Relationships between upper-limb functional limitation and self-reported disability 3 months after stroke

 Nothing here gets you recovered; so useless! Protocols get you recovered; CREATE THEM!

Relationships between upper-limb functional limitation and self-reported disability 3 months after stroke

Alexander W. Dromerick, MD; 

1–3* 

Catherine E. Lang, PhD, PT; 

3 

Rebecca Birkenmeier, MS, OTR; 

1 

Michele G. Hahn, MS, OTR; 

2 

Shirley A. Sahrmann, PhD, PT; 

1,3 

Dorothy F. Edwards, PhD 

1–2 

1 

Department of Neurology, and Programs in 

2 

Occupational Therapy and 

3 

Physical Therapy, Washington University, 

St. Louis, MO 

Abstract—This study explored relationships between upper- 

limb (UL) functional limitations and self-reported disability in 

stroke patients with relatively pure motor hemiparesis who were 

enrolled in an acute rehabilitation treatment trial. All participants 

were enrolled in the VECTORS (Very Early Constraint Treat- 

ment for Recovery from Stroke) study. VECTORS is a single- 

center pilot clinical trial of early application of constraint- 

induced movement therapy (CIMT). All 39 subjects who com- 

pleted 90 days of VECTORS were included in this analysis. 

Trained study personnel who were blinded to the treatment type 

performed all evaluations. Data in this article examine relation- 

ships between assessments performed 90 days after stroke. 

Functional limitation measures included the Action Research 

Arm (ARA) test and Wolf Motor Function Test (WMFT), and 

self-reported disability measures included the Functional Inde- 

pendence Measure (FIM) and Motor Activity Log (MAL) (by 

telephone). Mean plus or minus standard deviation time from 

stroke onset to randomization was 9.4 plus or minus 4.3 

days, and median time to follow-up was 99 days (range 68–178). 

Subjects with perfect or near-perfect scores on the ARA test or 

WMFT reported residual disability on the FIM and MAL. Qual- 

ity of movement on the WMFT (functional ability score) was not 

strongly associated with self-reported frequency, and speed of 

movement on the WMFT (timed score) was not associated with 

self-reported frequency (MAL amount of use). In this early UL 

intervention trial, we found that perceived disability measures 

captured information that was not assessed by functional limita- 

tion and impairment scales. Our results indicate that excellent 

motor recovery as measured by functional limitation and impair- 

ment scales did not equal restoration of everyday productive UL 

use and speed of task completion did not translate to actual use. 

Our results confirm the need for a measurement strategy(WRONG! You need to create EXACT RECOVERY PROTOCOLS! Don't you people have any functioning neurons? 'Measurements' do nothing towards recovery!) that is 

sensitive to change, assesses a broad performance range, and 

detects meaningful clinical improvements in early rehabilitation 

intervention trials. 

Key words: activities of daily living, arm, cerebrovascular 

accident, constraint therapy, functional limitation, hemiplegia, 

motor skills, outcome assessment (healthcare), randomized 

controlled trials, rehabilitation, upper limb.

Treating post-stroke depression is essential to overall recovery - Vero News

WRONG, WRONG, WRONG! You do the correct option and prevent depression by having EXACT 100% recovery protocols!   If your doctor needs to treat you for depression it means YOUR DOCTOR IS A COMPLETE FUCKING FAILURE!

 Treating post-stroke depression is essential to overall recovery - Vero News

Experts Warn: Strokes in Young People Are Preventable and Reversible | Nagpur News

 This part about reversible is TOTALLY FUCKING WRONG!

Read more at:
http://timesofindia.indiatimes.com/articleshow/115635054.cms?utm_source=contentofinterest&utm_medium=text&utm_campaign=cppst

Experts Warn: Strokes in Young People Are Preventable and Reversible | Nagpur News

Strokes: Offer patients three hours a day of rehab, NHS urged

WRONG, WRONG, WRONG! Rehab doesn't guarantee recovery because there are NO protocols out there for stroke. This is just a sop to look like the NHS is doing something. They should be delivering EXACT PROTOCOLS that deliver results and recovery. YOU need to get involved and change the mindset of all stroke medical 'professionals' to deliver recovery not just useless guidelines!

Strokes: Offer patients three hours a day of rehab, NHS urged

By Michelle RobertsDigital health editor

Getty Images

Stroke patients should be offered extra rehabilitation on the NHS, say updated guidelines for England and Wales.

The National Institute for Health and Care Excellence (NICE) had previously recommended 45 minutes a day.

But it believes some patients may need more intensive therapy for recovery and is suggesting three hours a day, five days a week.

Experts welcome the advice, but question how feasible it will be for a stretched health service to deliver.

NICE accepts it may be "challenging", but it says patients and families deserve the best care possible. That includes help regaining speech, movement and other functions caused by the damage that happens to the brain during a stroke.

NHS England has said increasing the availability of high quality rehabilitation is a priority. More people than ever are surviving a stroke thanks to improvements in NHS care, it added.

• Survivor calls for more support after stroke at 20
• BBC F1 broadcaster Jennie Gow tells of stroke recovery
• Student mistook stroke for hangover
• Half of stroke patients not getting necessary care

A stroke cuts off blood supply to parts of the brain, killing some cells. They are common and can affect people of all ages, but many patients survive if they receive prompt treatment.

All strokes are different, depending on the part of the brain that is damaged. For some people, the effects may be relatively minor and may not last long, while others may be left with more serious long-term problems.

There are around 85,000 strokes every year in England, and around a million stroke survivors, many of whom are living with long-term effects.

Some of the injury is reversible, though, with help from health teams providing services such as physiotherapy, as well as occupational, speech and language therapies.

Brenna Collie

After having a stroke at the age of 14, Brenna needed daily physiotherapy to learn how to walk

Although strokes usually affect older people, about 400 UK children have a stroke each year in the UK, leaving many with severe physical and mental after effects.

Brenna Collie, who is 21 and from Aberdeenshire, had a stroke in 2017, at the age of 14.

Brenna, who was a very sporty teenager, had intensive physiotherapy for about a year so that she could learn to walk again.

She's since been able to return to archery and playing hockey. During the Covid pandemic, Brenna learnt how to knit with her affected arm.

But she still experiences some after effects of her stroke - she wears an ankle support to help with a weakness called drop foot.

"I still have left sided weakness. I have neuropathic pain down my left side and I have migraines, light sensitivity and fatigue."

• Read more on Brenna's story

NICE says the evidence it reviewed when updating its guidance showed more intensive rehabilitation improves quality of life and important daily skills, such as being able to dress and feed yourself.

It also heard from people recovering from strokes, and from their families and carers, who felt strongly that more intensive rehabilitation would be useful in helping them recover faster.

Prof Jonathan Benger, chief medical officer at NICE, said: "We recognise the challenges the system faces in delivering these recommendations, not least the problems inherent in increasing service capacity and staff. We also know current practice is inconsistent, even when it comes to implementing our previous recommendations.

"But equally, it shouldn't be underestimated how important it is for people who have been left with disabilities following a stroke to be given the opportunity to benefit from the intensity and duration of rehabilitation therapies outlined in this updated guideline."

Its previous 2013 guidelines recommended offering at least 45 minutes of each relevant stroke rehabilitation therapy for a minimum of five days a week - although this could be increased in some cases.

Dr Maeva May from the Stroke Association said many stroke survivors receive only a fraction of what the guideline recommends, partly because there are too few staff to provide the care.

"It's vital that governments act urgently to address staffing issues across health and social care, and within rehabilitation services, and share detailed plans to support and resource them, so that these recommendations can become a reality," she told the BBC.

An NHS England spokesperson said: "Despite the current workforce and capacity pressures acknowledged by NICE, the NHS is delivering high-quality specialist support for stroke patients - including through physiotherapy, occupational therapy and speech and language therapy - closer to patients' home."

If you suspect that you or someone else are having a stroke, call emergency services - 999 in the UK - immediately and ask for an ambulance.

The main symptoms of stroke can be remembered with the word FAST:

• Face - drooping
• Arms - unable to lift both and keep them there.
• Speech - slurred, garbled or unresponsive
• Time - dial 999 immediately

Time is brain. Our number one priority in treating stroke patients is getting the right therapy to the right patients as quickly as possible. However, achieving this goal is not always straightforward.

WRONG, WRONG, WRONG! Your number 1 goal is 100% recovery, at least according to survivors. WHY THE FUCK AREN'T YOU DOING WHAT SURVIVORS WANT?

 Time is brain. Our number one priority in treating stroke patients is getting the right therapy to the right patients as quickly as possible. However, achieving this goal is not always straightforward.

Time is brain. Our number one priority in treating stroke patients is getting the right therapy to the right patients as quickly as possible. However, achieving this goal is not always straightforward.

One uncertainty is whether it is beneficial for patients with suspected large vessel occlusion (LVO) stroke to bypass a local primary stroke centre (PSC) and be brought directly to a mechanical thrombectomy (MT) capable comprehensive stroke centre (CSC). Two trials RACECAT¹, based in Catalonia and TRIAGE-STROKE², based in Denmark, have sought to address this question.

RACECAT was a cluster randomised trial set in predominantly non-urban regions in Catalonia. EMS personnel used the RACE Scale³ to predict LVO (score 5-9 suggesting LVO present). The unit of ‘clustering’ was temporal, i.e. 12 hour time slots, stratified by territory and day of the week. Patients were either brought to the nearest stroke centre, and if LVO confirmed transfer to MT capable centre or were transported directly to the MT capable centre. The primary outcome was disability at 90 days assessed by mRS.

1401 patients were randomised in RACECAT, however 7475 adults total were screened for inclusion. Most excluded did not meet eligibility criteria. LVO was detected in approximately two-thirds of the patients. Median time from onset to arrival at first hospital was 88 minutes (IQR 61-145) for PSC arm and 142 minutes (IQR 100-231) in CSC arm. Door-to-needle time for those receiving tPA was similar in both arms: 33 minutes (25-48) in PSC and 30 minutes (22-40) in CSC, but time from symptom onset to tPA was 34 minutes faster in the PSC arm. (PSC 120 minutes (IQR 89-168) versus CSC 155 minutes (IQR 120-195). Median stroke onset to groin puncture times was 270 minutes (215-347) in the PSC and 214 minutes (172-330) in the CSC arm (56 minutes quicker in CSC arm.)

RACECAT was halted at the second interim analysis due to futility. There was no significant difference in mRS at 90 days between the two transport strategies, with a median mRS of 3 in both arms at 90 days. Safety outcomes and 90 day mortality were the same between both arms. However, in a further secondary analysis the RACECAT⁴ authors reported that for patients with a final diagnosis of intracranial haemorrhage, (ICH) (302 patients in total, representing 21.6% of the total number randomised in RACECAT) transportation to a CSC was associated with worse functional outcome at 90 days, with higher rates of medical complications (22.6% in CSC arm compared with 5.6% in PSC arm) and specifically a higher rate of pneumonia in the CSC arm: 35.8% (versus 17.6% in PSC). Mortality at 90 days was numerically higher in the CSC arm for those with ICH (48.9% CSC versus 37.6% PSC) although this was not statistically significant.

A second RCT examining transport strategy in suspected LVO stroke was published in Stroke this month. TRIAGE-STROKE² was a multicentre RCT in Central and Northern Denmark which ran from 2018-2022. However, it was terminated at 4 years due to lack of funding and also hindered by lack of recruitment at all participating centres as well as withdrawal of two CSC from the trial due to increased burden of accepting bypassed patients directly. As such, TRIAGE-STROKE is underpowered to answer its primary outcome which was mRS at day 90.

In TRIAGE-STROKE the PASS⁵ score was used by EMS to predict LVO. The inclusion criteria was stricter than RACECAT and patients in TRIAGE-STROKE also had to be eligible for IVT as well as likely EVT, and to be able to arrive at the CSC and PSC within 4 hours of onset of stroke. The target sample size was 600 participants, but only 186 were screened and 171 were randomised. Of these, 104 were confirmed to have ischaemic stroke, with 51 haemorrhages and 16 mimics. LVO was confirmed in 71 (68.3%). Time from stroke onset to arrival at first hospital was 81 minutes (IQR 64-116) for PSC and 177 minutes (IQR 95-158) in CSC. Symptom onset to tPA was 30 minutes faster in the PSC arm: PSC 114 minutes (IQR 90-157) versus 144 minutes (IQR 122-171) in CSC arm. Stroke onset to groin puncture was 35 minutes faster in the CSC arm: 187 minutes (IQR 158-245) CSC arm versus 222 minutes (IQR 196-297) in PSC.

Due to lack of power, TRIAGE-STROKE was unable to demonstrate a functional benefit at 90 days. Despite low power, the OR of mRS shift for all 171 patients randomised was neutral OR 1.01 (0.60-1.71) For the haemorrhage subgroup (n=51) the OR was 0.94 (0.34-2.63) somewhat replicating the signal of harm for those with ICH if bypassed directly to a CSC, although due to wide confidence intervals, we cannot draw firm conclusions.

Overall, from these two trials there is certainly not an overwhelming signal that a  bypass approach is better for patients with suspected LVO. We certainly need to take heed of the signal of potential harm and increased complications for patients with ICH – especially considering ICH will often present similarly to LVO and will ‘screen positive for LVO’ on whatever pre-hospital clinical tool is used. The number-needed to harm (for a patient with ICH to have mRS of 5 or 6 at 90 days) in RACECAT ICH secondary analysis was 9. It would not be fair to streamline stroke workflow to benefit only ischaemic strokes to the determent of those with haemorrhagic strokes. Additionally, consider the increased burden on CSCs if all potential LVO strokes (including ICH and mimics) were admitted directly. Questions surrounding repatriation of stroke patients and mimics to their local hospital would need to be addressed.

Another take home point is to underscore the value of early Stroke Unit care and the importance of proactively managing medical complications, especially in haemorrhagic stroke. We must also consider that the potential beneficial effect of getting to EVT quicker may have been neutralised by the PSC arms getting to IVT quicker. The complex screening process, EMS training and coordinated workflows required to ensure these trials were performed must be commended, however these complex workflows may not translate into other countries or areas. Overall, I think we should focus on ensuring that our existing stroke pathways run smoothly and efficiently. For those delivering ‘drip-and-ship’ stroke care, these trials are reassuring that the stroke care we are delivering is as good as that at the CSC and we should be motivated to renew our efforts to keep door-to-needle and door-in-door-out times as brisk as possible.

Hospitals board agrees stroke care investment is needed

WRONG, WRONG,WRONG! 'Care' is not what survivors want, they want RESULTS AND RECOVERY! Do you people ever think?

Hospitals board agrees stroke care investment is needed

Sarah Lagan

Updated: Nov 01, 2023 08:23 AM

2 Comments

The Bermuda Hospitals Board said investment is needed in stroke rehabilitation after an island-wide survey revealed gaps in the quality of service being offered.

The survey by Evolution Healing Centre in Paget highlighted an “urgent need” for improved stroke rehabilitation services, including more specialised healthcare professionals on the job.

Carried out over an eight-week period, the survey sought to gather data about the lived experiences of stroke survivors in Bermuda and was completed by 56 people who met the eligibility criteria.

A BHB spokesman said: “BHB welcomes the survey by Evolution of the Lived Experiences of Stroke For Bermuda 2022.

“The data collected, although from a relatively small number of people, does indicate there are gaps in rehabilitation services for stroke patients.

“As we see it, the survey highlights the need for investment in this medical area. We are willing to work with stakeholders to improve services and also partner with them for the same.

“We are committed to pursuing excellence to improve the health and wellbeing for our Bermuda community.”

The survey was carried out by Kim Watkins, a doctor of physiotherapy, and Sandro Fubler, senior physiotherapist at Evolution, and was released in time for World Stroke Day on Sunday.

It recommends several changes, including increased insurance coverage for stroke survivors, an improved stroke care pathway and better specialised multidisciplinary care.

It also calls for more healthcare professionals who can deliver high-quality stroke rehabilitation and the setting-up of a support group for survivors and caregivers in Bermuda.

Dr Watkins said: “The response from the community regarding the survey is really positive. We acknowledge from the data that there are gaps in services across the whole continuum of care.

“We are very grateful for the response from BHB to work together to help establish services and a stroke care pathway.

“We look forward to keeping the community updated on the progress to help improve stroke rehabilitation services moving forward and coming together to make a strategic plan.

“I believe we are all on the same page in terms of helping to improve health and wellbeing.

“We will also have continued conversations with the private insurance companies and the Ministry of Health to improve investments in this area of need.”

The BHB’s Primary Stroke Centre, launched in 2019 as part of an affiliation with Johns Hopkins Medicine International, attained distinction certification from Accreditation Canada last year for its acute stroke and inpatient rehabilitation service standards.

Accreditation Canada’s report highlighted several “areas of success” at the centre, praising the leadership and organisational support, knowledgable and committed staff, community partnerships, public communication about strokes, and collaboration with Johns Hopkins Medicine International.

Dunklau Gardens to Participate in Post-Acute Care Standards Initiative for Stroke Patients - Fremont, Nebraska

 WRONG, WRONG, WRONG! Survivors don't want 'care you blithering idiots. They want RECOVERY AND RESULTS!  GET THERE!

In my opinion this is an incompetent hospital, you shouldn't go there until they have a plan for 100% recovery.

Dunklau Gardens to Participate in Post-Acute Care Standards Initiative for Stroke Patients

June 14th, 2023 | Methodist Fremont Health

FREMONT – Dunklau Gardens will participate in the American Heart Association’s Mission: Lifeline Stroke Post-Acute Care (PAC) initiative to enhance guideline-based care for stroke patients, ultimately improving and prolonging lives.

Evidence-based rehabilitation and secondary prevention interventions improve recovery after a stroke and reduce secondary complications. However, stroke rehabilitation expertise, processes of care and educational resources vary among sites where PAC is delivered. The American Heart Association, the world’s leading nonprofit organization focused on heart and brain health for all, developed quality standards based on its 2016 Guidelines for Adult Stroke Rehabilitation and Recovery to address these gaps.

“We’re committed to improving patient care by adhering to the latest guidelines,” said Jayma Brown, BSN, RN, MHA, NE-BC, director of long-term care nursing at Dunklau Gardens. “The post-acute care standards initiative makes it easier for our teams to put proven knowledge and guidelines to work on a daily basis, which studies show can help patients recover better. The end goal is to ensure that more people in Dodge County and the surrounding areas can experience longer, healthier lives.”

Facilities participating in the PAC standards initiative receive a participation stipend and site-specific quality improvement support and process improvement ideas surrounding quality standards for stroke recovery, rehabilitation and secondary prevention. Facilities also have the opportunity to be part of a learning collaborative, working with experts in stroke rehabilitation to build tools and share and create best practices. Participation improves collaboration between PAC facilities and others involved in stroke care, including hospitals and outpatient providers.

Participation in the program benefits stroke patients and caregivers with the knowledge that the facility is committed to providing services supported by American Heart Association science. They also have the assurance that the facility is collaborating with the association on standardizing its stoke rehabilitation program in alignment with expert guidance and evidence-based research.

Stroke is the No. 5 cause of death and a leading cause of disability in the U.S. A stroke occurs when a blood vessel that carries oxygen and nutrients to the brain is either blocked by a clot or bursts. When that happens, part of the brain cannot get the blood and oxygen it needs, so brain cells die. Early stroke detection and treatment are key to improving survival, minimizing disability and accelerating recovery times.

Mission: Lifeline Stroke is the American Heart Association’s community-based initiative to develop systems of care to improve outcomes for stroke patients. Made possible with a $1.5 million grant from The Leona M. and Harry B. Helmsley Charitable Trust, the PAC initiative will implement the newly developed American Heart Association Post-Acute Stroke Care Quality Standards program in rehabilitation facilities across Montana, Nebraska and North Dakota. The initiative has a goal of giving all patients the best chance at independent lives after stroke.

This work builds on the Mission: Lifeline Stroke Nebraska initiative launched in 2019. The new initiative is the first to implement the Post-Acute Stroke Care Quality Standards program developed and tested in Montana. Larger rehabilitation hospitals, skilled nursing facilities and critical access hospitals in rural and urban areas are eligible to participate.

Warning that Europe is failing to provide adequate stroke care and support – the scale of stroke care crisis is laid bare for first time by new data release

WRONG, WRONG, WRONG! The crisis is lack of recovery and results!  'Care' is useless if it doesn't produce recovery! Solve the correct problem; it's not 'care!

Warning that Europe is failing to provide adequate stroke care and support  – the scale of stroke care crisis is laid bare for first time by new data release

May 8, 2023

A Decrease font size. A Reset font size. A Increase font size.

New data released today from the Stroke Action Plan for Europe Services Stroke Tracker, reveals the gross inequity of access to care and support for stroke patients and stroke survivors across Europe.

 The Stroke Action Plan for Europe was launched in 2018, to provide a framework for European governments to improve stroke care and support for all citizens in Europe. As part of this Plan, and for the first time, data from across 36 countries across Europe, covering 12 key areas of improvement, has been collected and is available here [link to the website]. In summary the data shows:

• There is inequity in access to stroke care in Europe and insufficient access to care also in many high-income countries. This is the case for acute care, and to an even larger degree for rehabilitation and life after stroke support.
• National and/or regional data are crucial in planning, organising and documenting access to care; however, such data are lacking or incomplete in the majority of European countries. Most European countries do not have a National Stroke Plan or National/regional registries to monitor stroke care.
• The burden of stroke is predicted to increase but despite this, most countries do not have a plan for primordial or primary prevention.

Professor Hanne Karup Christensen, Stroke Action Plan for Europe steering committee chair: To reduce the burden of stroke in the years to come with its grave effects on individuals as well as societies, governments must prioritise implementing an adequate organization which include plans for primary and primordial prevention, National stroke plans and national/regional registries to monitor quality, outcomes and access to stroke care.

Arlene Wilkie, Director General, Stroke Alliance Eruope: This data released today shows a woeful lack of equitable access to stroke care and support across Europe. This is not good enough. Our governments must do more to prevent stroke, and when they do occur, ensure that every citizen has access to physical and emotional care and support in hospital as well as the ongoing long term support that each stroke survivor and carer needs when they go home. Urgent action is needed by each country to implement and fund a national stroke plan that covers everything from prevention, to acute care, rehabilitation and long term support.

All information can be found here

 

Post-Stroke Rehabilitation: Challenges and New Perspectives

THIS is why survivors need to be in charge. The stroke medical world doesn't have the best interests of survivors in place. 

Post-Stroke Rehabilitation: Challenges and New Perspectives

by

Giovanni Morone

^1,2 and

Floriana Pichiorri

^3,*

¹

Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy

²

San Raffaele Institute of Sulmona, 67039 Sulmona, Italy

³

Neuroelectrical Imaging and Brain–Computer Interface Laboratory, Fondazione Santa Lucia IRCCS, 00179 Rome, Italy

^*

Author to whom correspondence should be addressed.

J. Clin. Med. 2023, 12(2), 550; https://doi.org/10.3390/jcm12020550

Received: 30 December 2022 / Accepted: 4 January 2023 / Published: 10 January 2023

(This article belongs to the Special Issue Post-stroke Rehabilitation: Challenges and New Perspectives)

Download Versions Notes

A stroke is determined by insufficient blood supply to the brain due to vessel occlusion (ischemic stroke) or rupture (hemorrhagic stroke), resulting in immediate neurological impairment to differing degrees. Due to its etiology, it is prevalent among the elderly population even though its impact on young adults is possibly higher given the longer life expectancy of survivors. Stroke is the leading cause of disability worldwide and its incidence will increase along with the aging population. On one hand, improvements in acute stroke care (fibrinolytic therapy or endovascular treatment) aim to reduce the burden of residual neurological damage. On the other hand, efficient medical management of early phase complications (e.g., infections) will hopefully result in an increased number of stroke survivors.

Thus, neurorehabilitation remains crucial in determining the personal and societal burden of stroke consequences in the medium to long term. These range from sensorimotor impairment affecting the person’s ability to stand, walk or properly use the upper limbs to attend to the activities of daily life, cognitive impairment including speech disturbances, impaired swallowing and more. These factors, together with the management of comorbidities, stroke-related epilepsy, and sleep disturbances, all impact on the patient’s quality of life and social participation after the event.

In this multifaceted scenario, clinicians and researchers working in post-stroke rehabilitation in the last decade have produced a considerable amount of evidence for successfully assessing post-stroke consequences and have suggested treatment approaches with different degrees of technological complexity. This has resulted in a further increase in the number of characters composing the multidisciplinary rehabilitation team, now including bio-engineers and physicists besides the physicians nurses, therapists, and psychologists from several specialties.

The vast amount of work is reflected in European stroke rehabilitation guidelines [1,2,3] which now mention technology-based therapies for cognitive and motor rehabilitation alongside traditional indications on early mobilization, constraint-induced movement therapy, task-oriented repetitive training and aerobic exercises. The management of swallowing impairment, which leads to malnutrition and poor stroke outcomes [4] is also underlined in most rehabilitation guidelines and has now reached possibly the highest level of published evidence in the field [5].

Despite these advancements there is still little consensus on which approach is the most effective for each category of patient, among the plethora of novel solutions including those based on robotics, non-invasive brain stimulations, [6] brain–computer interfaces [7], and more. In other words, while many of these approaches have proven some level of efficacy, even in well-designed randomized controlled trials (RCTs), most patients are offered these options according to their availability in the facilities that they refer to for rehabilitation with the certainty that they will do no harm and in the presumption that they will contribute to a better outcome.

There is a tremendous need for patient stratification in order to direct resources to patients who will benefit most from a given rehabilitation approach(WRONG, WRONG, WRONG.That is cherry picking and against the precept of 'no survivor left behind!). To reach this goal, researchers should pursue a trade-off between large RCTs and improvements in longitudinal personalized approaches [8]. On one hand, large numbers are needed in order to overcome the intrinsic variability in the spontaneous recovery after a stroke. On the other hand, variability should be deeply investigated with the very intent of identifying markers of response to a given treatment, in order to improve the personalization of neurorehabilitation pathways. In this context, the advancements made in assessing specific deficits and in measuring specific outcomes via neuroimaging, neurophysiology and other advanced bioengineering techniques (i.e., robots and sensors) will hopefully lead to the identification of potential novel markers of good recovery. Needless to say, the achievements in the field of post-stroke rehabilitation will inevitably depend on the successful integration of different professionals, representing a unique opportunity for multidisciplinarity.

In the light of this scenario, with the aim of evaluating the efficacy of a specific therapy for the motor and cognitive recovery of patients with neurological disease, the aggregation of numerical data (as done in systematic reviews) is not always useful to deduce the dilemma. An example of this is a recent review of systematic reviews of robotics which showed that in the face of primary studies of excellent quality, most of the systematic reviews lack sufficient methodological quality with few exceptions [9].

It is fair to say that technological devices have now entered neurorehabilitation wards, at least in high-income countries [10]; however, efforts must be made to direct these interventions to the best responding categories of patients and possibly extend these benefits to mid- and low-income countries [11]. To reach this goal, extensive longitudinal assessments and defining measurable outcomes is paramount, and it must be directed to evaluate the benefits of rehabilitation in terms of actual improvements in daily life activities, i.e., the improvements must be clinically and functionally relevant to justify the investment of resources.

A further challenge that the neurorehabilitative community will have to face in the future concerns the great need for chronic care. Indeed, in the absence of an increase in devoted economic resources, the outpatient setting will not be able to respond adequately to such needs. It will likely be necessary to rethink the patient’s home as a place of care. In this sense, telemedicine and telerehabilitation have proven effective during periods of confinement (in the recent SARS-CoV-2 pandemic) and for remote rural areas, but could eventually become a resource to be added to chronic rehabilitation facilities [12]. The potential of telerehabilitation could also be effective in reducing the uneven availability of advanced treatment options, even in high-income countries (e.g., in peripheral and rural areas). These instruments could be used to identify, via remote assessments, candidates for specific interventions and thus eventually justify the logistical efforts on behalf of the patients, caregivers and healthcare providers. Additionally, this would apply to all geographic areas facing conflicts, natural disasters and other possible causes of isolation which are unfortunately very relevant nowadays. All in all, the post-stroke neurorehabilitation field is a complex and multifaceted one, requiring different skills and knowledge from clinicians and non-clinical specialists. To face this complexity, professionals willing to work in this field must be provided with adequate learning opportunities and specific training which is currently lacking in formal education programs, e.g., nurses, therapists and even physicians. Efforts are being made in this sense on behalf of national and international scientific societies in this field, which foster multidisciplinarity and integration with neighboring fields. However, there is still a wide gap between the research context and the everyday clinical practice. This gap must be filled with the contributions from formal educational institutions, clinics and government regulations to foster translationality, evenly distributed resources and optimized efforts. 

Conflicts of Interest

The authors declare no conflict of interest.

References

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Prediction of gait independence using the Trunk Impairment Scale in patients with acute stroke

 My god, is this bad research, and the mentors and senior researchers have to be just as bad in approving it!

Oops, I'm not playing by the polite rules of Dale Carnegie,  'How to Win Friends and Influence People'. 

Telling supposedly smart stroke medical persons they know nothing about stroke is a no-no even if it is true. 

Politeness will never solve anything in stroke. Yes, I'm a bomb thrower and proud of it. Someday a stroke 'leader' will try to ream me out for making them look bad by being truthful, I look forward to that day.

Prediction of gait independence using the Trunk Impairment Scale in patients with acute stroke

Masahiro Ishiwatari https://orcid.org/0000-0001-8564-4793 pt-ishi-ishi@tree.odn.ne.jp, Mami Tani, […], and Toshiyuki Fujiwara+8View all authors and affiliations

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https://doi.org/10.1177/17562864221140180

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Abstract

Background:

Gait recovery is one of the primary goals of stroke rehabilitation. Gait independence is a key functional component of independent activities in daily living and social participation. Therefore, early prediction of gait independence is essential for stroke rehabilitation.(WRONG, WRONG, WRONG! Delivering gait recovery is essential for stroke rehab. NOT  a prediction! ARE YOU THAT MUCH OF A BLITHERING IDIOT?) Trunk function is important for recovery of gait, balance, and lower extremity function. The Trunk Impairment Scale (TIS) was developed to assess trunk impairment in patients with stroke.

Objective:

To evaluate the predictive validity of the TIS for gait independence in patients with acute stroke.

Methods:

A total of 102 patients with acute stroke participated in this study. Every participant was assessed using the TIS, Stroke Impairment Assessment Set (SIAS), and Functional Independence Measure (FIM) within 48 h of stroke onset and at discharge. Gait independence was defined as FIM gait scores of 6 and 7. Multiple regression analysis was used to predict the FIM gait score, and multiple logistic regression analysis was used to predict gait independence. Cut-off values were determined using receiver operating characteristic (ROC) curves for variables considered significant in the multiple logistic regression analysis. In addition, the area under the curve (AUC), sensitivity, and specificity were calculated.

Results:

For the prediction of the FIM gait score at discharge, the TIS at admission showed a good-fitting adjusted coefficient of determination (R² = 0.672, p < 0.001). The TIS and age were selected as predictors of gait independence. The ROC curve had a TIS cut-off value of 12 points (sensitivity: 81.4%, specificity: 79.7%) and an AUC of 0.911. The cut-off value for age was 75 years (sensitivity: 74.6%, specificity: 65.1%), and the AUC was 0.709.

Conclusion:

The TIS is a useful early predictor of gait ability in patients with acute stroke.

Introduction

Gait recovery is a primary goal of stroke rehabilitation. Therefore, early prediction of gait independence is important for rehabilitation. Using neuroimaging, clinical studies have shown that the size of the brain lesion in stroke affects gait recovery.^1,2 Studies on the prognostic value of gait have reported effects on lower limb muscle strength, balance, and trunk function.^3–5 Gait disturbances in patients with stroke are caused by weakness (paresis or paralysis), abnormal tone in the limbs or trunk, or by disturbances in the sensory-motor system or central control mechanisms.⁶ Trunk control is an essential component of functional gait.⁷

In stroke rehabilitation, trunk control is a crucial element of motor activity for performing many functional tasks.⁸ A role for compensatory activation of noncrossing pathways in the recovery of trunk function has been suggested.^9,10 Clinical assessment tools to evaluate trunk function after stroke have been the subject of several systematic reviews.^11,12 Fujiwara et al.⁸ developed their Trunk Impairment Scale (TIS) to assess trunk function from a functional perspective and evaluated its psychometric properties. Many previous reports on trunk dysfunction after stroke have analyzed patient outcomes several weeks after stroke onset,^13,14 and not from the acute early onset. This may be due to the lack of an established method for acutely assessing the functional aspects of trunk dysfunction in patients with stroke.

Early inpatient rehabilitation can improve mortality and lessen the severity of disability.^15,16 A study on the length of hospital stays and outcomes of patients with stroke using the Uniform Data System for Medical Rehabilitation database reported that the hospital stay length decreased from an average of 19.6 days (±12.8 days) to 16.5 days (±9.8 days) over an 8-year study period.¹⁷ In the future, early rehabilitation interventions will become more important as the length of hospital stay is further reduced. Hence, early prediction of prognosis is necessary.

Our research question was: what is the predictive validity of the TIS for gait independence at hospital discharge when performed within 48 h of acute stroke onset? Thus, this study aimed to evaluate the predictive validity of the TIS for gait independence in patients with acute stroke.

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A cohesive, person-centric evidence-based model for successful rehabilitation after stroke and other disabling conditions

Except that successful rehabilitation only occurs 10% of the time.  To get better at that you're going to have to stop the 5 causes of the neuronal cascade of death in the first days, saving millions to billions of neurons. That might allow your rehab to actually work. What you call successful is the tyranny of low expectations that your survivors don't want. They want 100% recovery. GET THERE!

A cohesive, person-centric evidence-based model for successful rehabilitation after stroke and other disabling conditions

Harry McNaughton https://orcid.org/0000-0003-3030-6062 harry.mcnaughton@mrinz.ac.nz, John Gommans, […], and Vivian Fu+2View all authors and affiliations

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https://doi.org/10.1177/02692155221145433

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Professor Derick Wade, in his valedictory editorial for Clinical Rehabilitation after 27 years in the editor's chair, makes many important observations about the changing understanding of rehabilitation during his professional life and reflects on his phenomenal contribution to the field.¹ Most importantly, he states that ‘rehabilitation is much broader than traditional medical practice’ and that ‘psychology, sociology and other behavioural sciences’ are relevant to its practice. He champions the Biopsychosocial model of wellness and despairs of the ‘biomedical approach’ to much of non-rehabilitation medicine. He concludes that he has ‘developed a reasonably cohesive model of what rehabilitation is’.² We think he could go further and, in this article, using a much broader time horizon and evidence from large, randomised trials, we propose a cohesive model for rehabilitation with the evidence mainly from the field of stroke, arguing that successful rehabilitation depends most on the person, not the health professionals who may be involved.(WRONG, WRONG, WRONG! The health professional is required to provide EXACT REHAB PROTOCOLS LEADING TO 100% RECOVERY! Anything less is incompetence.) This key idea requires us to rethink current rehabilitation dogma, including the pre-eminence of the health professional team, the belief that success is fundamentally about rehabilitation ‘dose’ and the use of ‘SMART’ (Specific Measurable Achievable Realistic Timed) and similar goal-setting strategies.

In 1972, Dr Howard Rusk, often credited as the ‘father’ of modern comprehensive rehabilitation, proposed two principles for successful rehabilitation outcomes.³ The first was that ‘the whole person needed rehabilitation, not just the part of him that had been damaged’ and the second that ‘Ultimately, the success of all rehabilitation depends on the patient himself’. Even earlier, Abraham Maslow, one of the great pioneers of modern psychology, proposed that ‘the integrated wholeness of the organism must be one of the foundation stones of motivation theory’.⁴

Few rehabilitation clinicians today would argue with these statements, as they express the ideas that formed the ‘Biopsychosocial model of wellness’^5,6 which remains a core part of modern rehabilitation teaching. Yet, in the intervening 50 years, the actual practice of rehabilitation has focussed more and more on the ‘damaged part’ and less and less on the ‘whole person’. We argue here that the theory of a balanced Biopsychosocial model has become distorted in clinical practice to a biomedical-dominant idea of what successful rehabilitation is, particularly in the belief that ‘more therapy improves outcomes’ (Figure 1). With the focus on delivery of therapy, the balance in the therapeutic relationship between the person and the rehabilitation team has changed from the theoretical ideal of an equal partnership to one where the rehabilitation team dominates.

Figure 1. The Biopsychosocial model and balance of the therapeutic relationship: As originally envisioned (left) and their current distortion (right) – see text.

A recent Cochrane review found no convincing evidence that more rehabilitation therapy leads to better outcomes for people with stroke.⁷ Evidence from large, randomised trials in stroke, not included in the Cochrane review, have also failed to demonstrate a benefit for various types and doses of extra rehabilitation therapy, as we detail below. This evidence raises two important questions: (1) Is there a fundamental problem with the current dominant rehabilitation approach? And (2) Is there evidence to support an alternative? We think the answer to both these questions is ‘Yes’.

In the following paragraphs, we chart the rise of the ‘more therapy is better’ approach interrogating the evidence; propose an alternative and more Biopsychosocial approach applied in a person-centric manner with supportive evidence from randomised trials; and suggest the next steps for rehabilitation practice, practitioner training and research.

The rise of the ‘more therapy leads to better outcomes’ hypothesis

Supporters of a narrow biomedical approach to stroke rehabilitation point to a combination of ideas and evidence. The main ideas are that increased amounts of physical activity should enhance neuroplasticity in people with brain damage from stroke and that – just as increases in practice work for athletes who want to run further or faster or lift heavier weights – the same should apply to people recovering from a stroke.

The evidence underpinning this argument comes from three main sources. The first was a highly influential study by Kwakkel et al., and accompanying editorial published in The Lancet in 1999.^8,9 This small (n = 101, around 3% of all people screened) randomised controlled trial (RCT) with three arms compared significantly disabled patients with middle cerebral artery stroke receiving a baseline of 4 hours/week of usual rehabilitation therapy plus the use of an immobilising splint on their paretic arm and leg for 30 minutes five times a week for 20 weeks (the control group) against an additional 30 minutes five times a week of either arm therapy or leg therapy instead of the splint. The authors point to statistically significant differences in Barthel Index (BI) at 26 weeks after stroke as evidence that more exercise leads to more functional gains. The accompanying editorial said that ‘this study shows how great an effect a small quantity of a specific input may achieve’ and that ‘Few pharmaceutical or surgical interventions are so powerful’.⁹

The main problem with these conclusions was the significant imbalance of groups at baseline and associated failure to consider the natural recovery pathway for different types of ischaemic stroke when using a fixed assessment time point. The control group had more patients with total anterior circulation infarcts (TACIs), that is, large carotid territory strokes (control 68% vs. arm training 58% vs. leg training 55%) reflected in better baseline scores for activities of daily living and walking ability in the leg training group.¹⁰ The rate of gain in BI points over time for patients with TACIs is only 32–43% that of other (smaller) types of anterior circulation strokes.¹¹ At 26 weeks, we would expect the best BI scores in the group with the lowest proportion of TACIs, that is, the leg training group, which this study confirmed.

This interpretation is supported by the 1-year follow-up results¹² which show more of the control group patients improving and many fewer deteriorating between six months and 12 months than the two ‘active’ groups on BI score, walking speed, walking ability and hand dexterity. At 12 months, there was no difference between the three groups on any of the primary outcome measures. In summary, the additional therapy in this study made no difference to outcomes at the level of impairment or activity at 12 months.

The second strand of evidence comes from the Stroke Unit trials. These trials compared variable forms of organised inpatient stroke care (OISC) (either specialist stroke wards, mixed acute and rehabilitation stroke units or mobile stroke teams) with care on general medical wards with patients randomised and transferred to OISC any time from very early after stroke to a few weeks later.¹³ Key publications between 1993 and 1997 combined the results of several studies, conclusively showing a reduction in mortality for people with stroke managed in an OISC setting compared to a general medical ward with less clear improvements in the prospects of returning home and regaining independence in usual activities.¹⁴

The authors of the 1997 collaboration (19 trials, >3000 participants) used the features that were more common in OISC settings and less common in general ward settings to describe and recommend implementation of the ‘distinctive features’ of OISC: viz. organisation (coordinated multidisciplinary team care, nursing integration with multidisciplinary care and involvement of carers in the rehabilitation process), specialisation (medical and nursing interest and expertise in stroke and rehabilitation) and education (education and training programmes for staff, patients and carers).¹⁴

Only half (9/17, 53%) of OISC settings provided more physiotherapy or occupational therapy and a third provided earlier therapy intervention (7/20, 35%) than the general medical ward comparators. The authors concluded that ‘the benefits of organised stroke unit care, as opposed to conventional care, are not clearly due to … staff mix, or the amount of medical, nursing, and therapy input available’.¹⁴ Nevertheless, over time, the idea that more intensive, earlier therapy was the key to better outcomes gained ground. With this has come the rise of clinician experts, working in teams, determining the type and dose of rehabilitation for the person, linked to a goal-setting strategy – dominated by SMART goals – that can have the effect of reinforcing clinician power over patient autonomy.^15,16

Third, and most compelling at face value, are systematic reviews and modelling studies which, until the recent Cochrane review,⁷ provide strong conclusions supporting the idea that more therapy leads to better outcomes. Three of these reviews,^17,19 detailed in Table 1, form the basis for the strong recommendation ‘to provide as much therapy as possible’ in the Australasian stroke rehabilitation guidelines,²⁰ the most recently revised international guidelines. However, the more recent systematic review⁷ concludes the opposite – that ‘An increase in time spent in the same type of rehabilitation after stroke results in little to no difference in meaningful activities such as activities of daily living and activities of the upper and lower limb’. They point to the possibility that a much bigger dose (almost 17 extra hours) may produce a significant difference in the outcome, but the size of the effect would be small and ‘unlikely to represent a clinically meaningful change to a stroke survivor’.⁷

 

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