Dementia is associated with poorer quality of care and outcomes after stroke: An Observational Study

Wrong title and conclusion. 'Care' should not be in the title at all, should be poorer quality of rehab results. That's right, the blame for this lies directly upon the doctor for not having correct rehab protocols. The starting point to this whole failure cascade is that there is nothing for stopping the 5 causes of the neuronal cascade of death in the first week, allowing billions of neurons to die. I 'only' lost 5.4 billion neurons.

 

Dementia is associated with poorer quality of care and outcomes after stroke: An Observational Study

Michele L Callisaya, PhD, Tara Purvis, PhD, Katherine Lawler, PhD, Amy Brodtmann, PhD, Dominique A Cadilhac, PhD, Monique F Kilkenny, PhD

The Journals of Gerontology: Series A, glaa139, https://doi.org/10.1093/gerona/glaa139

Published:

04 June 2020

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ABSTRACT

BACKGROUND

To determine if pre-existing dementia is associated with poorer quality of care and outcomes after stroke in the acute hospital phase.

METHODS

This was a retrospective analysis of pooled data from the Australian Stroke Foundation national audit conducted in 2015 and 2017. Dementia status was obtained from the medical records. Processes of care to assess quality included: stroke unit care, time dependent therapy, nursing/allied health assessments and preparation for discharge. Outcomes included in-hospital complications, independence on discharge and destination. Logistic regression was used to examine associations between dementia status and processes of care. Multilevel random effects logistic regression, with level defined as hospital, was used to examine associations between dementia status and outcomes.

RESULTS

There were 683/7070 (9.7%) audited patients with dementia included. Patients with dementia were less likely to be treated in stroke units (58.3% versus 70.6%), receive thrombolysis if an ischemic stroke (5.8% versus 11.1%), have access within 48 hours to physiotherapy (56.4% versus 69.7%) or occupational therapy (46.8% versus 55.6%), see a dietitian if problems with nutrition (64.4% versus 75.9%), or have mood assessed (2.6% versus 12.3%). Patients with dementia were more likely to receive no rehabilitation (aOR 1.88 95%CI 1.25, 2.83) and be discharged to residential care (aOR 2.36 95%CI 1.50, 3.72).

CONCLUSION

People with dementia received poorer quality of care and had worse outcomes after stroke. Our findings raise questions regarding equity and the need for better understanding of why the quality of care differs after stroke for people with dementia.(Simple, look at the rehab they are getting, nothing that leads to 100% recovery. Why should I have to explain this? It is obvious to anyone with half a brain.)

Very Early Initiation Reduces Benefits of Poststroke Rehabilitation Despite Increased Corticospinal Projections

My God, have you got the conclusion wrong. The neuronal cascade of death

is still occurring  during this early rehab. And you didn't know about that or measure its occurrence? 

Very Early Initiation Reduces Benefits of Poststroke Rehabilitation Despite Increased Corticospinal Projections

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Naohiko Okabe, PhD, Naoyuki Himi, PhD, Emi Nakamura-Maruyama, PhD, ...

First Published May 29, 2019 Research Article

https://doi.org/10.1177/1545968319850132

Article information

Abstract

Background. Although the effect of rehabilitation is influenced by aspects of the training protocol, such as initiation time and intensity of training, it is unclear whether training protocol modifications affect the corticospinal projections.
Objective. The present study was designed to investigate how modification of initiation time (time-dependency) and affected forelimb use (use-dependency) influence the effects of rehabilitation on functional recovery and corticospinal projections.  
Methods. The time-dependency of rehabilitation was investigated in rats forced to use their impaired forelimb immediately, at 1 day, and 4 days after photothrombotic stroke. The use-dependency of rehabilitation was investigated by comparing rats with affected forelimb immobilization (forced nonuse), unaffected forelimb immobilization (forced use), and a combination of forced use and skilled forelimb training beginning at 4 days after stroke.  
Results. Although forced use beginning 1 day or 4 days after stroke caused significant functional improvement, immediate forced limb use caused no functional improvement. On the other hand, a combination of forced use and skilled forelimb training boosted functional recovery in multiple tasks compared to simple forced use treatment. Histological examination showed that no treatment caused brain damage. However, a retrograde tracer study revealed that immediate forced use and combination training, including forced use and skilled forelimb training, increased corticospinal projections from the contralesional and ipsilesional motor cortex, respectively.
Conclusions. These results indicate that although both very early initiation time and enhanced skilled forelimb use increased corticospinal projections, premature initiation time hampers the functional improvement induced by poststroke rehabilitation.

Keywords stroke, rehabilitation, constraint-induced movement therapy, corticospinal projection, motor function, time dependency, use dependency

Introduction

Rehabilitation is the most commonly used treatment for chronic stroke patients due to many evidences demonstrating its safety and effectiveness.¹ However, functional recovery is often incomplete even when intensive rehabilitation is carried out. Although preclinical studies showed neurorestorative effects of newly developing therapies such as stem cell therapy² or anti-NogoA immunotherapy,³ none of them has been approved in clinical setting. Thus, improving effectiveness of rehabilitation remains an essential strategy to attain better recovery after stroke.⁴ Since effect of rehabilitation is affected by modification of rehabilitation protocol as well as patient’s age, comorbidity, and size and location of infarct, guideline to design optimal rehabilitation protocol is required to maximize their efficacy. Nevertheless, it has not been accomplished due to lack of sufficient evidences.
Neural plasticity is heightened during the critical period of the early poststroke recovery phase. And the greatest gains in recovery occur in this period through activity-dependent neural network remodeling.⁵ Therefore, there is a general consensus that more intensive rehabilitation initiated in earlier recovery phase would cause better functional outcome, and which was actually supported by many clinical trials.^6,7 For example, a clinical trial that compared the functional improvement after constraint-induced movement therapy (CIMT) initiated in early (3-9 months after stroke) and delayed phase (15-21 months after stroke) demonstrated that early CIMT induces greater functional improvement (EXCITE Stroke Trial).⁸ However, some important questions remain to be clarified. Although it is generally accepted that early rehabilitation caused better functional outcome than later one, how early rehabilitation should begin is still controversial because previous studies demonstrated very early rehabilitation has a potential to increase damage to the ischemic penumbra.⁹ Recent big multicenter randomized controlled trial also reported that the higher dose, very early mobilization protocol was associated with a reduction in the odds of a favorable outcome at 3 months.¹⁰ Similarly, in the regard of training intensity, whereas dose-response relationship has been repeatedly evaluated by comparing total time for therapy,^6,7 a single-blind phase II trial of CIMT (Very Early Constraint-Induced Movement during Stroke Rehabilitation [VECTORS] study) reported that higher intensity CIMT resulted in less motor improvement at 90 days compared to lower intensity CIMT and traditional upper extremity therapy,¹¹ suggesting that too intense training could deteriorate functional recovery. To determine proper rehabilitation regimen, understanding of biological events underlying unfavorable effect induced by too early and intensive training is necessary. However, although previous studies have demonstrated that the integrity and plasticity of corticospinal projections are fundamental for rehabilitation-induced functional recovery after stroke,^12-14 it is not known how modifications of the rehabilitation protocol affect these projections.
The purpose of the present study was to examine how modifications of the rehabilitation protocol, and in particular of time of initiation (time dependency) and affected forelimb use (use dependency), impact functional recovery by rehabilitative training after severe cortical stroke and how corticospinal projections is also affected by these modifications.

Intensive upper limb neurorehabilitation in chronic stroke: outcomes from the Queen Square programme

Wrong conclusion. You are blaming the patient for their lack of recovery. The blame lies directly on the doctors for not having initiated a research program to stop the 5 causes of the neuronal cascade of death in the first week. With that accomplished there would be vastly less dead and damaged neurons. In my case 5.571 billion neurons died, by stopping the neuronal cascade of death,  I would have only lost 171 million neurons, that I could have easily recovered from.

Intensive upper limb neurorehabilitation in chronic stroke: outcomes from the Queen Square programme

1. Nick S Ward1,2,3,
2. Fran Brander2,3,
3. Kate Kelly2,3

Author affiliations

Abstract

Objective Persistent difficulty in using the upper limb remains a major contributor to physical disability post-stroke. There is a nihilistic view about what clinically relevant changes are possible after the early post-stroke phase. The Queen Square Upper Limb Neurorehabilitation programme delivers high-quality, high-dose, high-intensity upper limb neurorehabilitation during a 3-week (90 hours) programme. Here, we report clinical changes made by the chronic stroke patients treated on the programme, factors that might predict responsiveness to therapy and the relationship between changes in impairment and activity.

Methods Upper limb impairment and activity were assessed on admission, discharge, 6 weeks and 6 months after treatment, with modified upper limb Fugl-Meyer (FM-UL, max-54), Action Research Arm Test (ARAT, max-57) and Chedoke Arm and Hand Activity Inventory (CAHAI, max-91). Patient-reported outcome measures were recorded with the Arm Activity Measure (ArmA) parts A (0–32) and B (0–52), where lower scores are better.

Results 224 patients (median time post-stroke 18 months) completed the 6-month programme. Median scores on admission were as follows: FM-UL = 26 (IQR 16–37), ARAT=18 (IQR 7–33), CAHAI=40 (28-55), ArmA-A=8 (IQR 4.5–12) and ArmA-B=38 (IQR 24–46). The median scores 6 months after the programme were as follows: FM-UL=37 (IQR 24–48), ARAT=27 (IQR 12–45), CAHAI=52 (IQR 35–77), ArmA-A=3 (IQR 1–6.5) and ArmA-B=19 (IQR 8.5–32). We found no predictors of treatment response beyond admission scores.

Conclusion With intensive upper limb rehabilitation, chronic stroke patients can change by clinically important differences in measures of impairment and activity. Crucially, clinical gains continued during the 6-month follow-up period.

http://dx.doi.org/10.1136/jnnp-2018-319954