interest. Older HIV patients should be targeted by appropriate public health actions, such as opportunistic screening and easier access to healthcare service. The patients should be advised to disclose the disease to get support from communities around them.
... 7-10 First, our patients were younger than those reported (66-74 y). [7][8][9][10] In fact, because 50.5% of the persons hospitalized after a stroke in 2014-2015 in Quebec were aged 75 years or older, 28 it is likely that many older patients with a geriatric profile and comorbidities received their rehabilitation in specialized units for geriatric care rather than in our SRUs. Second, our patients were admitted later post-stroke onset (mean = 27.7 d) than the 13.8 and 11.5 days reported, respectively, in the US and NZ studies, but earlier than in the Ontario study (33 d); [8][9][10] in addition, patients in our study had a higher mean admission FIM total score (83) than those in the three studies (61-77), [8][9][10] indicating that our patients had more functional independence. ...
Purpose:
This study aimed to portray the characteristics, process variables, and sensorimotor outcomes of patients who had received their usual post-stroke in-patient rehabilitation in three stroke rehabilitation units in Quebec in 2013-2014.
Method:
We assessed patients (n = 264) at admission and discharge with a subset of a standardized assessment toolkit consisting of observational and performance-based assessment tools.
Results:
The patients, with a mean age of 60.3 (SD 15.4) years, were admitted 27.7 (SD 8.4) days post-stroke onset. They had a mean admission FIM score of 83.0 (SD 24.0), a mean length of stay of 48.4 (SD 31.1) days, a mean FIM discharge score of 104.0 (SD 17.0), and a mean FIM efficiency score of 0.44 (SD 0.29). All patient outcomes were significantly improved (p < 0.001) and clinically meaningful at discharge (moderate to large Glass's Δ effect sizes) with the improvements greater than or equal to the minimal detectable change at the 95% confidence level in 34%-75% of the patients. Improvements were larger on five of seven outcomes in a sub-group of patients with more severe stroke.
Conclusions:
The use of a combination of observational and performance assessment tools was essential to capture the full range of disabilities. We have documented significant and clinically meaningful improvements in functional independence, disability, and upper and lower extremity functions after usual post-stroke in-patient rehabilitation in the province of Quebec and provided baseline data for future studies.
... 25 Other procedures have attempted to define and compare the content of physiotherapy (PT) and occupational therapy (OT) interventions by first videotaping treatment sessions and then having trained observers use a scoring list of therapeutic activities to define the content. 26,27 Chart audits have been used to evaluate compliance with guidelines for outdoor mobility and transport training delivered to stroke survivors, 28 and workload measurement data, 29 or total time scheduled for therapy have been used as an indicator of amount of therapy time. 30 This array of methods to document therapy time and content reflects the complexity of the exercise and the need to match the chosen methodology to the specific needs, objectives, and resources available in different milieus. ...
Purpose:
This study creates a baseline clinical portrait of sensorimotor rehabilitation in three stroke rehabilitation units (SRUs) as a first step in implementing a multi-centre clinical research platform.
Method:
Participants in this cross-sectional, descriptive study were the patients and rehabilitation teams in these SRUs. Prospective (recording of therapy time and content and a Web-based questionnaire) and retrospective (chart audit) methods were combined to characterize the practice of the rehabilitation professionals.
Results:
The 24- to 39-bed SRUs admitted 100-240 inpatients in the year audited. The mean combined duration of individual occupational and physical therapy was 6.3-7.5 hours/week/patient. When evening hours and the contributions of other professionals as well as group therapy and self-practice were included, the total amount of therapy was 13.0 (SD 3) hours/patient/week. Chart audit and questionnaire data revealed the Berg Balance Scale was the most often used outcome measure (98%-100%), and other outcome measure use varied. Clinicians favoured task-oriented therapy (35%-100%), and constraint-induced movement therapy (0%-15%), electrical stimulation of the tibialis anterior (0%-15%), and body weight-supported treadmill training (0%-1%) were less often used.
Conclusions:
This study is the first to provide objective data on therapy time and content of stroke rehabilitation in Quebec SRUs.
... Shah, Cooper and Maas (1992) reported high correlations between the Barthel Index and the Kenny self-care evaluation (r = 0.73). The Barthel Index has been widely used in a number of studies relating to stroke rehabilitation research both internationally (De Wit et al. 2007) and locally (Rouillard et al. 2012). ...
Background
The majority of individuals report a decline in health-related quality of life following a stroke. Quality of life and factors predicting quality of life could differ in individuals from lower income countries. The aim of this study was therefore to determine the quality of life and factors influencing quality of life of community-dwelling stroke patients living in low-income, peri-urban areas in the Western Cape, South Africa.
Method
An observational, longitudinal study was used to collect data from a conveniently selected sample of first-ever stroke patients. The Rivermead Motor Assessment Scale and the Barthel Index were used to determine functional outcome and the EQ-5D was used to collect information relating to quality of life at two months and six months poststroke. Descriptive and inferential statistics were used to analyse the data.
Results
The total sample of 100 participants consisted of 50% men and 50% women with a mean age of 61 and a standard deviation of 10.55 years. Six-month quality of life data was analysed for 73 of the 100 participants. Of the 27 who were lost to follow-up, nine participants died, four withdrew from the study after baseline data was collected and eleven could not be followed up as they had either moved or no follow-up telephone numbers were available. A further three participants were excluded from the analysis of the EQ-5D as they were aphasic. Of these, approximately 35% had problems with mobility and self-care, whilst 42% had severe problems with everyday activities and 37.8% expressed having anxiety and depression. Quality of life at two months (p = 0.010) and urinary incontinence (p = 0.002) were significant predictors of quality of life at six months.
Conclusion
Health-related quality of life was decreased in the South African stroke sample. Functional ability and urinary incontinence were the factors affecting quality of life in the sample. These factors should be considered in the rehabilitation of stroke patients in these settings.
... Previous research using FAI as an outcome measure has often used a cut-off score of <15 to define participants as inactive, with research finding that after four years 29% of the participants fell under this definition [14], and after five years 21% [11] to 40% [8] did. In the present study only 16.5% were found to be inactive, which could possibly be explained by the low percent (4%) of inactive participants pre-stroke (pre-stroke levels are not given for the previous studies [8,11,14]), differences in the health and social care available in the study contexts [26,27], cultural backgrounds [8,28] or socioeconomic factors [9,28]. ...
Background:
Long-term disability following stroke can lead to participation restrictions in complex and social everyday activities, yet information is lacking on to what extent stroke survivors return to their pre-stroke levels of participation.
Objectives:
The objectives of this study were to investigate the level of participation in complex and social everyday activities 6 years after stroke, to compare this with pre-stroke participation and to identify predictors of returning to pre-stroke levels of participation.
Method:
All patients admitted to Karolinska University Hospital's stroke units during a 1-year period were eligible to participate and 349 patients were recruited. Assessments were made at base-line, 3 months and 6 years using self-reported outcome measures. Participation was assessed using the Frenchay Activities Index (FAI). The 6-year score for each participant was compared to the pre-stroke score, both for the total score and for each domain (domestic chores, leisure/work and outdoor activities). Predictors of having the same or better level of participation at 6 years were identified using logistic regression.
Results:
At 6 years, 121 participants were followed up, 166 were deceased, 44 declined to take part and 18 could not be traced. At 6 years 84% could be described as active (FAI≥15). The same level of participation or better than pre-stroke was found in 35% of participants, in 65% the level was lower. Similar predictors were identified for achieving the same or better level of participation at 6 years for FAI total and the three domains; ability to walk without aids and a lower age at stroke onset, and perceived mobility, participation and recovery at 3 months.
Conclusion:
Six years after stroke, 35% of participants had the same or better level of participation as pre-stroke. Rehabilitation after stroke to improve walking ability and participation might improve long-term participation in complex and social everyday activities.
Engaging in meaningful and repetitive goal-oriented functional tasks can effectively enhance neuroplasticity and facilitate recovery following a stroke. This particular approach has primarily been studied in relation to functional outcomes and has predominantly focused on late subacute and chronic stroke patients. However, there is a lack of information regarding the standardized protocol of lower extremity functional training, its constituent elements, and its impact on motor recovery during the early subacute phase of stroke. The aim of this study was to examine the available evidence related to the intervention protocol of lower extremity functional training in order to identify common training elements and assess their impact on motor and functional outcomes in stroke survivors. A systematic search was conducted on PubMed and Scopus, covering the period from 2000 to 2022. A total of 1786 articles were retrieved and screened based on predefined inclusion criteria. A total of 36 articles were included in this review. The primary findings were classified into categories such as intervention protocols for functional training and their constituent elements, outcome measures utilized, minimal clinically important
differences (MCID) reported, and the conclusions drawn by the respective studies. Only a limited quantity of studies reported on the intervention protocol of lower extremity functional training. The majority of these studies focused on the efficacy of functional training for enhancing gait and balance, as evaluated through
functional outcome assessments, particularly in the context of chronic stroke patients. In most studies, the evaluation of outcomes was typically based on statistical significance rather than clinical significance. In light of these findings, it is recommended that future studies be conducted during the early subacute phase of stroke to further investigate the impact of functional training on motor outcomes. This will contribute to a broader understanding of the benefits of functional training in facilitating motor recovery in the lower extremities and its clinical significance in stroke survivors.
Background
Several studies have demonstrated improved outcomes post-stroke when higher intensity rehabilitation is provided. Canadian Stroke Best Practice Recommendations advise patients receive 180 minutes of therapy time per day, however, the exact amount required to reach benefit is unknown.
Aims
The primary aim of this study was to determine the association between rehabilitation intensity and total Functional Independence Measure® Instrument change. Secondary aims included determining the association between rehabilitation intensity and discharge location, 90-day home time, rehabilitation effectiveness, and motor and cognitive FIM change.
Methods
A retrospective cohort study was conducted using available administrative databases of acute stroke patients discharged to inpatient rehabilitation facilities in Ontario, Canada from January 2017 to December 2021. Rehabilitation intensity was defined as number of minutes per day of direct therapy by all providers divided by rehabilitation length of stay. The association between rehabilitation intensity and the outcomes of interest were analyzed using regression models with restricted cubic splines.
Results
12,770 individuals were included. Mean age of the sample was 72.6 years, 46.0% of individuals were female, and 87.6% had an ischemic stroke. Mean rehabilitation intensity was 74.7 minutes (range 5 to 162 minutes) per day. Increased rehabilitation intensity was associated with an increase in mean FIM change. However, there was diminishing incremental increase after reaching 95 mins/day. Increased rehabilitation intensity was positively associated with motor and cognitive FIM change, rehabilitation effectiveness, 90-day home time, and discharge to pre-admission setting. Higher rehabilitation intensity was associated with a lower likelihood of discharge to long-term care.
Conclusions
None of the patients met the recommended rehabilitation intensity of 180 mins/day based on the Canadian Stroke Best Practice Recommendations. Despite this, higher intensity was associated with better outcomes. Given that most positive associations were observed with a RI ≥95 mins/day, this may be a more feasible target.
In two freestanding volumes, Textbook of Neural Repair and Rehabilitation provides comprehensive coverage of the science and practice of neurological rehabilitation. Revised throughout, bringing the book fully up to date, this volume, Medical Neurorehabilitation, can stand alone as a clinical handbook for neurorehabilitation. It covers the practical applications of the basic science principles presented in Volume 1, provides authoritative guidelines on the management of disabling symptoms, and describes comprehensive rehabilitation approaches for the major categories of disabling neurological disorders. New chapters have been added covering genetics in neurorehabilitation, the rehabilitation team and the economics of neurological rehabilitation, and brain stimulation, along with numerous others. Emphasizing the integration of basic and clinical knowledge, this book and its companion are edited and written by leading international authorities. Together they are an essential resource for neuroscientists and provide a foundation of the work of clinical neurorehabilitation professionals.
In two freestanding volumes, Textbook of Neural Repair and Rehabilitation provides comprehensive coverage of the science and practice of neurological rehabilitation. Revised throughout, bringing the book fully up to date, this volume, Medical Neurorehabilitation, can stand alone as a clinical handbook for neurorehabilitation. It covers the practical applications of the basic science principles presented in Volume 1, provides authoritative guidelines on the management of disabling symptoms, and describes comprehensive rehabilitation approaches for the major categories of disabling neurological disorders. New chapters have been added covering genetics in neurorehabilitation, the rehabilitation team and the economics of neurological rehabilitation, and brain stimulation, along with numerous others. Emphasizing the integration of basic and clinical knowledge, this book and its companion are edited and written by leading international authorities. Together they are an essential resource for neuroscientists and provide a foundation of the work of clinical neurorehabilitation professionals.
In two freestanding volumes, Textbook of Neural Repair and Rehabilitation provides comprehensive coverage of the science and practice of neurological rehabilitation. Revised throughout, bringing the book fully up to date, this volume, Medical Neurorehabilitation, can stand alone as a clinical handbook for neurorehabilitation. It covers the practical applications of the basic science principles presented in Volume 1, provides authoritative guidelines on the management of disabling symptoms, and describes comprehensive rehabilitation approaches for the major categories of disabling neurological disorders. New chapters have been added covering genetics in neurorehabilitation, the rehabilitation team and the economics of neurological rehabilitation, and brain stimulation, along with numerous others. Emphasizing the integration of basic and clinical knowledge, this book and its companion are edited and written by leading international authorities. Together they are an essential resource for neuroscientists and provide a foundation of the work of clinical neurorehabilitation professionals.
In two freestanding volumes, Textbook of Neural Repair and Rehabilitation provides comprehensive coverage of the science and practice of neurological rehabilitation. Revised throughout, bringing the book fully up to date, this volume, Medical Neurorehabilitation, can stand alone as a clinical handbook for neurorehabilitation. It covers the practical applications of the basic science principles presented in Volume 1, provides authoritative guidelines on the management of disabling symptoms, and describes comprehensive rehabilitation approaches for the major categories of disabling neurological disorders. New chapters have been added covering genetics in neurorehabilitation, the rehabilitation team and the economics of neurological rehabilitation, and brain stimulation, along with numerous others. Emphasizing the integration of basic and clinical knowledge, this book and its companion are edited and written by leading international authorities. Together they are an essential resource for neuroscientists and provide a foundation of the work of clinical neurorehabilitation professionals.
In two freestanding volumes, Textbook of Neural Repair and Rehabilitation provides comprehensive coverage of the science and practice of neurological rehabilitation. Revised throughout, bringing the book fully up to date, this volume, Medical Neurorehabilitation, can stand alone as a clinical handbook for neurorehabilitation. It covers the practical applications of the basic science principles presented in Volume 1, provides authoritative guidelines on the management of disabling symptoms, and describes comprehensive rehabilitation approaches for the major categories of disabling neurological disorders. New chapters have been added covering genetics in neurorehabilitation, the rehabilitation team and the economics of neurological rehabilitation, and brain stimulation, along with numerous others. Emphasizing the integration of basic and clinical knowledge, this book and its companion are edited and written by leading international authorities. Together they are an essential resource for neuroscientists and provide a foundation of the work of clinical neurorehabilitation professionals.
In two freestanding volumes, Textbook of Neural Repair and Rehabilitation provides comprehensive coverage of the science and practice of neurological rehabilitation. Revised throughout, bringing the book fully up to date, this volume, Medical Neurorehabilitation, can stand alone as a clinical handbook for neurorehabilitation. It covers the practical applications of the basic science principles presented in Volume 1, provides authoritative guidelines on the management of disabling symptoms, and describes comprehensive rehabilitation approaches for the major categories of disabling neurological disorders. New chapters have been added covering genetics in neurorehabilitation, the rehabilitation team and the economics of neurological rehabilitation, and brain stimulation, along with numerous others. Emphasizing the integration of basic and clinical knowledge, this book and its companion are edited and written by leading international authorities. Together they are an essential resource for neuroscientists and provide a foundation of the work of clinical neurorehabilitation professionals.
Background
Conventional and complementary treatments are often used in rehabilitation for persons with stroke. The conventional treatment makes use of medications, physiotherapy, occupational, speech, and diet therapies, while the complementary treatment makes use of homeopathy, naturopathy, massage, and acupuncture. The structure, process, and outcomes of stroke rehabilitation using conventional or complementary treatments have not been empirically investigated in Ghana.
Aims
This study aims to investigate the structure, process, and outcomes of stroke rehabilitation at the Korle Bu Teaching Hospital (KBTH) in Accra and Kwayisi Christian Herbal Clinic (KCHC) in Nankese-Ayisaa, Ghana, and to explore the experiences of persons with stroke.
Methods
This study involves a mixed methods approach. This study will utilize three study designs, namely, cross-sectional, hospital-based cohort, and qualitative exploratory study designs. The objectives of the study will be achieved using three phases, namely, phase one will recruit health professionals and gather information on the structure and process of stroke rehabilitation at a conventional and complementary hospital using adapted questionnaires; phase two will determine the outcomes of stroke patients attending a conventional and complementary hospital facility at baseline, 2-, 3-, and 6-month follow-up using outcome measures based on the International Classification of Functioning, Disability and Health (ICF) model; and phase three will explore the experiences of stroke patients who use complementary or conventional treatment using an interview guide.
Data analysis
IBM SPSS Statistics Version 27 will be used to analyze the data using descriptive and inferential statistics. Repeated measures of ANOVA will be used to determine the differences between variables at baseline, 2-, 3-, and 6-month post-stroke. The qualitative data will be transcribed and entered into Atlas Ti version 9.0. The data will be coded and analyzed using thematic areas that will be generated from the codes.
Conclusion
The study protocol will provide a comprehensive overview of the structure, process, and outcomes of stroke rehabilitation in Ghana, incorporating both conventional and complementary treatment and rehabilitation into the stroke recovery journey. It will also inform clinical practice, with new insights on the experiences of stroke patients based on their choice of rehabilitation pathway.
Background
There is a need to provide highly repetitive and intensive therapy programs for patients after stroke to improve sensorimotor impairment. The employment of technology-assisted training may facilitate access to individualized rehabilitation of high intensity. The purpose of this study was to evaluate the safety and acceptance of a high-intensity technology-assisted training for patients after stroke in the subacute or chronic phase and to establish its feasibility for a subsequent randomized controlled trial.
Methods
A longitudinal, multi-center, single-group study was conducted in four rehabilitation clinics. Patients participated in a high-intensity 4-week technology-assisted trainings consisting of 3 to 5 training days per week and at least 5 training sessions per day with a duration of 45 min each. Feasibility was evaluated by examining recruitment, intervention-related outcomes (adherence, subjectively perceived effort and effectiveness, adverse events), patient-related outcomes, and efficiency gains. Secondary outcomes focused on all three domains of the International Classification of Functioning Disability and Health. Data were analyzed and presented in a descriptive manner.
Results
In total, 14 patients after stroke were included. Participants exercised between 12 and 21 days and received between 28 and 82 (mean 46 ± 15) technology-assisted trainings during the study period, which corresponded to 2 to 7 daily interventions. Treatment was safe. No serious adverse events were reported. Minor adverse events were related to tiredness and exertion. From baseline to the end of the intervention, patients improved in several functional performance assessments of the upper and lower extremities. The efficiency gains of the trainings amounted to 10% to 58%, in particular for training of the whole body and for walking training in severely impaired patients.
Conclusions
Highly intensive technology-assisted training appears to be feasible for in- and outpatients in the subacute or chronic phase after stroke. Further clinical trials are warranted in order to define the most comprehensive approach to highly intensive technology-assisted training and to investigate its efficacy in patients with neurological disorders.
Trial registration
ClinicalTrials.gov Identifier: NCT03641651 at August 31st 2018
Stroke is the second‐leading cause of death and a major cause of disability worldwide. The principle underlying all rehabilitation is that the brain has an inherent capacity to recover lost function after stroke. This is based on observations that most survivors regain some or many of the functions initially lost as a result of the stroke. Rehabilitation in stroke is essentially a multidisciplinary activity, which has been described as a problem‐solving educational process focusing on disability and intended to reduce handicap. Rehabilitation has four important components: assessment, planning, intervention, and evaluation. Restoration of motor function is a primary objective of stroke rehabilitation, and there are several pooled data analyses of studies on various strategies for improving motor performance in stroke patients. Evidence suggests that organised care, such as that provided in stroke units, both facilitates neurological recovery and expedites discharges.
An improvement in the activities of daily living (ADLs) is significantly related to the quality of life and prognoses of patients with stroke. However, the factors predicting significant improvement in ADL (SI-ADL) have not yet been clarified. Therefore, we sought to identify the key factors affecting SI-ADL in patients with stroke after rehabilitation therapy using both logistic regression modeling and decision tree modeling. We retrospectively collected and analyzed the clinical data of 190 patients with stroke who underwent rehabilitation therapy at our hospital between January 2020 and July 2020. General and rehabilitation therapy data were extracted, and the Barthel index (BI) score was used for outcome assessment. We defined SI-ADL as an improvement in the BI score by 15 points or more during hospitalization. Logistic regression and decision tree models were established to explore the SI-ADL predictors. We then used receiver operating characteristic (ROC) curves to compare the logistic regression and decision tree models. Univariate analysis revealed that compared with the non-SI-ADL group, the SI-ADL group showed a significantly shorter course of stroke, longer hospital stay, and higher rate of receiving occupational and speech therapies (all P < 0.05 ). Binary logistic regression analysis revealed the course of stroke at admission ( odds ratio OR = 0.986 , 95 % confidence interval CI = 0.979 –0.993; P < 0.001 ) and the length of hospital stay ( OR = 1.030 , 95 % CI = 1.013 –1.047; P =0.001) as the independent predictors of SI-ADL. ROC comparisons revealed no significant differences in the areas under the curves for the logistic regression and decision tree models (0.808 vs. 0.831; z = 0.977 , P = 0.329 ). Both models identified the course of disease at admission and the length of hospital stay as key factors affecting SI-ADL. Early initiation of rehabilitation therapy is of immense importance for improving the ADLs in patients with stroke.
ABSTACT
The rate of prevalence of HIV among adults has been increasing in Sub-Sahara African countries over the last decade. The objective of this study was to identify the most significant variables associated with the variation of CD4 cell count and body mass index (BMI) of HIV positive adults who initiated HAART at Felege Hiwot Teaching and Specialized Hospital, North-West Ethiopia. This study also aimed to compare the precision of parameter estimates conducted by separate and joint models.A cohort longitudinal study of 792 HIV-infected patients was performed. A joint model was employed to identify predictor variables. A random of 792 samples was taken among patients using individual charts in the hospital.
Among the main effects, Socio-demographic variables (Level of education, level of disclosure of the disease to persons living together and Marital status), individuals factors(age, weight and gender), economic factors (ownership of cell phone, level of income), clinical factors (baseline CD4 cell count) retention (food and medication adherence, follow-up time/visit) significantly affected the variables of interests. Similarly, the interaction effects of follow-up times/visits * cell phone ownership, follow-up times/visits * gender, age * gender of patients significantly affected both response variables in current investigation. Socio-demographic, individual and Clinical variables had significant effect on CD4 cell count and BMI in HAART medication program. Follow-up time/visit in the HAART program had also direct and significant effect on the variables of interest. The patients should be advised to disclose the disease to get support from communities around them.
This article focuses on an eHealth application, CogniViTra, to support cognitive and physical training (i.e., dual-task training), which can be done at home with supervision of a health care provider. CogniViTra was designed and implemented to take advantage of an existing Platform of Services supporting a Cognitive Health Ecosystem and comprises several components, including the CogniViTra Box (i.e., the patient terminal equipment), the Virtual Coach to provide assistance, the Game Presentation for the rehabilitation exercises, and the Pose and Gesture Recognition to quantify responses during dual-task training. In terms of validation, a functional prototype was exposed in a highly specialized event related to healthy and active ageing, and key stakeholders were invited to test it and share their insights. Fifty-seven specialists in information-technology-based applications to support healthy and active ageing were involved and the results and indicated that the functional prototype presents good performance in recognizing poses and gestures such as moving the trunk to the left or to the right, and that most of the participants would use or suggest the utilization of CogniViTra. In general, participants considered that CogniViTra is a useful tool and may represent an added value for remote dual-task training.
Introduction
In the last 15 years, considerable improvements have been made in acute stroke care in Guipuzkoa, including the implementation of a centralised care model at Hospital Universitario Donostia (HUD), improved coordination between professionals, early detection campaigns, new treatments, a stroke unit, and specific rehabilitation. The aim of this work is to describe the results of a reference hospital (HUD) in a centralised care model.
Material and methods
We performed a retrospective observational study of a sample of patients discharged between August and December 2015 from the HUD with a diagnosis of acute stroke (ICD-9-CM codes 430-436, except 433.10). We review patients’ baseline characteristics, acute-phase care, and functional outcomes and mortality at discharge and at one year.
Results and discussion
We identified 536 patients, with a mean age of 73.6 years and a high comorbidity rate. Ischaemic stroke accounted for 64.8% of patients, followed by haemorrhagic stroke (20%) and transient ischaemic attack (14.8%). A total of 53% of patients were attended in < 6 hours, with code stroke being activated in 37.1%; 52.2% of patients were admitted to the stroke unit. Intravenous therapy was administered to 8.3% of patients with ischaemic stroke, and 9.5% underwent mechanical thrombectomy. Surgery was performed in 12.1% patients with haemorrhagic stroke. Rehabilitation was started at hospital in 56% of patients, and 39.6% continued with this treatment at discharge. Mortality was 13.8% at discharge and 25.9% at one year (ischaemic stroke, 25.3%; haemorrhagic stroke, 47.5%); these figures are lower than those previously reported in Guipuzkoa. At one year, 62.5% of patients had a Barthel Index score of 95-100, and 50% a modified Rankin Scale score of 0-2.
Conclusions
After the strategic changes implemented in acute stroke care in Guipuzkoa, including the centralisation of the acute stroke care model, mortality rates at discharge and at one year are lower in 2015 than the previously reported rates, with similar rates of independence. These results are consistent with those published by other Spanish and European centres.
Sarcopenia is a syndrome characterized by progressive systemic muscle loss and decreased function. The loss of systemic muscle mass and decreased function after stroke can't be explained by brain injury alone, and it is considered to be a kind of secondary sarcopenia, which is called stroke-related sarcopenia. More and more evidence shows that stroke-related sarcopenia can promote the occurrence and development of sarcopenia through a variety of pathogenesis, such as immobilization, impaired feeding, sympathetic activation, inflammation and denervation. Post-stroke disability brings difficulties to the screening and diagnosis of sarcopenia. Simple and easy rehabilitation scores and clinical tests can be used for the determination of body function under specific conditions of stroke, as well as for the screening stroke-related sarcopenia. At present, there is still no particularly effective way to stop its progress,however, the combination of rehabilitation exercise, nutrition supply and drugs may delay or even prevent the development of stroke-related sarcopenia. This article reviews the latest progress in the pathogenesis, screening, evaluation and treatment of stroke-related sarcopenia to provide reference for clinical treatment and rehabilitation of stroke.
Les AVC constituent une urgence hospitalière. Il faut agir au plus tôt pour sauver la vie du malade, limiter les atteintes neurologiques et réduire les dysfonctionnements ultérieurs. Les survivants d’AVC ont des limitations fonctionnelles et en récupèrent incomplètement dans la grande majorité des cas. La plupart d’entre eux marchent avec des séquelles persistantes, à cause de l’hémiparésie. Les résultats modestes obtenus après la rééducation/réadaptation renforcent le besoin de s’interroger sur la part des déterminants de la marche dans la faible capacité de déambulation des hémiparétiques. La problématique de cette thèse est fondée sur la capacité de marche post-AVC. Son but était de rechercher d’une part, les liens possibles entre les atteintes périphériques du muscle, sa neurophysiologie et les limitations de performances motrices observées chez l’hémiparétique ; et d’autre part, les possibilités d’amélioration des processus de commandes centrales de la marche en rapport avec la plasticité cérébrale grâce à l’utilisation d’une technique innovante, la stimulation transcrânienne à courant directe (tDCS) et par un ré-entrainement.Les résultats obtenus à l’issue des quatre études menées apportent de meilleures connaissances sur l’état fonctionnelle du muscle après l’AVC et sur la possibilité d’améliorer la marche de l’hémiparétique. Un état des lieux de la capacité de marche en prenant pour repère l’environnement socio-économique de la prise comme un des déterminants de l’amélioration de la récupération motrice a permis non seulement de comprendre l’importance de cette donnée (souvent négligée par la littérature), dans la capacité de déambulation et donc d’intégration des hémiparétiques. Les autres études ont ressorti, la part des limitations induites par les modifications musculaires après l’AVC et ont favorisé la conception et la mise en place des stratégies de prise en charge de la marche. L’ensemble des altérations structurelle, biochimique et neurophysiologique du muscle suite à l’AVC participe à l’expression des diverses déficiences motrices observées chez le patient hémiplégique, par un amoindrissement de sa force, sa puissance et son endurance. Dans le cas de la réadaptation de la marche chez l’hémiparétique, deux études ont été conduites en utilisant la tDCS. Elles ont permis de montrer que la tDCS peut améliorer la plasticité cérébrale, observation faite à travers le gain global sur les performances de marche avec une stimulation unique ; mais aussi qu’elle peut être utilisée en stimulation itératives combiné à un programme au ré-entrainement à l’effort.La tDCS à cause de sa portabilité, son utilisation relativement facile et surtout son coût moins élevé reste un outil qui peut facilement s’intégrer au contexte de la prise en charge dans les pays à revenus limités. Les résultats obtenus à travers cette Thèse sont porteurs d’espoir quant à l’amélioration de la performance de marche chez l’hémiplégique vasculaire.
Objectives
To understand why most stroke patients receive little therapy. We investigated the factors associated with the amount of stroke therapy delivered.
Methods
Data regarding adults admitted to hospital with stroke for at least 72 hours (July 2013–July 2015) were extracted from the UK’s Sentinel Stroke National Audit Programme. Descriptive statistics and multilevel mixed effects regression models explored the factors that influenced the amount of therapy received while adjusting for confounding.
Results
Of the 94,905 patients in the study cohort (mean age: 76 (SD: 13.2) years, 78% had a mild or moderate severity stroke. In all, 92% required physiotherapy, 87% required occupational therapy, 57% required speech therapy but only 5% were considered to need psychology. The average amount of therapy ranged from 2 minutes (psychology) to 14 minutes (physiotherapy) per day of inpatient stay. Unmodifiable characteristics (such as stroke severity) dominated the variation in the amount of therapy. However important, modifiable organizational factors were the day and time of admission, type of stroke team, timely therapy assessments, therapy and nursing staffing levels (qualified and support staff), and presence of weekend or early supported discharge services.
Conclusion
The amount of stroke therapy is associated with unmodifiable patient-related characteristics and modifiable organizational factors in that more therapy was associated with higher therapy and nurse staffing levels, specialist stroke rehabilitation services, timely therapy assessments, and the presence of weekend and early discharge services.
Objective
The rate of prevalence of HIV/AIDS among adults has been increasing in Sub-Sahara African countries over the last decade. Currently, an estimated number of 722, 248 people are living with HIV, 23, 000 people are newly infected with HIV and 11,000 people are died because of AIDS related illness. The purpose of this study was to identify the most significant variables associated with the variation of CD4 cell count and body mass index (BMI) of HIV positive adults who initiated HAART at Felege Hiwot Teaching and Specialized Hospital, North-West Ethiopia.
Methods
To analyze the long-term CD4 cells count and body mass index of HIV infected adults, a prospective follow-up study of 792 HIV-infected patients was performed. A joint model was employed to identify the variables associated with the variation of CD4 cell count and body mass index of adults receiving HAART. A random of 792 samples was taken among charts in the hospital.
Results
Among the main effects, Socio-demographic variables (Level of education, level of exposedness of disease to persons living together, Marital status and residence area), individuals characteristics (age and weight), economic factors (ownership of cell phone, level of income), clinical factors (baseline CD4 cell count), level of retention (time to follow ups, food and medical adherence) and economic factors(owner of cell phone) significantly affected the variables of interests. Similarly, the interaction effects of time of follow-up visits * cell phone ownership, follow-up visits * gender, age * sex significantly affected both response variables through a linear link function in current investigation.
Conclusion
Socio-demographic, individual and Clinical variables had significant effect on CD4 cell count and BMI in HAART medication program. Time to follow ups in the HAART program had also direct and significant effect on the variables of interest.
Die Symptome bei HirntumorpatientInnen sind abhängig von der Lage des Tumors und der möglichen Beeinflussung eloquenter Hirnareale wie Lähmungen, Gefühlsstörungen, Ausfall von Sinneswahrnehmungen, Sprachstörungen, epileptische Anfälle, Änderung der Persönlichkeit, oder durch Erhöhung des Hirndruckes wie Kopfschmerzen besonders am Morgen, Übelkeit und Erbrechen, Somnolenz bis zum Bewusstseinsverlust. Die Einstellung zu Bewegungstraining bei KrebspatientInnen hat sich in den letzten Jahrzehnten grundlegend geändert; weg vom Prinzip, dass Kranke sich primär schonen müssten, hin zur Erkenntnis, dass ein an individuellen Fähigkeiten angepasstes Bewegungstraining viele positive Effekte über den Erhalt von Kondition und Beweglichkeit hinaus, bieten kann. Dies zeigt einen größeren Einfluss auf die Überlebenszeit der HirntumorpatientInnen als jegliche bisher bekannte medikamentöse Therapie. Weiters zeigt es auf, wie wichtig es ist, die PatientInnen zur Beibehaltung von Bewegungstraining auch über die Dauer eines ambulanten oder stationären Rehabilitationsprogramms hinaus zu motivieren.
Resumen: Introducción: En los últimos 15 años se han introducido importantes mejoras en la atención de la enfermedad cerebrovascular aguda (ECVA) en Guipúzcoa, que incluyen la implementación de un modelo centralizado en el Hospital Universitario Donostia (HUD), una mejor coordinación entre profesionales, campañas para su detección precoz, nuevos tratamientos, Unidad de Ictus y una rehabilitación específica. El objetivo de este trabajo es describir los resultados de un hospital de referencia (HUD) en un modelo de atención centralizado. Material y métodos: Estudio observacional retrospectivo de una muestra de pacientes dados de alta en el periodo de agosto-diciembre del año 2015 del HUD con diagnóstico de ECVA (CIE-9-MC-430-436 excepto 43310). Revisión de las características basales, atención en fase aguda y resultados funcionales y de mortalidad al alta y al año. Resultados y discusión: Se incluyó a 536 pacientes cuya media de edad fue de 73,6 años y cuya comorbilidad era elevada. El ictus isquémico supuso el 64,8% de las altas, seguido de la ECVA hemorrágica (20%) y del accidente isquémico transitorio (14,8%). Se atendió en
Aim:
To explore and compare the content of rehabilitation practices in, respectively, a Danish and a Norwegian region, focusing on how the citizens' rehabilitation needs are met during rehabilitation in the municipalities.
Method:
Six Danish and five Norwegian cases were followed 12 months after the onset of stroke. Field work and focus group interviews with multidisciplinary teams in the municipalities were conducted. The conceptual frame of the International Classification of Functioning was used to outline general patterns and local variation in the rehabilitation services.
Findings:
Each of the settings faces different challenges and opportunities in the provision of everyday life-supportive rehabilitation services. Rehabilitation after stroke in both settings basically follows the same guidelines, but the organization of rehabilitation programmes is more specialized in Denmark than in Norway. Team organization, multidisciplinarity, and collaboration to assess and target the patients' needs characterized the Danish rehabilitation services. Decentralized coordination and monodisciplinary contributions with scarce or unsystematic collaboration were common in the Norwegian cases. Seamless holistic rehabilitation was challenged in both countries, but more notably in Norway. The municipal services emphasized physical functioning, which could conflict with the patients' needs. Cognitive disturbances to and aspects of activity or participation were systematically addressed by the interdisciplinary teams in Denmark, while practitioners in Norway found that these disturbances were scarcely addressed.
Discussion:
The study showed major differences in municipal stroke rehabilitation services in the Northern Norway and Central Denmark Regions-in their ability to conduct everyday life-supportive rehabilitation services. Despite the fact that biopsychosocial conceptions of disease and illness, as recommended in the ICF, have been generally accepted, they seemed scarcely implemented in the political and health managerial arenas, especially in Norway. These national diversities can partly be explained by the size of the municipalities and the available health profiles in delivering patient and family-centred rehabilitation services.
Objective:
To describe the dose, intensity and context of physiotherapy for balance and mobility problems after stroke.
Design:
Process mapping to describe the context and non-participant observation of therapy sessions to describe the dose and content of therapy.
Setting:
Four inpatient stroke units in North-West England.
Participants:
Therapy staff and previously mobile stroke survivors who were treating, or receiving treatment for balance and mobility problems in the participating units.
Results:
Two units were stand-alone rehabilitation units; two offered a service at the weekends. One had no access to community-based rehabilitation. All had dedicated treatment facilities but often did not use them because of lack of space and difficulty transporting patients. Twenty-two patients participated and 100 treatment sessions were observed. Practicing walking, sit-to-stand and transfers were the most frequent objectives and interventions usually with the therapist(s) physically facilitating the patient's movements. The dose of practise was low; mean repetitions of sit-to-stand per session was 5 (SD 6.4); mean time spent upright per session was 11.24 (SD = 7) minutes, and mean number of steps per session was 202 (SD 118). The mean number of staff per patient was 2.1 (SD = 0.6, mode = 2), usually involving two qualified therapists. Falls prevention or management, wheelchair skills and bed mobility were not practised.
Conclusion:
Stroke physiotherapy for balance and mobility problems features low-dose, low-intensity therapist-led practice, mainly of walking and sit-to-stand. Staff:patient ratios were high. Therapists need to organize treatment sessions to maximize the intensity of functional task practice.
Background and purpose:
Prediction of outcome after stroke rehabilitation may help clinicians in decision-making and planning rehabilitation care. We developed and validated a predictive tool to estimate the probability of achieving improvement in physical functioning (model 1) and a level of independence requiring no more than supervision (model 2) after stroke rehabilitation.
Methods:
The models were derived from 717 patients admitted for stroke rehabilitation. We used multivariable logistic regression analysis to build each model. Then, each model was prospectively validated in 875 patients.
Results:
Model 1 included age, time from stroke occurrence to rehabilitation admission, admission motor and cognitive Functional Independence Measure scores, and neglect. Model 2 included age, male gender, time since stroke onset, and admission motor and cognitive Functional Independence Measure score. Both models demonstrated excellent discrimination. In the derivation cohort, the area under the curve was 0.883 (95% confidence intervals, 0.858-0.910) for model 1 and 0.913 (95% confidence intervals, 0.884-0.942) for model 2. The Hosmer-Lemeshow χ(2) was 4.12 (P=0.249) and 1.20 (P=0.754), respectively. In the validation cohort, the area under the curve was 0.866 (95% confidence intervals, 0.840-0.892) for model 1 and 0.850 (95% confidence intervals, 0.815-0.885) for model 2. The Hosmer-Lemeshow χ(2) was 8.86 (P=0.115) and 34.50 (P=0.001), respectively. Both improvement in physical functioning (hazard ratios, 0.43; 0.25-0.71; P=0.001) and a level of independence requiring no more than supervision (hazard ratios, 0.32; 0.14-0.68; P=0.004) were independently associated with improved 4-year survival. A calculator is freely available for download at https://goo.gl/fEAp81.
Conclusions:
This study provides researchers and clinicians with an easy-to-use, accurate, and validated predictive tool for potential application in rehabilitation research and stroke management.
Objectives: Rehabilitation interventions are expected to ensure best possible recovery and minimize functional disability in stroke survivors. However, not many studies have investigated patterns of recovery and outcomes after stroke in low-income countries. The objective of this study is to identify the biological, psychological, and social components associated with functioning over time in Indian stroke patients using the International Classification of Functioning, Disability and Health (ICF)-based tools and the Functional Independence Measure (FIM).
Methods: The functioning profile of stroke survivors who received a standard multi-disciplinary rehabilitation was prospectively assessed using the ICF and the FIM at admission (baseline), at 12 & 24 weeks. Descriptive analyses were performed to identify changes in the frequencies of ICF categories and qualifiers from admission to follow-up.
Results: One hundred and twenty-seven participants (mean age of 56 years) with mean FIM score 68 at baseline participated and completed the study. The mean FIM score at follow-up was 108. The numbers and frequency of ICF categories for activities and participation reduced after rehabilitation. More numbers of environmental factors were identified as barriers at follow-up (15 out of 33) compared to baseline. Within the components of Activities and Participation, significant improvement in functioning was found in 43 out of 51 categories.
Conclusion: The results show a reduction in frequencies in ICF activities and participation categories corresponding to basic activities of daily living. Categories corresponding to employment and social integration showed little or no improvement.
Patienten, die am Ende der Anschlussrehabilitation nach Schlaganfall wieder mobil und selbstständig in Alltagsaktivitäten sind, erhalten sich dies in der Regel über die nächsten fünf Jahre. Sonst droht schleichender Rückschritt. Neben dem funktionellen Zustand muss aber auch der gesundheitsbezogenen Lebensqualität deutlich mehr Aufmerksamkeit gewidmet werden, da sie zumindest gleich stark den Langzeitverlauf beeinflusst.
Introduction:
Generally, nursing interventions during the acute stages following a stroke aim at preventing secondary brain injury (intracranial hypertension), maintaining the airways (due to paralysis of the pharynx muscles), providing general body support (vital signs, fluid and electrolyte balance), and anticipating the occurrence of complications (atelectasis and pneumonia).
Aim:
This literature review is to prioritize nursing interventions for acute stroke and to update nursing roles and input considering recommended levels of evidence of care to date.
Method and materials:
A systematic review was undertaken, and databases searched were Electronic Library Information Navigator (ELIN), Medline and the Cumulative Index to Nursing and Allied Health Literature from 1990 to 2015, using the OVID interface.
Results:
The search originally yielded 400 articles of which 65 were selected for analysis and 12 of these included evidence synthesis (class I-IV, level A-Good Clinical Practice [GCP]). To facilitate early patient recovery, advanced nursing care should include the routine practice of a wide range of specific nursing interventions such as continence management, pressure area care, swallowing management, and early mobilization. Other important nursing interventions include the prevention of pulmonary thromboembolism and early antiplatelet therapy.
Conclusions:
For over 20 years, it has been established that specialized stroke care save lives, reduce disability, shorten length of stay, and generally have been associated with improved patient outcomes. Highly specialized nursing input is of paramount importance in achieving optimum patient outcomes and high quality of interdisciplinary care, providing a comprehensive, interactive, and holistic approach for both acute stroke and rehabilitation.
Purpose:
This international study aims to examine the size and determinants of the impact of stroke on five-year survivors' health-related quality of life (HRQoL) in four different European countries.
Method:
Patients were recruited consecutively in four European rehabilitation centers. Five years after stroke, the EuroQol-visual analog scale (EQ-VAS) was administered in 226 first-ever stroke patients. Impact of stroke was determined by calculating EQ-VAS z-norm scores (= deviation - expressed in SD - of patients' EQ-VAS level relative to their age-and gender-matched national population norms). Determinants of EQ-VAS z-norm scores were identified using multivariate linear regression analysis.
Results:
Five years post-stroke, patients' mean EQ-VAS was 63.74 (SD = 19.33). Mean EQ-VAS z-norm score was -0.57 [95%CI: (-0.70)-(-0.42)]. Forty percent of the patients had an EQ-VAS z-norm score <-0.75 SD; 52% had an EQ-VAS z-norm score between -0.75 and +0.75 SD, only 8% scored >+0.75 SD. Higher patients' levels of depression, anxiety and disability were associated with increasingly negative EQ-VAS z-norm scores (adjusted R(2)( )=( )0.392).
Conclusions:
Five years after stroke, mean HRQoL of stroke survivors showed large variability and was more than ½ SD below population norm. Forty percent had a HRQoL level below, 52% on, and 8% above population norm. The variability could only partially be explained by the variables considered in this study. Longitudinal studies are needed to increase our understanding of the size and determinants of the impact of stroke on the HRQoL of long-term stroke survivors. Implications for rehabilitation The current European concept of stroke rehabilitation is focused on the acute and sub-acute rehabilitation phase, i.e., in the first months after stroke. The results of this study show that at five years after stroke, the mean level of HRQoL of stroke survivors remains below the healthy population level. This finding shows the need for continuation of rehabilitation in the chronic phase. At five years after stroke, higher patients' levels of depression, anxiety and disability were associated with lower scores for HRQoL. This finding implicates that chronic rehabilitation programs should be multi-faceted in order to increase long-term survivors' psychosocial outcomes.
Objectives:
The use of medication plays an important role in secondary stroke prevention and treatment of post-stroke comorbidities. The Collaborative Evaluation of Rehabilitation in Stroke across Europe (CERISE) was set up to investigate the inpatient stroke rehabilitation process in four centres, each in a different European country: Belgium, Germany, United Kingdom and Switzerland.
Patients and methods:
Patients' medication use 5 years post-stroke was compared between countries. Focus was put on cerebrovascular secondary prevention, including (a) adequate antithrombotic treatment, (b) treatment of cardiovascular comorbidities and diabetes, and (c) the use of lipid-lowering drugs; as well as on the treatment of stroke-related disorders such as depression, anxiety and pain.
Results:
Medication data were available for 247 patients. Data about depression and anxiety were available for 233.
Conclusion:
There were no significant differences between the four centres in antithrombotic treatment and in the treatment of cardiovascular comorbidities and diabetes. However, significantly more patients from the UK were treated with lipid-lowering drugs compared to Belgian patients. Significant differences were also observed between the centres in the prevalence and treatment of depression. More Belgian patients suffered from depression compared to German patients and significantly more Belgian patients took antidepressants than patients in Germany. This was in contrast to the prevalence and treatment of anxiety and pain, for which no significant differences between the centres were seen. Related to pain treatment, it was observed that almost 40% of all patients suffering from pain, used no specific medication.
In westerse landen is CVA bij volwassenen de belangrijkste reden voor het ontstaan van een ernstige chronische beperking. Ongeveer 70 procent van de patiënten die in Nederland een CVA overleven, ondervindt onomkeerbare problemen in de activiteiten van hun dagelijks leven (ADL) en sociale participatie. Revalidatie is de belangrijkste behandeling, waarin fysiotherapie wordt beschouwd als een van de kerndisciplines. Tot voor kort werden patiënten na een CVA ‘methodegericht’ (Bobath/NDT, Brunnstrom, enz.) gerevalideerd, veelal gericht op verbetering van functies en behandeling van stoornissen. Tegenwoordig is de visie dat patiënten na een CVA vooral baat hebben bij functionele, taak- en contextspecifieke oefentherapie. Die moet al snel na het CVA van start gaan en daarbij moet het liefst veel tijd worden besteed aan training. Voor het beoordelen van de functionele status van patiënten en het meten van de resultaten van een behandeling wordt de fysiotherapeut geadviseerd zeven meetinstrumenten te gebruiken. Dat komt de kwaliteit van de zorg en de communicatie met de betrokkenen ten goede. Aan het eind van dit hoofdstuk worden aanbevelingen gedaan om enkele nieuwere behandelmethoden in de KNGF-richtlijn op te nemen en wordt de vraag beantwoord of de normale motoriek wel bruikbaar is als referentiekader om het bewegen van mensen na een CVA te beschrijven en te beoordelen.
Introduction The neurological basis of recovery Patterns of recovery Objectives of rehabilitation Process of rehabilitation Common problems in stroke rehabilitation Conclusion References
Abstract
A World Health Organization Working Group has developed a major international collaborative study with the objective of measuring over 10 years, and in many different populations, the trends in, and determinants of, cardiovascular disease. Specifically the programme focuses on trends in event rates for validated fatal and non-fatal coronary heart attacks and strokes, and on trends in cardiovascular risk factors (blood pressure, cigarette smoking and serum cholesterol) in men and women aged 25–64 in the same defined communities. By this means it is hoped both to measure changes in cardiovascular mortality and to see how far they are explained; on the one hand by changes in incidence mediated by risk factor levels; and on the other by changes in case-fatality rates, related to medical care. Population centres need to be large and numerous; to reliably establish 10-year trends in event rates within a centre 200 or more fatal events in men per year are needed, while for the collaborative study a multiplicity of internally homogeneous centres showing differing trends will provide the best test of the hypotheses. Forty-one MONICA Collaborating Centres, using a standardized protocol, are studying 118 Reporting Units (sub-populations) with a total population aged 25–64 (both sexes) of about 15 million
Keywords
Cardiovascular disease; Cerebrovascular disease; Coronary heart disease; Etiology; Epidemiology; Mortality rates; Morbidity; Incidence; Blood pressure; Smoking; Cholesterol; Coronary care
A ranked assessment of daily living (ADL) scale has been developed to assess activities which may be important to stroke patients who have been discharged home. A questionnaire incorporating 22 ADL activities in four sections was sent by post to 80 consecutively registered stroke patients. Gutmann scaling was carried out on the returned questionnaires, producing acceptable coefficients of reproducibility and scalability. The revised questionnaire was then sent to 20 stroke patients. The same patients were sent an identical questionnaire two weeks later. The overall level of agreement between the two assessments was satisfactory. The extended ADL scale could therefore be used as a postal questionnaire to assist in the follow-up of patients discharged home after a stroke. Due to the scaling properties of the assessment, patient's progress can be monitored and patients can also be compared on the basis of their scale score.
The Rivermead stroke Assessment may be used to assess patients recovering from strokes. It has been shown to be both reliable and valid as a measure of recovery, provided certain conditions are met. The authors hope that the scale will be used by other centres so that further studies can replicate their findings, and so that communication between different physiotherapists treating stroke patients will become more standardised. It is intended that the scale should be suitable for both research and clinical work. The results in 51 patients are reported.
We designed a 15-item neurologic examination stroke scale for use in acute stroke therapy trials. In a study of 24 stroke patients, interrater reliability for the scale was found to be high (mean kappa = 0.69), and test-retest reliability was also high (mean kappa = 0.66-0.77). Test-retest reliability did not differ significantly among a neurologist, a neurology house officer, a neurology nurse, or an emergency department nurse. The stroke scale validity was assessed by comparing the scale scores obtained prospectively on 65 acute stroke patients to the patients' infarction size as measured by computed tomography scan at 1 week and to the patients' clinical outcome as determined at 3 months. These correlations (scale-lesion size r = 0.68, scale-outcome r = 0.79) suggested acceptable examination and scale validity. Of the 15 test items, the most interrater reliable item (pupillary response) had low validity. Less reliable items such as upper or lower extremity motor function were more valid. We discuss methods for improving the reliability and validity of brief examination scales to be used in stroke therapy trials.
To show the influence of variations in case mix on clinical outcome indicators for patients admitted to hospital with acute stroke.
"Before and after" cohort study, with prospective, consecutive identification of patients and prospective follow up; multiple logistic regression analyses to correct for case mix variations.
University teaching hospital.
216 patients with stroke identified before the introduction of an organised stroke service, and 252 patients with stroke identified after its introduction.
Case fatality at 30 days and 12 months; for survivors at 12 months, proportions of patients who were independent (according to the Oxford handicap scale) and of those living at home.
Crude outcome data suggested that patients in the cohort identified after the introduction of the stroke service were significantly more likely to be alive, independent, and living at home than patients managed before the stroke service. After adjustment for age and sex these "improvements" were less impressive but still significant. After adjustment for many other possible prognostic indicators, however, the differences between the two groups for all four outcomes were non-significant, suggesting that the "improvements" may have been entirely due to differences in case mix between the two cohorts, rather than the new stroke service.
Variations in case mix have a crucial influence on the interpretation of outcome data, and this is particularly important in non-randomised comparative studies. Such studies, comparing performance within and between different provider units, are likely to become increasingly common in the new reformed NHS. To allow meaningful interpretation, these studies must try to correct for case mix.
Research articles on the prognosis of stroke patients were analysed to identify studies that met sound methodological principles of prognostic research as well as to identify variables capable of predicting functional outcome (ADL) after stroke. Data sources comprised a computer-aided search of published prognostic studies and references to literature used in prognostic studies. Seventy-eight studies were tested for adherence to the following key methodological criteria: reliability and validity of measurement instruments used to assess dependent and independent variables; inclusion of an inception cohort; adequate and uniform end-point of observation; control for drop-outs during period of observation; statistical testing ofpresumed relationship between dependent and independent variables; sufficient sample size in relation to number of determinants; control for multicollinearity; specification of patient characteristics (i.e. age, type, recurrent stroke and localization of stroke); description of interfering treatment effects during the period of observation; and cross-validation of the prediction model in a second independent group of patients.
Only three studies satisfied nine out of 11 criteria and ten studies eight criteria for the determination of valid prognostic research. The results of these studies indicate that the following variables are valid predictors for functional recovery after stroke: age; previous stroke; urinary continence; consciousness at onset; disorientation in time and place; severity of paralysis; sitting balance; admission ADL score; level of social support and metabolic rate of glucose outside the infarct area in hypertensive patients. This study supports the general opinion that not only are differences in objectives and heterogeneity in stroke patients responsible for the lack of accuracy in predicting functional outcome, but also the methodological flaws in published prognostic research.
The aims of this study were: (1) to identify reliable prognostic factors for detecting subgroups of no, low and high response in consecutive patients admitted for rehabilitation of first stroke sequelae, and (2) to quantify the relative risk of poor or excellent prognosis on both Activities of Daily Living (ADL) and mobility for each significant variable. We prospectively studied 440 of 475 patients. From a group of 32 independent variables, those significantly associated with no, low and high effectiveness on both ADL and mobility were selected by means of multiple regression; then, the relative risk was calculated for each variable that significantly entered the multiple regressions. Patients with severe impairment or with global aphasia showed a relative risk of no response 4-6 times higher than that of other patients. An interval before rehabilitation longer than 2 months was associated with an increasing risk of no response. Elderly patients had a significantly higher relative risk of low response both on ADL and mobility. The presence of hemineglect and depression was associated with an increasing risk of low response on ADL but not on mobility. The absence of hemineglect and a short interval are prerequisites for an excellent functional prognosis on both ADL and mobility. A minor impairment, employed status, the absence of global aphasia and age < or = 65 years increased the risk of high response. At the beginning of treatment, clear prognostic factors for the detection of subgroups with poor or excellent rehabilitation prognosis can be identified.
To identify evidence-based prognostic factors in the subacute phase after stroke for activities of daily living (ADL) and ambulation at six months to one year after stroke.
Systematic literature search designed in accordance with the Cochrane Collaboration criteria with the following data sources: (1) MEDLINE, EMBASE, CINAHL, Current Contents, Cochrane Database of Systematic Reviews, Psyclit, and Sociological Abstracts. (2) Reference lists, personal archives, and consultation of experts. (3) Guidelines.
Inclusion criteria were: (1) cohort studies of patients with an ischaemic or haemorrhagic stroke; (2) inception cohort with assessment of prognostic factors within the first two weeks after stroke; (3) outcome measures for ADL and ambulation; and (4) a follow-up of six months to one year. Internal, statistical and external validity of the studies were assessed using a checklist with 11 methodological criteria in accordance with the recommendations of the Cochrane Collaboration.
From 1,027 potentially relevant studies 26 studies involving a total of 7,850 patients met the inclusion criteria. Incontinence for urine is the only prognostic factor identified in three studies with a level A (i.e., a good level of scientific evidence according to the methodological score). The following factors were found in one level A study: initial ADL disability and ambulation, high age, severe paresis or paralysis, impaired swallowing, ideomotor apraxia, ideational apraxia, and visuospatial construction problems; as well as factors relating to complications of an ischaemic stroke, such as extraparenchymal bleeding, cerebral oedema and size of intraparenchymal haemorrhage.
The present evidence concerning possible predictors in the subacute stage of stroke has insufficient quality to make an evidence-based prediction of ADL and ambulation after stroke because only one prognostic factor was demonstrated in at least two level A studies, our cut-off for sufficient scientific evidence.
There are significant variations in the short term patterns of care and outcome after a first stroke in Europe.
To estimate the variation in stroke care and outcome up to 1 year after a stroke in selected European centres.
Hospital based stroke registers were established in 11 hospitals in seven western and central European countries to collect demographic, clinical, and resource use data at the time of first ever stroke during 1993-4. At 3 and 12 months, details of survival, activities of daily living score, and use of services were recorded. Univariate comparisons between centres were made using the chi2 test and stepwise regression was used to identify associations between centre, case mix, therapy provision, and outcomes.
Of the 4048 patients registered, 23% were lost to follow up and 38% had died at 1 year. The proportions of survivors who felt they needed assistance at 12 months ranged from 35% in Italy to 77% in UK2. There were comparatively high amounts of therapy provided up to 1 year in UK3, France and Germany 1, mainly at home. At 1 year, social services were still providing support in UK1, UK5 and France, with some support in Germany 1 and family support was provided in France. In multivariate analysis, after adjustment for case mix and receipt of rehabilitation, non-UK centres had improved activities of daily living (p<0.001). Older age was indicative of more need for assistance, but less likelihood of assistance from the family. Those in France were more likely to get assistance from their family than any other centre. Mainland European patients were more likely to get help from their family than those in the UK. Patients in all areas except UK2 and UK3 were more likely to be dead or dependent at 1 year than patients in UK1.
There were significant variations in the pathways of care for stroke across European centres in the mid 1990s, which were associated with variation in outcome, and remain unexplained. Family support is more prevalent in southern Europe and service support more prevalent in the UK.
A 66-year-old man was suddenly unable to speak, follow directions, or move his right arm and leg. He received tissue plasminogen activator within 90 minutes. Four days later, his speech was limited to effortful answers of yes or no. He could not walk or use his right arm, and self-care tasks required maximal assistance. What advice would you offer him and his family regarding rehabilitation for his disabilities?
The aim of this study was to compare the time allocated to therapeutic activities (TA) and non-therapeutic activities (NTA) of physiotherapists (PT) and occupational therapists (OT) in stroke rehabilitation units in four European countries.
Therapists documented their activities in 15-min periods for two weeks. They recorded: activity, number of patients, number of stroke patients, involvement of other people, location and frequency of each activity. Kruskal-Wallis tests and negative binomial regression models were used to compare activities between professional groups and between units.
The average proportion of TA per day ranged between 32.9% and 66.1% and was higher for PT than for OT in each unit. For OT, significant differences emerged between the units in the proportion of time allocated to TA compared to NTA with British OTs spending significantly less time in TA. In the Belgian unit, three times less time was spent on patient-related co-ordination activities (e.g., administration, ward rounds) compared to the British and Swiss units.
Time allocation differed between PT and OT and between units, affecting the time available for TA. Further investigation is necessary to study the effect of work organization in stroke rehabilitation units on the efficiency of rehabilitation regimes.
This book provides a comprehensive treatment on modeling approaches for non-Gaussian repeated measures, possibly subject to incompleteness. The authors begin with models for the full marginal distribution of the outcome vector. This allows model fitting to be based on maximum likelihood principles, immediately implying inferential tools for all parameters in the models. At the same time, they formulate computationally less complex alternatives, including generalized estimating equations and pseudo-likelihood methods. They then briefly introduce conditional models and move on to the random-effects family, encompassing the beta-binomial model, the probit model and, in particular the generalized linear mixed model. Several frequently used procedures for model fitting are discussed and differences between marginal models and random-effects models are given attention
The authors consider a variety of extensions, such as models for multivariate longitudinal measurements, random-effects models with serial correlation, and mixed models with non-Gaussian random effects. They sketch the general principles for how to deal with the commonly encountered issue of incomplete longitudinal data. The authors critique frequently used methods and propose flexible and broadly valid methods instead, and conclude with key concepts of sensitivity analysis.
Without putting too much emphasis on software, the book shows how the different approaches can be implemented within the SAS software package. The text is organized so the reader can skip the software-oriented chapters and sections without breaking the logical flow.
Geert Molenberghs is Professor of Biostatistics at the Universiteit Hasselt in Belgium and has published methodological work on surrogate markers in clinical trials, categorical data, longitudinal data analysis, and the analysis of non-response in clinical and epidemiological studies. He served as Joint Editor for Applied Statistics (2001–2004) and as Associate Editor for several journals, including Biometrics and Biostatistics. He was President of the International Biometric Society (2004–2005). He was elected Fellow of the American Statistical Association and received the Guy Medal in Bronze from the Royal Statistical Society.
Geert Verbeke is Professor of Biostatistics at the Biostatistical Centre of the Katholieke Universiteit Leuven in Belgium. He has published a number of methodological articles on various aspects of models for longitudinal data analyses, with particular emphasis on mixed models. Geert Verbeke is Past President of the Belgian Region of the International Biometric Society, International Program Chair for the International Biometric Conference in Montreal (2006), and Joint Editor of the Journal of the Royal Statistical Society, Series A (2005–2008). He has served as Associate Editor for several journals including Biometrics and Applied Statistics.
The authors also wrote a monograph on linear mixed models for longitudinal data (Springer, 2000) and received the American Statistical Association's Excellence in Continuing Education Award, based on short courses on longitudinal and incomplete data at the Joint Statistical Meetings of 2002 and 2004.
A World Health Organization Working Group has developed a major international collaborative study with the objective of measuring over 10 years, and in many different populations, the trends in, and determinants of, cardiovascular disease. Specifically the programme focuses on trends in event rates for validated fatal and non-fatal coronary heart attacks and strokes, and on trends in cardiovascular risk factors (blood pressure, cigarette smoking and serum cholesterol) in men and women aged 25–64 in the same defined communities. By this means it is hoped both to measure changes in cardiovascular mortality and to see how far they are explained; on the one hand by changes in incidence mediated by risk factor levels; and on the other by changes in case-fatality rates, related to medical care. Population centres need to be large and numerous; to reliably establish 10-year trends in event rates within a centre 200 or more fatal events in men per year are needed, while for the collaborative study a multiplicity of internally homogeneous centres showing differing trends will provide the best test of the hypotheses. Forty-one MONICA Collaborating Centres, using a standardized protocol, are studying 118 Reporting Units (sub-populations) with a total population aged 25–64 (both sexes) of about 15 million
This paper presents a simple and widely ap- plicable multiple test procedure of the sequentially rejective type, i.e. hypotheses are rejected one at a tine until no further rejections can be done. It is shown that the test has a prescribed level of significance protection against error of the first kind for any combination of true hypotheses. The power properties of the test and a number of possible applications are also discussed.
This book provides a comprehensive treatment on modeling approaches for non-Gaussian repeated measures, possibly subject to incompleteness. The authors begin with models for the full marginal distribution of the outcome vector. This allows model fitting to be based on maximum likelihood principles, immediately implying inferential tools for all parameters in the models. At the same time, they formulate computationally less complex alternatives, including generalized estimating equations and pseudo-likelihood methods. They then briefly introduce conditional models and move on to the random-effects family, encompassing the beta-binomial model, the probit model and, in particular the generalized linear mixed model. Several frequently used procedures for model fitting are discussed and differences between marginal models and random-effects models are given attention.
The authors consider a variety of extensions, such as models for multivariate longitudinal measurements, random-effects models with serial correlation, and mixed models with non-Gaussian random effects. They sketch the general principles for how to deal with the commonly encountered issue of incomplete longitudinal data. The authors critique frequently used methods and propose flexible and broadly valid methods instead, and conclude with key concepts of sensitivity analysis.
Without putting too much emphasis on software, the book shows how the different approaches can be implemented within the SAS software package. The text is organized so that the reader can skip the software-oriented chapters and sections without breaking the logical flow.
The most powerful predictors of functional recovery and eventual home discharge among stroke survivors are the initial severity of the stroke and the patient's age. We analyzed a large population of stroke rehabilitation admissions by stratifying subgroups with coherent outcomes in an attempt to define potentially more efficient patterns of providing rehabilitation care.
We retrospectively analyzed 520 consecutive patients admitted to a rehabilitation hospital (1 calendar year) with cerebral infarction or hemorrhage. Side of index stroke, age, and functional disability at admission were the independent variables. Change in functional disability and home versus nursing home discharge were the dependent measures.
Recovery was overall most closely related to admission severity and age, but the relations between recovery and independent measures were complex. Patients aged < 55 years all were discharged home whatever their initial severity. Patients admitted with modest functional disability were almost all discharged home (96%), whatever their age. For the remainder of the patients, admission severity and age interacted to create two groups with very different prospects for home discharge (P < .0001). Within the groups that eventually returned home, there were very different rates of functional improvement that were directly related to length of hospital stay.
Standard clinical measures available at rehabilitation admission carry enough predictive power to define management strategies for stroke survivors. A management algorithm is proposed that might increase the efficiency of stroke rehabilitation programs and might allow comparisons of efficacy between different treatment settings.
Physiotherapy is an established component of stroke rehabilitation but uncertainties remain about the most appropriate intensity of therapy input. We conducted a systematic review of the randomised trials of physiotherapy after stroke where qualitatively similar therapy regimens were provided at different levels of intensity. A heterogeneous group of seven randomised trials (597 patients) was identified. Dichotomous outcomes (death or the combined poor outcome of death or deterioration) were analysed by use of the odds ratio and 95% confidence interval. Patients subjected to more intensive physiotherapy input showed a non-significant reduction in case fatality (odds ratio 0.60; 95% CI 0.33-1.09) and a significant reduction (OR 0.54; 95% CI 0.34-0.85; p < 0.01) in the combined poor outcome of death or deterioration by the end of follow-up. Two statistical techniques were used to identify patterns within the continuous data. Firstly, impairment and disability scores were converted to a standardised measure of 0-100 and the weighted mean difference (WMD) between the scores in the intensive and conventional physiotherapy groups were then calculated. Modest improvements were observed in both the impairment (WMD+5; 95% CI-1-11) and disability scores (WMD+5; 95% CI 0-10) recorded at the initial review (median 3 months post-stroke), but not at the final review (median 1 year post-stroke). Secondly, Fisher's inverse chi-squared test was used to combine the p values from individual trials; this confirmed the above findings (p < 0.05 at initial review; p > 0.05 at final review). More intensive physiotherapy input was associated with a reduction in the combined poor outcome of death or deterioration and may enhance the rate of recovery. These observations warrant further investigation.
A description of the nursing role in stroke rehabilitation
A theoretical description of the nursing role in stroke rehabilitation remains elusive in the literature. The United Kingdom strategy for health service development will increasingly require nurses from all clinical specialities to collaborate with other health care professionals and stakeholders to evaluate the services they provide. In stroke rehabilitation, an understanding of the contribution that nursing makes is essential, if that collaboration is to be effective. This paper details a study undertaken to describe the nature of the nursing role in stroke rehabilitation, and the factors that shape this role. A reflective enquiry was used to enable the collection of data grounded in the realities of clinical practice. Study participants were qualified nursing staff ( n =13) working in a rehabilitation unit in the north‐west of England. A total of 35 in‐depth reflections were obtained for analysis. Three role categories were identified in the data: the nurse as care giver, facilitator of personal recovery and care manager. Sub‐categories of nursing intervention were identified within each category, together with anticipated outcomes and contextual features that shaped the category. The results of the study were verified by a purposive sample of nursing staff from the rehabilitation unit.
This study describes the large variations in outcome after stroke between countries that participated in the International Stroke Trial and seeks to define whether they could be explained by variations in case mix or by other factors.
We analyzed data from the 15 116 patients recruited in Argentina, Australia, Italy, the Netherlands, Norway, Poland, Sweden, Switzerland, and the United Kingdom: We compared crude case fatality and the proportion of patients dead or dependent at 6 months; we used logistic regression to adjust for age, sex, atrial fibrillation, systolic blood pressure, level of consciousness, and number of neurological deficits. We used the frequency of prerandomization head CT scan and prescription of aspirin at discharge to indicate quality of care.
The differences in outcome (all treatment groups combined) between the "best" and "worst" countries were very large for death (171 cases per 1000 patients) and for death or dependency (375 cases per 1000 patients). The differences were somewhat smaller after adjustment for case mix (160 and 311 cases per 1000 patients, respectively). Process of care may have accounted for some but not all of the residual variation in outcome.
Adjustment for case mix explained only some of the variation in outcome between countries. The residual differences in outcome were too large to be explained by variations in care and most likely reflect differences in unmeasured baseline factors. These findings demonstrate the need to achieve balance of treatment and control within each country in multinational randomized controlled stroke trials and the need for caution in the interpretation of nonrandomized comparisons of outcome after stroke between countries.
Several prognostic factors have been identified for outcome after stroke. However, there is a need for empirically derived models that can predict outcome and assist in medical management during rehabilitation. To be useful, these models should take into account early changes in recovery and individual patient characteristics. We present such a model and demonstrate its clinical utility.
Data on functional recovery (Barthel Index) at 0, 2, 4, 6, and 12 months after stroke were collected prospectively for 299 stroke patients at 2 London hospitals. Multilevel models were used to model recovery trajectories, allowing for day-to-day and between-patient variation. The predictive performance of the model was validated with an independent cohort of 710 stroke patients.
Urinary incontinence, sex, prestroke disability, and dysarthria affected the level of outcome after stroke; age, dysphasia, and limb deficit also affected the rate of recovery. Applying this to the validation cohort, the average difference between predicted and observed Barthel Index was -0.4, with 90% limits of agreement from -7 to 6. Predicted Barthel Index lay within 3 points of the observed Barthel Index on 49% of occasions and improved to 69% when patients' recovery histories were taken into account.
The model predicts recovery at various stages of rehabilitation in ways that could improve clinical decision making. Predictions can be altered in light of observed recovery. This model is a potentially useful tool for comparing individual patients with average recovery trajectories. Patients at elevated risk could be identified and interventions initiated.
To present a systematic review of studies that addresses the effects of intensity of augmented exercise therapy time (AETT) on activities of daily living (ADL), walking, and dexterity in patients with stroke.
A database of articles published from 1966 to November 2003 was compiled from MEDLINE, CINAHL, Cochrane Central Register of Controlled Trials, PEDro, DARE, and PiCarta using combinations of the following key words: stroke, cerebrovascular disorders, physical therapy, physiotherapy, occupational therapy, exercise therapy, rehabilitation, intensity, dose-response relationship, effectiveness, and randomized controlled trial. References presented in relevant publications were examined as well as abstracts in proceedings. Studies that satisfied the following selection criteria were included: (1) patients had a diagnosis of stroke; (2) effects of intensity of exercise training were investigated; and (3) design of the study was a randomized controlled trial (RCT). For each outcome measure, the estimated effect size (ES) and the summary effect size (SES) expressed in standard deviation units (SDU) were calculated for ADL, walking speed, and dexterity using fixed and random effect models. Correlation coefficients were calculated between observed individual effect sizes on ADL of each study, additional time spent on exercise training, and methodological quality. Cumulative meta-analyses (random effects model) adjusted for the difference in treatment intensity in each study was used for the trials evaluating the effects of AETT provided. Twenty of the 31 candidate studies, involving 2686 stroke patients, were included in the synthesis. The methodological quality ranged from 2 to 10 out of the maximum score of 14 points. The meta-analysis resulted in a small but statistically significant SES with regard to ADL measured at the end of the intervention phase. Further analysis showed a significant homogeneous SES for 17 studies that investigated effects of increased exercise intensity within the first 6 months after stroke. No significant SES was observed for the 3 studies conducted in the chronic phase. Cumulative meta-analysis strongly suggests that at least a 16-hour difference in treatment time between experimental and control groups provided in the first 6 months after stroke is needed to obtain significant differences in ADL. A significant SES supporting a higher intensity was also observed for instrumental ADL and walking speed, whereas no significant SES was found for dexterity.
The results of the present research synthesis support the hypothesis that augmented exercise therapy has a small but favorable effect on ADL, particularly if therapy input is augmented at least 16 hours within the first 6 months after stroke. This meta-analysis also suggests that clinically relevant treatment effects may be achieved on instrumental ADL and gait speed.
Large differences in outcome and resource utilisation
Stroke is a major health burden throughout Europe. Despite a reducing incidence in Western Europe,1 the rise in the elderly population and increasing incidence rates in Eastern Europe will result in it becoming a mounting population burden. It consumes a large amount of healthcare resources; in the UK about 5% of the National Health Services’ budget is spent on stroke care. Therefore optimal models for delivery of stroke care, which result in good outcome at reasonable cost, are of great importance. Although robust data has shown that care in a stroke unit (with most trials looking at rehabilitation units) is associated with improved outcome,2 we have limited understanding of which components of this organised care are responsible for this benefit. Comparing practice and outcome across different European countries may give clues that can help us to develop new hypotheses and interventions, which should then be ideally tested in controlled studies.
In this issue (pp 1702–6) the BIOMED European Study of Stroke Care Group present data from 11 centres in several Central and West European countries.3 The group have …
This study examined the effect of a 10-min, halftime cooling application on physiological and psychological parameters known to affect performance. Fourteen volunteers (10 male, 4 female) completed two randomised trials 48 hr to 7 days apart. Trials consisted of a 1-hr cycling protocol: 30 min at 75% VO2max followed by 10 min cooling (application of a cooling jacket) or passive recovery (control), and a second 30-min exercise bout consisting of 20 min at 75% VO2max, immediately followed by a 10-min maximal effort, where work was measured as energy expended (kJ). Performance of the 10-min maximal intensity phase tended to improve (171.5 +/- 30.4 kJ vs 165.4 +/- 29.2 kJ, p = 0.087) following the cooling trial. Heart rate during the 5th min of the maximal effort, (183 +/- 9 beats.min(-1) vs 180 +/- 7 beats.min(-1), p = 0.024), blood lactate concentration at 6 min post-exercise (9.3 +/- 3.1 mmolxL(-1) vs 7.9 +/- 3.2 mmolxL(-1), p = 0.007), rating of perceived exertion at the 20th min post-halftime recovery (15 +/- 2 vs 16 +/- 2, p = 0.042), and subjective rating of feelings and emotions differed between the cooling and control conditions. Sweat loss, core and mean skin temperature and rating of thermal sensation failed to differ significantly between conditions. Halftime cooling tended to result in greater aerobic performance. Psychological assessment revealed a dramatic placebo effect from the cooling application confounding these results. Furthermore, the cooling intervention failed to induce any significant thermoregulatory effects.
Differences exist between European countries in the proportion of patients who die or become dependent after stroke. The aim of the present study was to identify differences in the use of time by stroke patients in 4 rehabilitation centers in 4 European countries.
In each of the 4 centers, 60 randomly selected stroke patients were observed at 10-minute intervals using behavioral mapping. Observations took place on 30 weekdays selected at random, on equal numbers of morning, afternoon, and evening sessions. A logistic generalized estimating equation model with correction for differences in case mix and multiple testing was used for the analysis.
Overall time available from different professions was the highest in the United Kingdom, but patients in the United Kingdom spent on average only 1 hour per day in therapy. This was significantly less than patients in Belgium and Germany, who spent approximately 2 hours, and patients in Switzerland who spent approximately 3 hours per day in therapy. In all centers, patients spent less than half their time in interactions and >72% of the time in nontherapeutic activities.
Important differences in the use of time were established, which appeared dependent on management decisions rather than the number of staff available. Patients in the Swiss and German centers spent more time in therapy, possibly because of the structured organization of rehabilitation. Further studies will verify whether this has an effect on outcome.
Horn SD, DeJong G, Ryser DK, Veazie PJ, Teraoka J. Another look at observational studies in rehabilitation research: going beyond the holy grail of the randomized controlled trial. This commentary compares randomized controlled trials (RCTs) and clinical practice improvement (CPI) approaches to study design, evaluates their relative advantages and disadvantages, and discusses their implications for rehabilitation research and evidence-based practice. Many argue that observational cohort studies are not sufficient as scientific evidence for practice change. We challenge this assertion by introducing the concept of a CPI study: a comprehensive observational paradigm structured to decrease biases generally associated with observational research. One strength of CPI studies is their attention to defining and characterizing the "black box" of clinical practice. CPI studies require demanding data collection, but by using bivariate and multivariate associations among patient characteristics, process steps, and outcomes, they can uncover best practices more quickly while achieving many of the presumed advantages of RCTs.
Physiotherapy (PT) and occupational therapy (OT) are key components of stroke rehabilitation. Little is known about their content. This study aimed to define and compare the content of PT and OT for stroke patients between 4 European rehabilitation centers.
In each center, 15 individual PT and 15 OT sessions of patients fitting predetermined criteria were videotaped. The content was recorded using a list comprising 12 therapeutic categories. A generalized estimating equation model was fitted to the relative frequency of each category resulting in odds ratios.
Comparison of PT and OT between centers revealed significant differences for only 2 of the 12 categories: ambulatory exercises and selective movements. Comparison of the 2 therapeutic disciplines on the pooled data of the 4 centers revealed that ambulatory exercises, transfers, exercises, and balance in standing and lying occurred significantly more often in PT sessions. Activities of daily living, domestic activities, leisure activities, and sensory, perceptual training, and cognition occurred significantly more often in OT sessions.
This study revealed that the content of each therapeutic discipline was consistent between the 4 centers. PT and OT proved to be distinct professions with clear demarcation of roles.
This chapter reviews recent developments in the analysis of categorical and contingency-table data. The first portion examines developments in model testing and selection. The second portion examines work on models for the structure of dependence. These include log-linear parameter models, models for latent classes, models for missing observations, numerical-scale-based association and correlation models (such as correspondence analysis), the treatment of ordered categories, and models for marginal distributions.
on behalf of the IST collaborative group. Variations between countries in outcome after stroke in the International Stroke Trial (IST)
- Nu Weir
- Lewis Pag Sandercock
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- Df Signorini
- Warlow
Weir NU, Sandercock PAG, Lewis SC, Signorini DF, Warlow CP; on behalf of the IST collaborative group. Variations between countries in outcome after stroke in the International Stroke Trial (IST). Stroke. 2001;322:1370 –1377.