Precision rehabilitation, from foundational concepts to contemporary perspectives: a mixed-methods scoping review

 For stroke this requires:

1. An objective damage diagnosis, a 3d rendering of dead and damaged gray and white matter. mRS and the Berthel Index ARE NOT DAMAGE DIAGNOSES, they do not give you the 3d location of your dead and damaged neurons. All problems relate to those damaged or dead neurons so if you don't know what you are dealing with you CAN'T FIX ANYTHING WITH PRECISION!
2. EXACT REHAB PROTOCOLS; numbers and movement or thought patterns.

Don't worry, nothing will occur, your stroke medical 'professionals' haven't done any thinking since entering medical school.

Precision rehabilitation, from foundational concepts to contemporary perspectives: a mixed-methods scoping review

• Annie Pouliot-Laforte,
• Évemie Dubé,
• Dahlia Kairy &
• Danielle E. Levac 

We’re sharing this article early to provide faster access to peer-reviewed, accepted research. It is citable and carries a permanent DOI. This version is subject to further edits and will be replaced automatically by the final Version of Record. All legal disclaimers apply.

Abstract

Background

Precision health approaches aim to predict, deliver and optimize the right intervention, at the right time, for the right person. While precision medicine is well-established, its application in rehabilitation remains nascent. This study aimed to (1) Map foundational concepts of precision rehabilitation by describing the extent, scope and nature of the literature, identifying similarities and differences with precision medicine, and describing the role of technologies and artificial intelligence (AI); (2) Describe knowledge users’ perspectives on precision rehabilitation; and (3) Integrate quantitative and qualitative results to develop a working definition of precision rehabilitation.

Methods

A convergent mixed-methods design was used to conduct a scoping review with a qualitative consultation phase. The scoping review followed Johanna Briggs Institute methodological recommendations and PRISMA-ScR reporting guidelines. Five databases were searched for adjacent keywords ‘precision’ AND ‘rehabilitation’. Data were extracted and analyzed descriptively and thematically. In parallel, individual interviews were conducted with knowledge users at three North American rehabilitation centers. Transcripts were analyzed using deductive content analysis. Mixed method integration synthesized and contrasted literature-derived and knowledge users-derived insights.

Results

Forty-nine articles met inclusion criteria; 26 (53%) were primary research studies, while 23 (47%) were non-empirical publications. Amongst research studies, 14 (54%) involved technology use, while 5 (19%) used AI. Seven (14%) articles included a definition of precision medicine, while 22 (45%) included a definition of precision rehabilitation. Interviews with 16 knowledge users highlighted that personalization is uniquely expressed in precision rehabilitation as compared to medicine and identified rehabilitation-specific facilitators and barriers to precision approaches. Data integration confirmed that a focus on function differentiates precision approaches in rehabilitation from medicine, clarified rehabilitation-specific logistical barriers to technology-enabled data collection in precision approaches, and attributed limited AI use to concerns about predictions based solely on data that excludes psychosocial factors and population heterogeneity.

Conclusions

Results indicate greater similarities than differences between precision approaches in rehabilitation and medicine, while highlighting rehabilitation’s emphasis on personalization, function and participation. Findings identify key barriers and facilitators and support a proposed definition of precision rehabilitation for further refinement through peer consensus to accompany advances in research and clinical practice.

University of Oklahoma is Developing Individualized, Optimized Brain Injury Rehabilitation

And a a lot of your problems are that you have no objective damage diagnosis. The NIHSS and Rankin scales are worthless for being able to match protocols to damage.

University of Oklahoma is Developing Individualized, Optimized Brain Injury Rehabilitation

NORMAN, Okla. , March 3, 2023 /PRNewswire/ -- More than 500,000 people in the United States undergo rehabilitation following a stroke or brain injury every year. Movement impairments following a stroke are a major cause of adult disability in the United States, and routine treatments are not currently optimized for individual patient needs.

Yuan Yang, Ph.D., assistant professor of biomedical engineering at the University of Oklahoma, will use a National Science Foundation CAREER award to pioneer tailored rehabilitation strategies for brain injury patients, while connecting scientists, clinicians and the next generation of rehabilitation experts.

University of Oklahoma biomedical engineer Yuan Yang, Ph.D., has received a five-year "CAREER" award from the National Science Foundation to advance the scientific study of brain functional changes after a stroke and pioneer a tailored rehabilitation strategy that fits individual needs.

"The way a stroke victim's brain adapts to the injury varies from individual to individual," Yang said. "But routine clinical practice tends to treat everyone the same. When that happens, doctors cannot provide an optimal treatment for each patient."

Yang is an OU-Tulsa assistant professor in the Stephenson School of Biomedical Engineering, Gallogly College of Engineering. He will use multi-modal MRI scans in combination with an electrical neural activity scan to precisely assess the changes to motor control in an injured brain.

"Despite numerous efforts to develop new technologies for movement rehabilitation after a stroke, optimal recovery is still limited due to a lack of imaging guidance and real-time neurofeedback to tailor a rehabilitation strategy for each individual," Yang said. "Our program will be able to tell doctors which areas of the brain to stimulate in a non-invasive, non-painful manner to reduce a patient's recovery time and reduce the health care and nursing costs for long-term disability caused by stroke and other similar brain injuries."

The project will also support the development of a multidisciplinary research education ecosystem to connect engineering students, clinician trainees and STEM educators. Learn more at https://bit.ly/OUYangCAREER

SOURCE University of Oklahoma

Standardized Nomenclature for Modified Rankin Scale Global Disability Outcomes: Consensus Recommendations From Stroke Therapy Academic Industry Roundtable XI

Why standardize the Rankin scale since it is useless, not objective except for #6, dead? You can't use it to objectively point to the EXACT STROKE PROTOCOLS  needed.  The exact same deficit could have 9 causes.

See this example of nine reasons for a movement disability:

 

You can't tell me these all have the same solution, I'm not that stupid.
1. Penumbra damage to the motor cortex.
2. Dead brain in the motor cortex.
3. Penumbra damage in the pre-motor cortex.
4. Dead brain in the pre-motor cortex.
5. Penumbra damage in the executive control area.
6. Dead brain in the executive control area.
7. Penumbra damage in the white matter underlying any of these three.
8. Dead brain in the white matter underlying any of these three.
9. Spasticity preventing movement from occurring.

The latest here:

Standardized Nomenclature for Modified Rankin Scale Global Disability Outcomes: Consensus Recommendations From Stroke Therapy Academic Industry Roundtable XI

Jeffrey L. Saver

,

Napasri Chaisinanunkul

,

Bruce C.V. Campbell

,

James C. Grotta

,

Michael D. Hill

,

Pooja Khatri

,

Jaren Landen

,

Maarten G. Lansberg

,

Chitra Venkatasubramanian

, … See all authors

Originally published29 Jul 2021https://doi.org/10.1161/STROKEAHA.121.034480Stroke. ;0:STROKEAHA.121.034480

Abstract

The modified Rankin Scale (mRS), a 7-level, clinician-reported, measure of global disability, is the most widely employed outcome scale in acute stroke trials. The scale’s original development preceded the advent of modern clinimetrics, but substantial subsequent work has been performed to enable the mRS to meet robust contemporary scale standards. Prior research and consensus recommendations have focused on modernizing 2 aspects of the mRS: operationalized assignment of scale scores and statistical analysis of scale distributions. Another important characteristic of the mRS still requiring elaboration and specification to contemporary clinimetric standards is the Naming of scale outcomes. Recent clinical trials have used a bewildering variety, often mutually contradictory, of rubrics to describe scale states. Understanding of the meaning of mRS outcomes by clinicians, patients, and other clinical trial stakeholders would be greatly enhanced by use of a harmonized, uniform set of labels for the distinctive mRS outcomes that would be used consistently across trials. This statement advances such recommended rubrics, developed by the Stroke Therapy Academic Industry Roundtable collaboration using an iterative, mixed-methods process. Specific guidance is provided for health state terms (eg, Symptomatic but Nondisabled for mRS score 1; requires constant care for mRS score 5) and valence terms (eg, excellent for mRS score 1; very poor for mRS score 5) to employ for 23 distinct numeric mRS outcomes, including: all individual 7 mRS levels; all 12 positive and negative dichotomized mRS ranges, positive and negative sliding dichotomies; and utility-weighted analysis of the mRS.

 

Upper limb recovery in early acute phase stroke survivors by coupled EMG-triggered and cyclic neuromuscular electrical stimulation

More non objective research starting points. Severe has no objective meaning. Don't give me the excuse it is using the Rankin scale, that is not objective at all except for #6, death.

Upper limb recovery in early acute phase stroke survivors by coupled EMG-triggered and cyclic neuromuscular electricalstimulation

NeuroRehabilitation , Volume 46(3) , Pgs. 417-422.

NARIC Accession Number: J83974.  What's this?
ISSN: 1053-8135.
Author(s): Obayashi, Shigeru ; Takahashi, Rina ; Onuki, Mitsugu.
Publication Year: 2020.
Number of Pages: 6.
Abstract: Study investigated the effects of coupled electromyography (EMG)-triggered and cyclic neuromuscular electrical stimulation (NMES) on upper-extremity (UE) paresis during the early acute phase of stroke. Seventeen participants with severe UE disability completed the study. Eight subjects in the intervention group received 15 to 20 minutes of NMES prior to 20 minutes of standard care per day, 5 times per week. Nine age- and severity-matched subjects received a two consecutive 20-minute sessions of standard care per day, 5 times per week. Outcome measures included the UE motor section of the Fugl-Meyer Motor Assessment Scale (FMA-UE), the Wolf motor function test (WMFT), and the Box and Block Test (BBT). The NMES group received treatment (average session: 10.87) after a median 7 days from stroke (16.5 sessions after 5 days for controls). To adjust the different treatment durations, "progress rate" was defined as the gains of UE function scores divided by treatment duration. The progress rate was significantly different in FMA-UE, but not in WMFT and BBT. The results indicate the beneficial effect of coupled EMG-triggered and cyclic NMES for UE paresis during early acute phase of stroke.
Descriptor Terms: ACUTE CARE, ELECTRICAL STIMULATION, ELECTROPHYSIOLOGY, LIMBS, MOTOR SKILLS, PHYSICAL THERAPY, REHABILITATION SERVICES, SERVICE DELIVERY, STROKE.


Can this document be ordered through NARIC's document delivery service*?: Y.
Get this Document: https://content.iospress.com/articles/neurorehabilitation/nre203024.

Citation: Obayashi, Shigeru , Takahashi, Rina , Onuki, Mitsugu. (2020). Upper limb recovery in early acute phase stroke survivors by coupled EMG-triggered and cyclic neuromuscular electrical stimulation.  NeuroRehabilitation , 46(3), Pgs. 417-422. Retrieved 7/18/2020, from REHABDATA database.

Effectiveness of Stroke Early Supported Discharge

But you are not measuring the only goal in stroke, 100% RECOVERY.  The Rankin scale is useless, not objective except for #6, dead. The only reason I can see for ESD is to get survivors out of the hospital and not measure their failure to recover.  If you don't measure you don't have to improve anything. Of course if the board of directors was any good at all they would mandate measuring everything and insist upon constant improvements in stroke recovery. But I'm sure your board of directors is incompetent.

Effectiveness of Stroke Early Supported Discharge

Analysis From a National Stroke Registry

Rebecca J. Fisher

,

Adrian Byrne

,

Niki Chouliara

,

Sarah Lewis

,

Lizz Paley

,

Alex Hoffman

,

Anthony Rudd

,

Thompson Robinson

,

Peter Langhorne

,

Marion F. Walker

Originally published17 Jul 2020https://doi.org/10.1161/CIRCOUTCOMES.119.006395Circulation: Cardiovascular Quality and Outcomes. ;0

Abstract

Background

Implementation of stroke early supported discharge (ESD) services has been recommended in many countries’ clinical guidelines, based on clinical trial evidence. This is the first observational study to investigate the effectiveness of ESD service models operating in real-world conditions, at scale.

Methods AND RESULTS

Using historical prospective data from the United Kingdom Sentinel Stroke National Audit Programme (January 1, 2016–December 31, 2016), measures of ESD effectiveness were “days to ESD” (number of days from hospital discharge to first ESD contact; n=6222), “rehabilitation intensity” (total number of treatment days/total days with ESD; n=5891), and stroke survivor outcome (modified Rankin scale at ESD discharge; n=6222). ESD service models (derived from Sentinel Stroke National Audit Programme postacute organizational audit data) were categorized with a 17-item score, reflecting adoption of ESD consensus core components (evidence-based criteria). Multilevel modeling analysis was undertaken as patients were clustered within ESD teams across the Midlands, East, and North of England (n=31). A variety of ESD service models had been adopted, as reflected by variability in the ESD consensus score. Controlling for patient characteristics and Sentinel Stroke National Audit Programme hospital score, a 1-unit increase in ESD consensus score was significantly associated with a more responsive ESD service (reduced odds of patient being seen after ≥1 day of 29% [95% CI, 1%–49%] and increased treatment intensity by 2% [95% CI, 0.3%–4%]). There was no association with stroke survivor outcome measured by the modified Rankin Scale.(Whatever the hell this means.)

Conclusions

This study has shown that adopting defined core components of ESD is associated with providing a more responsive and intensive ESD service. This shows that adherence to evidence-based criteria is likely to result in a more effective ESD service as defined by process measures.

REGISTRATION:

URL: http://www.isrctn.com/; Unique identifier: ISRCTN1556816

Alteplase for Acute Ischemic Stroke in Patients Aged >80 Years

Good stroke outcome (Sorry but 1 is not a good outcome).

THIS IS THE TYRANNY OF LOW EXPECTATIONS IN FULL DISPLAY. Until stroke survivors get in charge and remove any semblance of that tyranny we will never get anywhere in stroke. These people need to be read the riot act on the only goal in stroke; 100% recovery.  

Alteplase for Acute Ischemic Stroke in Patients Aged >80 Years

Pooled Analyses of Individual Patient Data

Erich Bluhmki

,

Thierry Danays

,

Gabriele Biegert

,

Werner Hacke

,

Kennedy R. Lees

Originally published2 Jul 2020https://doi.org/10.1161/STROKEAHA.119.028396Stroke. ;0

Abstract

Background/Purpose:

Expert guidelines specify no upper age limit for alteplase for thrombolysis of acute ischemic stroke (AIS) but, until recently, European regulatory criteria restricted its use to patients aged 18 to 80 years. We performed pooled analyses of randomized controlled trial (RCT) and registry data to evaluate the benefit-risk profile of alteplase for AIS among patients aged >80 years to support a regulatory application to lift the upper age restriction.

Methods:

Individual patient data were evaluated from 7 randomized trials of alteplase (0.9 mg/kg) versus placebo or open control for AIS, and the European SITS-UTMOST registry database. Clinical outcomes, including good functional outcome (score 0–1, modified Rankin Scale day 90 or Oxford Handicap Score day 180), were evaluated in the full RCT and registry populations, and specified age-based subgroups (≤80 or >80 years) who met existing European regulatory criteria for alteplase, excluding upper age restriction.

Results:

Regardless of treatment allocation, 90-day mortality was lower among RCT patients aged ≤80 versus >80 years who otherwise met existing European regulatory criteria (246/2405 [10.2%] versus 307/1028 [29.9%], respectively). Among patients aged >80 years, alteplase versus placebo was associated with a higher proportion of good stroke outcome (Sorry but Rankin1 is not a good outcome) (modified Rankin Scale score 0–1; 99/518 [19.1%] versus 67/510 [13.1%]; P=0.0109) and similar 90-day mortality (153/518 [29.5%] versus 154/510 [30.2%]; P=0.8382). The odds of a good stroke outcome following alteplase allocation in the full RCT population were independent of age (P=0.7383). Good stroke outcome was reported for almost half (4821/11 169 [43.2%]) of the patients who received alteplase in routine practice. Outcomes in routine practice supported those achieved in RCTs.

Conclusions:

Alteplase for AIS has a positive benefit-risk profile among patients aged >80 years when administered according to other regulatory criteria. Alteplase for AIS should be evaluated on an individual benefit-risk basis.

Footnotes

This manuscript was sent to Gregory W. Albers, Consulting Editor, for review by expert referees, editorial decision, and final disposition.
For Sources of Funding and Disclosures, see page XXX.
The Data Supplement is available with this article at https://www.ahajournals.org/doi/suppl/10.1161/STROKEAHA.119.028396.

Correspondence to: Erich Bluhmki, PhD, Analytical Development Biologicals, Boehringer Ingelheim Pharma GmbH & Co. KG, Birkendorferstr 65, Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany. Email erich.bluhmki@boehringer-ingelheim.com

Intravenous Thrombolysis Administration 3–4.5 h After Acute Ischemic Stroke: A Retrospective, Multicenter Study

Did the patients say they were 100% recovered?  I don't trust raters and the Rankin scale. What are you doing about the 66% of patients that did not get (mRS) 0–1? I'd say a 66% failure rate is failure.

Intravenous Thrombolysis Administration 3–4.5 h After Acute Ischemic Stroke: A Retrospective, Multicenter Study

Yu-Wei Chen^1,2, Sheng-Feng Sung³, Chih-Hung Chen⁴, Sung-Chun Tang², Li-Kai Tsai², Huey-Juan Lin⁵, Hung-Yu Huang⁶, Helen L. Po⁷, Yu Sun⁸, Po-Lin Chen⁹, Lung Chan^10,11,12, Cheng-Yu Wei¹³, Jiunn-Tay Lee¹⁴, Cheng-Yang Hsieh¹⁵, Yung-Yang Lin¹⁶, Shoou-Jeng Yeh¹⁷, Li-Ming Lien^12,18* and Jiann-Shing Jeng²

• ¹Department of Neurology, Landseed International Hospital, Taoyuan, Taiwan
• ²Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
• ³Division of Neurology, Department of Internal Medicine, Ditmanson Medical Foundation Chiayi Christian Hospital, Chiayi, Taiwan
• ⁴Department of Neurology, National Cheng Kung University Hospital, Tainan, Taiwan
• ⁵Department of Neurology, Chi Mei Medical Center, Tainan, Taiwan
• ⁶Department of Neurology, China Medical University Hospital, Taichung, Taiwan
• ⁷Department of Neurology, Mackay Memorial Hospital, Taipei, Taiwan
• ⁸Department of Neurology, En Chu Kong Hospital, New Taipei City, Taiwan
• ⁹Department of Neurology, Taichung Veterans General Hospital, Taichung, Taiwan
• ¹⁰Department of Neurology and Stroke Center, Taipei Medical University–Shuang Ho Hospital, New Taipei City, Taiwan
• ¹¹Taipei Neuroscience Institute, Taipei Medical University, New Taipei City, Taiwan
• ¹²Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
• ¹³Department of Neurology, Chang Bing Show Chwan Memorial Hospital, Changhwa, Taiwan
• ¹⁴Department of Neurology, Tri Service General Hospital, Taipei, Taiwan
• ¹⁵Department of Neurology, Tainan Sin Lau Hospital, Tainan, Taiwan
• ¹⁶Department of Neurology and Department of Critical Care Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
• ¹⁷Department of Neurology, Cheng Ching General Hospital, Taichung, Taiwan
• ¹⁸Department of Neurology, Shin Kong WHS Memorial Hospital, Taipei, Taiwan

Background and Objectives: Intravenous recombinant tissue plasminogen activator (rt-PA) has been approved for acute ischemic stroke (AIS) within 3 h after onset and the treatment was then extended to 4.5 h. However, the Food and Drug Administration did not approve the indication in the expanded time window. This retrospective, matched cohort study aims to investigate the effectiveness and safety of rt-PA in AIS at 3–4.5 h after onset.

Materials and Methods: The treatment group included AIS patients receiving rt-PA at 3–4.5 h after onset, otherwise complying with the regulation, in the stroke registries in 16 hospitals between 2008 and 2017. The control group included age- and sex-matched patients not receiving intravenous thrombolysis from the same registries, excluding those with contraindications. The primary outcome was modified Rankin Scale (mRS) 0–1 at day 90. The safety outcomes were any intracerebral hemorrhage (ICH), early neurological deterioration and 3-month mortality.

Results: Each group had 374 patients. There were 34.0% of patients with 3-month mRS 0-1 in the treatment group vs. 22.7% in the control group with an odds ratio of 1.75 (95% confidence intervals, 1.27 to 2.42, P = 0.001). There was no difference in symptomatic ICH, early neurological deterioration and 3-month mortality rates between two groups. The 3-month mRS and symptomatic ICH did not differ significantly in patients receiving standard dose or low dose of rt-PA.

Conclusions: Our results support the prescription of rt-PA in AIS patients 3–4.5 h after onset as an effective and tolerable treatment in their functional recovery.

Rehabilitation for survivors of severe stroke

You can see that even a Ph.D candidate can't find stroke protocols with advisors help.  

Rankin scale is worthless, not objective except for 6 - death.

You still don't know that the NIHSS subjective stroke scale is worthless?

 

Rehabilitation for survivors of severe stroke 

Mohapatra, Sushmita (2019) Rehabilitation for survivors of severe stroke. PhD thesis, University of Nottingham.

PDF (Thesis - as examined) - Repository staff only - Requires a PDF viewer such as GSview, Xpdf or Adobe Acrobat Reader Download (5MB)

Abstract

Providing appropriate rehabilitation for stroke survivors with severe disabilities can be challenging. This is due to the magnitude of neurological impairment early after stroke as well as the complexity of delivering long-term care post-hospital discharge. Severe stroke survivors have limited access to rehabilitation as a likely result of uncertainty related to their potential for functional gains. They are also likely to require greater health and social care resources for long-term care with significant cost implications. Rehabilitation following stroke has been proven beneficial after a severe stroke; however, recovery remains ambiguous. Several clinical and non-clinical factors are evidenced to influence the provision of rehabilitation interventions. However, it is not known how the decisions are made in practice for service provision, what service they receive and how they relate to the stroke survivors’ recovery and rehabilitation.(So everything in stroke rehab is just a wild-assed guess. Hope you are OK with that level of incompetency. Maybe you want to ask for an anxiety reducing protocol.)

Aims

This thesis aimed to explore the recovery and rehabilitation of severe stroke survivors by investigating the decision-making process for determining rehabilitation and service provided as a result. The study also evaluated the functional recovery made by severe stroke survivors in the first six months and investigated their caregivers’ perspectives on rehabilitation services they received.

Methods

A prospective design with a fixed convergent mixed method approach was chosen to investigate the research questions. Three independent studies were conducted concurrently in two distinctive phases with independent sets of results.

A qualitative approach was taken in the first phase to explore the decision-making process using semi-structured interviews with 22 hospital staff responsible for determining rehabilitation for severe stroke survivors. Functional recovery was investigated in the second phase using an observational cohort study. Patient outcomes were longitudinal measured using validated tools in 52 severe stroke survivors (NIHSS ≥ 10 and mRS ≥4 at admission). Information was also obtained on rehabilitation services accessed post-hospital discharge in the first six months post-stroke. The second part of the study also used semi-structured interviews with 18 caregivers to investigate their experience of the rehabilitation received post-stroke.

All data were collected from a single hospital site, covering a selected region in the East Midlands. The data were analysed separately and integrated using a structured triangulation method in the interpretation stage complement, validate and strengthen the overall findings.

Results

Results established a complex, dynamic, temporal process of decision-making for post-stroke rehabilitation of people with severe functional disability. This required multiple stages of corroborations amongst key decision makers to evaluate the impacts of several social and external factors, additional to severity of stroke. Severity of stroke was defined for rehabilitation purposes and a clinically meaningful change in functional abilities was evidenced in 69% of stroke survivors with severe disabilities with no causal relationship with the initial severity. A noticeable involvement of healthcare professionals during this period suggested the possible contribution of rehabilitation in the early phase post stroke. Rehabilitation was valued for recovery; however, an integrated, client-centred approach was identified as lacking for managing severe disabilities after stroke. This, along with limited shared-planning for rehabilitation led to a low confidence of caregivers in the current healthcare system.

Conclusions

The overall findings of the thesis established a complex, dynamic, cognitive process of clinical reasoning amongst hospital staff for deciding rehabilitation of severe stroke survivors. The study quantified the recovery made in the first six months and suggested that a significant functional improvement is possible in the severely disabled patients that could influence their rehabilitation plan. Thesis findings also highlighted the potential inadequacies in rehabilitation services provided and emphasized the need for incorporating the service users’ expert knowledge in shaping future models of care for severe stroke survivors and their caregivers.

Item Type:	Thesis (University of Nottingham only) (PhD)
Supervisors:	Fisher, Rebecca Walker, Marion
Keywords:	Severe stroke; Rehabilitation
Subjects:	W Medicine and related subjects (NLM Classification) > WL Nervous system
Faculties/Schools:	UK Campuses > Faculty of Medicine and Health Sciences > School of Medicine
Item ID:	56449
Depositing User:	Mohapatra, Sushmita
Date Deposited:	21 Aug 2019 14:25
Last Modified:	22 Aug 2019 08:17
URI:	http://eprints.nottingham.ac.uk/id/eprint/56449

Outcomes of Thrombectomy in Transferred Patients With Ischemic Stroke in the Late Window

Useless crap. They don't even bother to tell us how many got fully recovered. And using the subjective Rankin scale for measuring anything is stroke in worthless.  Comparing failures and suggesting those outcomes are ok is not the way research should be done.

Utility-weighted modified Rankin Scale: Still too crude to be a truly patient-centric primary outcome measure?

The latest here:

Outcomes of Thrombectomy in Transferred Patients With Ischemic Stroke in the Late Window

A Subanalysis From the DEFUSE 3 Trial

Educational Objective
To determine whether patients with ischemic stroke with large-vessel occlusion in the anterior circulation who were transferred from outside facilities for endovascular thrombectomy have similar outcomes(So the comparison is to failure to fully recover?) in the late window compared with patients who were directly admitted to thrombectomy-capable hospitals.

1 Credit CME

JAMA Neurology

June 1, 2019

Original Investigation

Article Information and Disclosures

Amrou Sarraj, MD¹; Michael Mlynash, MD²; Sean I. Savitz, MD¹; et al Jeremy J. Heit, MD, PhD³; Maarten G. Lansberg, MD, PhD²; Michael P. Marks, MD³; Gregory W. Albers, MD² Author Affiliations Read article on JAMA Network

MOC/CME Information

Read Article Take Quiz

Key Points

Question  Do patients with ischemic stroke with large-vessel occlusion in the anterior circulation who were transferred from outside facilities and had penumbral imaging mismatch prior to endovascular thrombectomy have similar outcomes with thrombectomy in the late window as those who were directly admitted to thrombectomy-capable hospitals?
Findings  In this secondary analysis of a randomized clinical trial, transfer and direct patients had comparable rates of functional independence(How many got 100% recovered? THAT IS THE CORRECT ENDPOINT. Not the tyranny of low expectations you want us to accept.) and similar treatment effect with endovascular thrombectomy as well as similar symptomatic intracranial hemorrhage and mortality.
Meaning  Transferring patients for late-window thrombectomy may be associated with substantial clinical benefits and should be encouraged.

Abstract

Importance  Although thrombectomy benefit was maintained in transfer patients with ischemic stroke in early-window trials, overall functional independence rates were lower in thrombectomy and medical management–only groups.
Objective  To evaluate whether the imaging-based selection criteria used in the Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke 3 (DEFUSE 3) trial would lead to comparable outcome rates and treatment benefits in transfer vs direct-admission patients.
Design, Setting, and Participants  Subgroup analysis of DEFUSE 3, a prospective, randomized, multicenter, blinded–end point trial. Patients were enrolled between May 2016 and May 2017 and were followed up for 90 days. The trial comprised 38 stroke centers in the United States and 182 patients with stroke with a large-vessel anterior circulation occlusion and initial infarct volume of less than 70 mL, mismatch ratio of at least 1.8, and mismatch volume of at least 15 mL, treated within 6 to 16 hours from last known well. Patients were stratified based on whether they presented directly to the study site or were transferred from a primary center. Data were analyzed between July 2018 and October 2018.
Interventions or Exposures  Endovascular thrombectomy plus standard medical therapy vs standard medical therapy alone.
Main Outcomes and Measures  The primary outcome was the distribution of 90-day modified Rankin Scale scores.
Results  Of the 296 patients who consented, 182 patients were randomized (66% were transfer patients and 34% directly presented to a study site). Median age was 71 years (interquartile range [IQR], 60-79 years) vs 70 years (IQR, 59-80 years); 69 transfer patients were women (57%) and 23 of the direct group were women (37%). Transfer patients had longer median times from last known well to study site arrival (9.43 vs 9 hours) and more favorable collateral profiles (based on hypoperfusion intensity ratio): median for transfer, 0.35 (IQR, 0.18-0.47) vs 0.42 (IQR, 0.25-0.56) for direct (P = .05). The primary outcome (90-day modified Rankin Scale score shift) did not differ in the direct vs transfer groups (direct OR, 2.9; 95% CI, 1.2-7.2; P = .01; transfer OR, 2.6; 95% CI, 1.3-4.8; P = .009). The overall functional independence rate (90-day modified Rankin Scale score 0-2) in the thrombectomy group did not differ (direct 44% vs transfer 45%) nor did the treatment effect (direct OR, 2.0; 95% CI, 0.9-4.4 vs transfer OR, 3.1; 95% CI, 1.6-6.1). Thrombectomy reperfusion rates, mortality, and symptomatic intracranial hemorrhage rates did not differ.
Conclusions and Relevance  In late-window patients selected by penumbral mismatch criteria, both the favorable outcome rate and treatment effect did not decline in transfer patients. These results have health care implications indicating transferring potential candidates for late-window thrombectomy is associated with substantial clinical benefits and should be encouraged.
Trial Registration  ClinicalTrials.gov identifier: NCT02586415

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Impact of infarct location on functional outcome following endovascular therapy for stroke

You mean we might finally get infarct location mapped to functional disability? And that could mean objective damage diagnosis rather than the subjective crapola of the Rankin scale.  Progress might finally be made.  

Impact of infarct location on functional outcome following endovascular therapy for stroke

1. Charlotte Rosso1,2,
2. Raphael Blanc3,
3. Julien Ly1,2,
4. Yves Samson1,2,
5. Stéphane Lehéricy1,4,
6. Benjamin Gory5,
7. Gautier Marnat6,
8. Mikael Mazighi3,
9. Arturo Consoli7,
10. Julien Labreuche8,
11. Suzana Saleme9,
12. Vincent Costalat10,
13. Serge Bracard5,
14. Hubert Desal11,
15. Michel Piotin3,
16. Bertrand Lapergue7
17. on behalf of the ASTER Trial and Pitié-Salpêtrière Investigators

Author affiliations

Abstract

Objectives The relationship between stroke topography (ie, the regions damaged by the infarct) and functional outcome can aid clinicians in their decision-making at the acute and later stages. However, the side (left or right) of the stroke may also influence the identification of clinically relevant regions. We sought to determine which brain regions are associated with good functional outcome at 3 months in patients with left-sided and right-sided stroke treated by endovascular treatment using the diffusion-weighted imaging-Alberta Stroke Program Early CT Score (DWI-ASPECTS).

Methods Patients with ischaemic stroke (n = 405) were included from the ASTER trial and Pitié-Salpêtrière registry. Blinded readers rated ASPECTS on day 1 DWI. Stepwise logistic regression analyses were performed to identify the regions related to 3-month outcome in left (n = 190) and right (n = 215) sided strokes with the modified Rankin scale (0–2) as a binary independent variable and with the 10 regions-of-interest of the DWI-ASPECTS as independent variables.

Results Median National Institute of Health Stroke Scale (NIHSS) at baseline was 17 (IQR: 12–20), median age was 70 years (IQR: 58–80) and median day-one NIHSS 9 (IQR: 4–18). Not all brain regions have the same weight in predicting good outcome at 3 months; moreover, these regions depend on the affected hemisphere. In left-sided strokes, the multivariate analysis revealed that preservation of the caudate nucleus, the internal capsule and the cortical M5 region were independent predictors of good outcome. In right-sided strokes, the cortical M3 and M6 regions were found to be clinically relevant.

Conclusion Cortical non-motors areas related to outcome differed between left-sided and right-sided strokes. This difference might reflect the specialisation of the dominant and non-dominant hemispheres for language and attention, respectively. These results may influence decision-making at the acute and later stages.

Trial registration number NCT02523261.

http://dx.doi.org/10.1136/jnnp-2018-318869

Utility-weighted modified Rankin Scale: Still too crude to be a truly patient-centric primary outcome measure?

I can't tell what this actually is but it has been out for 5 years already. But since the original Rankin scale was totally subjective and pretty much useless I don't see how this improves things.  Until we get to an objective 3d damage diagnosis, location and size of dead and damaged neurons, we will never get to rehab protocols based on factual objective criteria. Until then your doctor and therapists are completely guessing what needs to be fixed. 

See this example of nine reasons for a movement disability:

You can't tell me these all have the same solution, I'm not that stupid.
1. Penumbra damage to the motor cortex.
2. Dead brain in the motor cortex.
3. Penumbra damage in the pre-motor cortex.
4. Dead brain in the pre-motor cortex.
5. Penumbra damage in the executive control area.
6. Dead brain in the executive control area.
7. Penumbra damage in the white matter underlying any of these three.
8. Dead brain in the white matter underlying any of these three.
9. Spasticity preventing movement from occurring.
First we need an objective 3d damage diagnosis, without that there is no point in going forward. Dr. Watson likely to the rescue. 

 

A Utility-Weighted Modified Rankin Scale: Derivation and Application to Completed Stroke Trials (P5.008)

April 2014

 

Utility-weighted modified Rankin Scale: Still too crude to be a truly patient-centric primary outcome measure?

Show all authors

Venesha Rethnam, Julie Bernhardt, Helen Dewey, ...

First Published February 12, 2019 Research Article

https://doi.org/10.1177/1747493019830583

Article information

Abstract

Background

The utility-weighted modified Rankin Scale (UW-mRS) is an outcome measure recently proposed to improve statistical efficiency and interpretability of the mRS. Statistical properties of the UW-mRS have been well investigated, but construct validity has yet to be established.

Aims

To investigate the construct validity of the UW-mRS as a primary outcome measure by assessing variability in utility values within and between mRS categories, over time post-stroke, and by different derivation methods.

Methods

UW-mRS was derived using assessment of quality of life (AQoL-4D) and mRS scores at 3 and 12 months (n = 2030) from a large randomized controlled trial, A Very Early Rehabilitation Trial (AVERT). Receiver operator characteristic (ROC) analysis of AQoL-4D was conducted to differentiate between sequential mRS categories. Intraclass correlation was used to explore variability in utility values over time post-stroke, UW-mRS values, and derivation methods from multiple studies.

Results

UW-mRS values for mRS categories 0–6 at three months were 0.80, 0.78, 0.63, 0.37, 0.11, 0.03, and 0. Based on AQoL-4D utility values, areas under the ROC curve varied from 0.54 to 0.87. Time post-stroke explained 42%–56% of variability in AQoL-4D utility values in patients with no change in mRS between 3 and 12 months. The choice of the derivation method contributed to 25% of the variability in UW-mRS values. (Whatever this gobbledegook means. Obviously not meant for layperson survivors. If you can't explain this to normal people you have failed in your research.)

Conclusions

The high variability in utility values between and within mRS categories, over time post-stroke, and using different derivation methods is not adequately reflected in the UW-mRS. These threats to construct validity warrant caution when using UW-mRS as a primary outcome measure.

Trial registration

Australian New Zealand Clinical Trials Registry (ACTRN12606000185561

Benefit of Endovascular Therapy Dwindles With Large-Core Strokes

Fuck this diminishing returns talk. If you can't be enough of a leader to even try to achieve a goal of 100% recovery for all stroke survivors; Get the hell out of stroke!  I'm pretty sure my infarct volume is way above 100ml. As a researcher said when he looked at my MRI, I'm surprised you can walk and talk.  Picture of my damage down at the bottom of this blog.

Benefit of Endovascular Therapy Dwindles With Large-Core Strokes

But is thrombectomy still better than medical management alone for these cases?

• by Nicole Lou, Contributing Writer, MedPage Today February 08, 2019

HONOLULU -- Patients with large-core strokes didn't share the same benefits of endovascular therapy with peers presenting with smaller ischemic cores, according to one study reported here, though another suggested that core volume did not change the treatment effect of late thrombectomy.
With data pooled from the SELECT and TREVO studies, 187 patients were stratified by ischemic core volume, i.e., the amount of tissue with regional cerebral blood flow (rCBF) <30% on CT perfusion imaging. Outcomes were worse with larger ischemic cores, according to Amrou Sarraj, MD, of UT McGovern Medical School in Houston:

• 90-day modified Rankin Scale (mRS) score 0-2: 45% for ischemic cores <50 mL vs 29% for 50-100 mL vs 11% for >100 mL (P=0.018)
• Symptomatic intracerebral hemorrhage: 2% vs 7% vs 33% (P=0.002)
• Neurological worsening (NIH Stroke Scale score decline by 4+ points at 24 hours): 3% vs 18% vs 56% (P<0.001)
• Mortality at 90 days: 11% vs 29% vs 33% (P=0.019)

Along with perfusion core volumes, increasing time to reperfusion was also tied to poor rates of functional independence and growing rates of mortality and symptomatic hemorrhage, Sarraj said at a late-breaking trial session at the International Stroke Conference.
Nearly one in ten patients in the study had ischemic core volumes above 100 mL.
"It isn't particularly surprising that strokes with large cores do poorly with endovascular therapy. Is there room for improvement with treatment? Future trials will tell but a floor effect may be a problem," commented S. Claiborne Johnston, MD, PhD, of the University of Texas at Austin Dell Medical School, who was not involved in the trial.
"At some point we need to think about diminishing returns, particularly when we are considering the kinds of outcomes patients want. Many patients would find a stroke with mRS=5 an outcome not worth pursuing or even worse than death," Johnston told MedPage Today.(You're suggesting survivors should live with their disabilities because YOU are too fucking lazy to do your job. I'm being polite here.) SELECT was a non-randomized study comparing thrombectomy vs medical management, and TREVO, a post-marketing registry for the stent retriever from Stryker.
Together they showed that good outcomes were not common once infarct cores grew beyond 100 mL. However, thrombectomy in these cases may still be better than medical management, Sarraj suggested.
Given the lack of medical management controls in the present study, randomized clinical trials are needed to answer that question, he emphasized.
His SELECT 2 is one such trial that plans to enroll 460 patients with large cores (ASPECTS 3-5 and rCBF [<30%] volumes at 50-100 mL), the presenter noted.
Studies in large-core strokes mark the evolution of endovascular therapy, which had been proven beneficial at first for small cores in the early stage, then more recently for small cores at a later window.
"The exciting news is that this study suggests like a few others that we may be able to offer mechanical thrombectomy to patients currently being excluded on the basis of a large stroke core volume," according to Demetrius Lopes, MD, of Advocate Lutheran General Hospital in Park Ridge, Illinois.
Yet in a separate analysis by the same group -- also reported here, with a simultaneous journal publication -- outcomes with late thrombectomy did not differ with infarct core size.
A subgroup analysis from DEFUSE 3 involved stroke patients undergoing thrombectomy 6-16 hours from last known well who were either transferred from another hospital or directly admitted to the endovascular-capable center.
Among its findings were that no heterogeneity in the thrombectomy treatment effect was seen in transferred patients when stratified by ischemic core volume (either on CT perfusion or diffusion-weighted imaging) or by ASPECTS, Sarraj and colleagues reported.
Two-thirds of the 182 people randomized in the DEFUSE 3 cohort had been transferred for endovascular therapy.
The new analysis mainly focused, however, on comparisons between the transfer cohort and direct arrivals. The former waited a median 26 minutes longer to get to the thrombectomy center (9.43 vs 9 hours from last known well to study site arrival). For the most part, there were no differences in outcomes:

• 90-day mRS score shift: transfer OR 2.6 vs direct OR 2.9
• Overall functional independence (mRS score 0-2): 45% vs 44%
• Thrombectomy treatment effect: OR 3.1 vs OR 2.0

"Thrombectomy reperfusion rates, mortality, and symptomatic intracranial hemorrhage rates did not differ," the investigators added in their study published online in JAMA Neurology.
"Both direct and transfer patients who received endovascular thrombectomy had significantly better outcomes than patients receiving medical management, with similar safety profiles," they concluded. "These results have health care implications indicating transferring potential candidates for late-window thrombectomy associated with substantial clinical benefits and should be encouraged."
The trial had imaging-based enrollment criteria requiring that each participant have a large-vessel anterior circulation occlusion and initial infarct smaller than 70 mL, mismatch ratio of at least 1.8, and mismatch volume at least 15 mL.
Findings of the present analysis fall in line with another recent DEFUSE 3 analysis showing the generalizability of thrombectomy's benefits to a broad patient population even 6-16 hours after stroke onset.

Sarraj disclosed receiving grant support from and serving as scientific advisor, consultant, and speaker for Stryker Neurovascular.
Lopes reported being a scientific advisor for Stryker.

• Primary Source

  ISC 2019

  Source Reference: Sarraj A, et al "Endovascular thrombectomy outcomes in large core on CT are strongly associated with perfusion core volume and time: implications from two large cohorts for future trials" ISC 2019.

• Secondary Source

  JAMA Neurology

  Source Reference: Sarraj A, et al "Outcomes of thrombectomy in transferred patients with ischemic stroke in the late window: a subanalysis from the DEFUSE 3 trial" JAMA Neurol 2019; DOI: 10.1001/jamaneurol.2019.0118.