Stroke Rehabilitation: Which is the Main Functional Outcome to Reach?

 

For FUCKING STUPIDITY'S SAKE!  The ONLY goal in stroke is 100% RECOVERY! 

I'd have all of you fired for extreme stupidity! 

Send me personal hate mail on this: oc1dean@gmail.com. I'll print your complete statement with your name and my response in my blog. Or are you afraid to engage with my stroke-addled mind? No excuses are allowed! You're medically trained; it should be simple to precisely state EXACTLY WHY you aren't working on 100% recovery protocols with NO EXCUSES! Your definition of competence in stroke is obviously much lower than stroke survivors' definition of your competence! Swearing at me is allowed, I'll return the favor. Don't even attempt to use the excuse that brain research is hard.

Stroke Rehabilitation: Which is the Main Functional Outcome to Reach?

Loredana Cavalli*, Andrea Guazzini, Bruno Rossi and Carmelo Chisari University of Florence, Italy 

 Abstract 

 Background: 

Stroke rehabilitation targets range from treatment of spasticity to pain reduction, gait speed gain, or autonomy amelioration. A correct evaluation of individual residual capabilities is essential to select the most appropriate rehabilitative programme; furthermore the observation of rehabilitative outcomes can provide information about gait training effects and possible compensation mechanisms. 

Aim: 

To investigate the main outcome to reach in stroke rehabilitation. 

 Methods: 

We examined retrospectively a heterogeneous sample of 119 subjects recovered for the treatment of stroke outcomes. Functional parameters were assessed before and after rehabilitative treatment, such as upper limbs motility impairment, lower limb sensitiveness, muscle trophism or tone, necessity of auxilium, Berg and Fugl-Meyer scale. 

Results: 

A consistent improvement of standing equilibrium was reported, regardless of gender, stroke nature, hemiparetic side, type of rehabilitation performed, botulin toxin use and initial conditions, with an average increase of Berg and Fugl-Meyer scales score of 14% and 21%, respectively. The variation of equilibrium and motility across treatment resulted directly proportional and negatively correlated to lower limbs sensitivity impairment. On the contrary, initial equilibrium resulted inversely correlated with the variation of motility and vice versa. Interestingly, older subjects seem to better increase equilibrium and sensitivity as measured by Fugl-Meyer scale. 

Conclusion: 

In stroke subjects any type of rehabilitation leads to a consistent improvement of standing balance. While proportional to motility and sensitivity increase, this result is inversely correlated to initial motility score, suggesting that an appropriate evaluation of the stroke patient’s functional parameters at admission contributes to select the main rehabilitation targets and the best therapeutic strategy. Keywords: Stroke; Rehabilitation; Equilibrium; Motility; Age; Ischemic stroke 

Introduction 

 Stroke is the major cause of disability worldwide, with an important social-economic impact [1]. One stroke on four is fatal and between 25 to 50% of the survivors requires a rehabilitative treatment [2]. According to the Copenhagen Stroke Study, 14% of survivors walk with assistance, while 22% are unable to ambulate [3], resulting in impairment in daily living [4]. Stroke rehabilitation is complex, long lasting and expensive and its functional outcome is influenced not only by brain lesion site and extension, but also by medical, demographic and neuropsycologic factors [1]. Age, for example, was reported as inversely proportional to amount of recovery [5]; similarly, disability at admission, measurable as Barthel Index (BI), is a powerful predictor of functional final outcome [1], as well as comorbidity. A further variable showing a relevant relationship with later outcome is the onset-to-admission interval (OAI), as rehabilitation beginning within 60 days after the stroke onset has been recognized to obtain better results compared to delay one [1]. T he functions most frequently compromised by stroke are muscle strength, power, balance and gait [6], often associated with spasticity [7-9]. Muscle hypostenia, reduction in range of motion, abnormal muscle tone and loss of sensory and motor coordination contribute to difficulties of postural control in stroke patients [10], thus increasing the risk of falls, with a relevant socio-economic burden [11]. T herefore, recovering trunk control and balance is one of the main targets of rehabilitation for patients with stroke. Materials and Methods A retrospective analysis of records related to post-acute phase stroked patients was reported. Once excluded patients with disorders of consciousness, or with consistent comorbidity influencing the final outcome, such as severe respiratory or cardiovascular insufficiency, recent femoral fracture, general debility associated mental illness, or severe anemia, a total of 119 subjects admitted in Neuro-Rehabilitation Unit of Cisanello Hospital in Pisa, Italy, between 2009 and 2013 were included. Clinical characteristics detected by the physiatrist at the entrance in hospital were reported as distinct discrete parameters, including hemiparetic side, functional impairment of the affected upper limb, spasticity and hypotrophy of the lower limb, compromised tactile and proprioceptive sensitivity of lower limbs. The gait ability before rehabilitation was indicated with a score rising from 0 to 7 on the basis of the necessity of increasingly important walking aids. For each patient, the rehabilitative program was indicated, both for upper limbs (conventional physiotherapy, isokinetic dynamometer or no treatment) and for lower limbs (Lokomat, tapis roulant and conventional physiotherapy), as well as botulin toxin employment for the treatment of spasticity. The rehabilitative project outcome was reported as a clinical improvement in the control of the trunk, in the standing posture and in the gait pattern. Moreover, standing balance was evalued by Berg scale, while Fugl-Meyer (FM) scale was performed to assess motility, equilibrium, sensitivity, articolarity and pain, before and after the treatment (Table 1). Of the whole sample, only thirty subjects performed gait tests and data about six min walking (6MWT), ten-meters (10MWT), time to get  tactile and/or proprioceptive sensitivity compromised in lower limbs and deambulation ability, are summarized in Figures 1A and 1B, rehabilitation strategies in Figure 1C. The results of FM scale, performed in 104 subjects and Berg scale, assessed in 50 patients, before and after rehabilitative treatment are reported in Table 1, as well as 6MWT, TUG, 10MWT performed in 30 subjects. Statistically significant Pearson correlations among variables (p<0.05) are reported in Table 2A. Equilibrium assessed by Berg and FM scales score results more impaired in oldest subjects, who require more important auxilia for walking, as well as tactile and proprioceptive sensitivity of lower limbs, which correlates with need of auxilia. Table 2: Statistically significant correlations between the functional parameters analyzed: A) Correlations between age, hospitalization, auxilium and the other parameters; B) Correlations between FM scores and other parameters; C) Berg scores correlations. correlation analysis was carried out in order to investigate relations among clinical and quantitative parameters; then, a Monte Carlo Bootstrap method was applied for each variable in order to extract subsamples of comparable size, followed by the execution of the t test or of the ANOVA test