Changing stroke rehab and research worldwide now.Time is Brain! trillions and trillions of neurons that DIE each day because there are NO effective hyperacute therapies besides tPA(only 12% effective). I have 523 posts on hyperacute therapy, enough for researchers to spend decades proving them out. These are my personal ideas and blog on stroke rehabilitation and stroke research. Do not attempt any of these without checking with your medical provider. Unless you join me in agitating, when you need these therapies they won't be there.

What this blog is for:

My blog is not to help survivors recover, it is to have the 10 million yearly stroke survivors light fires underneath their doctors, stroke hospitals and stroke researchers to get stroke solved. 100% recovery. The stroke medical world is completely failing at that goal, they don't even have it as a goal. Shortly after getting out of the hospital and getting NO information on the process or protocols of stroke rehabilitation and recovery I started searching on the internet and found that no other survivor received useful information. This is an attempt to cover all stroke rehabilitation information that should be readily available to survivors so they can talk with informed knowledge to their medical staff. It lays out what needs to be done to get stroke survivors closer to 100% recovery. It's quite disgusting that this information is not available from every stroke association and doctors group.

Monday, June 13, 2016

The Utility of Quantifiable Neurologic Assessments After Stroke In response to Marsh et al, “The NIH Stroke Scale Has Limited Utility in Accurate Daily Monitoring of Neurologic Status”

Anything that uses the National Institutes of Health Stroke Scale for measurement is almost worthless because of subjectivity.
http://nho.sagepub.com/content/6/3/95?etoc
  1. James E. Siegler, MD1
  1. 1Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
  1. James E. Siegler, Department of Neurology, Hospital of the University of Pennsylvania, 3400 Spruce St, 3 W Gates, Philadelphia, PA 19104, USA. Email: james.siegler@uphs.upenn.edu
In the most recent edition of The Neurohospitalist, Marsh and colleagues reported a significant limitation of serial National Institutes of Health Stroke Scale (NIHSS) assessments in patients with acute ischemic stroke.1 The investigators rightfully concluded that an improvement in 4 points on the NIHSS was less sensitive for detecting neurologic recovery when compared to a comprehensive neurologic examination. Recognition of this weakness is pertinent to all clinicians who rely on the NIHSS to identify neurologic recovery (or worsening), especially when using a prethresholded NIHSS improvement in the definition of recovery.
The NIHSS is certainly not a replacement for a full neurologic examination. This tool, however, has traditionally been utilized to quantitate neurologic change in patients with stroke and serves as a useful adjunct in clinical decision-making and for research purposes. In some of the earliest clinical trials using serial NIHSS assessments, a clinically significant change has been prespecified at the same 4-point minimum as in this study.2 This is reasonable given the (1) imperfect interrater reliability and (2) fluctuations in neurologic symptoms depending on patient alertness and time of day, which may render a 2-point threshold less specific. However, in my experience, a 2-point threshold may be more sensitive and maintain a high specificity when compared to these historic 4-point cutoffs.3 As the authors demonstrate,1 a 2-point improvement actually confers nearly identical prognostic information regarding improvement when compared to the comprehensive neurologic assessment. It may even overestimate the degree of improvement. Specifically, at 24 hours post-tissue plasminogen activator, 78% of patients improved by ≥2 points compared to 71% who improved according to non-NIHSS neurologic assessment. At discharge, this rose to 83% and 71%, respectively, and at ∼1-month follow-up, 100% and 95%, respectively. Therefore, a 2-point threshold may perhaps be superior for quantitating improvement in this population when compared to the 4-point cutoff.
That being said, should the primary outcome of investigations such as these be improvement? The authors conclude that serial NIHSS assessments are inadequate for capturing changes in functional outcome when in fact their findings indicate inadequately captured improvement. The delivery of positive prognostic information to patients should certainly be pursued and explored with research efforts, but (as the authors affirm) serial NIHSS assessments may be most relevant when “considering functional decline.”1 In my experience3 and others,4 serial NIHSS assessments can successfully capture deterioration. Confirmatory research is called upon to determine whether prethresholded NIHSS changes can be implemented clinically to determine when it is appropriate to intervene and where it may be effective in identifying reversible causes of deterioration.
The NIHSS is not an ideal tool for detecting neurologic change after stroke. But a quantitative assessment should be implemented as an adjunct to the physical examination in order to monitor for progression. For the time being, I find it reasonable to perform serial NIHSS assessments in order to detect neurologic deterioration—especially when a lower threshold (eg, 2- vs 4-point worsening) is used to detect a clinically meaningful decline.5

References

No comments:

Post a Comment