Self-efficacy and Reach Performance in Individuals With Mild Motor Impairment Due to Stroke

Cherry picking again. What about helping those with medium to major impairment?  Stop ignoring the real world, the real world exists. Stroke survivors live in the real world, not some idealized world only researchers inhabit.

Self-efficacy and Reach Performance in Individuals With Mild Motor Impairment Due to Stroke

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Jill Campbell Stewart, PhD, Rebecca Lewthwaite, PhD, Janelle Rocktashel, MS, ...

First Published March 18, 2019 Research Article

https://doi.org/10.1177/1545968319836231

Article information

Abstract

Background: Persistent deficits in arm function are common after stroke. An improved understanding of the factors that contribute to the performance of skilled arm movements is needed. One such factor may be self-efficacy (SE).  
Objective: To determine the level of SE for skilled, goal-directed reach actions in individuals with mild motor impairment after stroke and whether SE for reach performance correlated with actual reach performance.  
Methods:
A total of 20 individuals with chronic stroke (months poststroke: mean 58.1 ± 38.8) and mild motor impairment (upper-extremity Fugl-Meyer [FM] motor score: mean 53.2, range 39 to 66) and 6 age-matched controls reached to targets presented in 2 directions (ipsilateral, contralateral). Prior to each block (24 reach trials), individuals rated their confidence on reaching to targets accurately and quickly on a scale that ranged from 0 (not very confident) to 10 (very confident).
Results: Overall reach performance was slower and less accurate in the more-affected arm compared with both the less-affected arm and controls. SE for both reach speed and reach accuracy was lower for the more-affected arm compared with the less-affected arm. For reaches with the more-affected arm, SE for reach speed and age significantly predicted movement time to ipsilateral targets (R² = 0.352), whereas SE for reach accuracy and FM motor score significantly predicted end point error to contralateral targets (R² = 0.291).
Conclusions: SE relates to measures of reach control and may serve as a target for interventions to improve proximal arm control after stroke.

Keywords stroke, self-efficacy, confidence, arm, kinematics

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For Brain Bleeds, 'Gentle' but Thorough Surgery May Boost Outcomes

What will it take before we start using 100% recovery as the measurement of success? Rankin scale is worthless, not objective except for 6 - death. How many stroke researchers and stroke hospital presidents need to have strokes before we actually start working on fixing all the problems in stroke?  Hell the top doctor in Canada had a stroke and I saw no change in anything coming out of there. 

Even Canada's top doctor had trouble recognizing when he was having a stroke

June 2017

 

For Brain Bleeds, 'Gentle' but Thorough Surgery May Boost Outcomes

MISTIE III trial failed overall but showed functional benefit with extensive clot removal

• by Crystal Phend, Senior Associate Editor, MedPage Today February 07, 2019

HONOLULU -- A minimally invasive, gentle surgical approach to removing stable clot material left after large intracranial bleeds didn't improve outcomes overall in the MISTIE III trial, although results were promising with more complete removal.
Good functional outcome at 1 year (modified Rankin Scale [mRS] score of 0-3) adjusted for factors like clot size and location was no more likely with the intervention than standard medical care in the primary efficacy analysis of all eligible, randomly assigned patients who were exposed to treatment (45% vs 41%, P=0.33).
However, functional recovery was significantly tied to how much clot was left behind(That makes no sense at all, go back and figure out the real reason.), Daniel Hanley, MD, of Johns Hopkins University, reported here at the American Heart Association's International Stroke Conference. The results were also published simultaneously in The Lancet.
The 58% of patients left with less than 15 mL of clot -- the aim of the procedure -- did have a significant benefit from surgery in an exploratory analysis, with a 10.5% greater likelihood (P=0.03) of mRS scores of 0–3 at 1 year adjusted for initial severity factors and severity matching.
A second presentation by Issam Awad, MD, of the University of Chicago, at the same session showed that intracerebral hemorrhage (ICH) removal beyond the 15 mL threshold increased the chance of a good functional outcome by 10% per additional 1 mL (P=0.002) and that removal of more than 70% was similarly independently associated with functional outcome.
There was no increased risk of death, brain infection, or symptomatic bleeds. In fact, estimated all-cause mortality as a secondary outcome was significantly lower with intervention at 1 year, with a severity-adjusted Cox proportional HR of 0.67 in the overall population (P=0.037).
"The frequency of survival is modestly improved with MISTIE without a price in surgical risk or vegetative state," Hanley told the audience.
"We have to go back and do a similar trial showing that with knowing the goals and that we must reach the goal, there can be a general benefit," he told reporters.
‘Landmark’ Trial
"It's clear less is more," commented session moderator Louise McCullough, MD, PhD, of the University of Texas Health Science Center at Houston.
J Mocco, MD, of Icahn School of Medicine at Mount Sinai in New York City, drew parallels to mechanical thrombectomy for large vessel occlusion strokes.
“The groundbreaking therapy was done with lytic therapies that provided the first evidence that this is something we should pursue,” he told MedPage Today. “Based on those experiences, physicians developed and pioneered improved selection and improved tools to remove blood clots, and now we have one of the most efficacious treatments that exist in medicine. Likewise for ICH, I think this study is landmark in that it provides the critical data to encourage all of us to do better.”
So while “the technique was not as successful as they hoped, they correctly estimated what needed to be achieved to demonstrate benefit,” Mocco added. “This provides a threshold, a bar, for other future and ongoing studies to achieve.”
Brian Silver, MD, of UMass Memorial Medical Center in Worcester, Massachusetts, likewise pointed to thrombectomy. ”We would not have adopted that if we said ‘game over’ after the first three negative trials — they just had to redesign things a little bit, change the tool that they used, selection criteria.” (So you had to cherry pick patients instead of solving for real world patients? You move the bar for declaring success, but you didn't help every patient because you decided to leave some survivors behind.)
He predicted that a redesign with altered selection criteria and endpoints could be successful for minimally-invasive surgery in ICH.
“The fact that we see these very strong trends and evidence that the patients who had the good removal rates had good outcomes, we should push forward to try to new therapies,” agreed Gregory Albers, MD, of Stanford University Medical Center in Stanford, California.
Broader Implications
Even now, though, the trial can have a big impact because of the high survival rates found with good medical care, Awad argued.
At 1 year, 83% of patients were alive and at home or in acute rehabilitation, "which has not ever been recorded," he said. "It's the end of nihilism. ... The trial as a whole allowed us to show we can do better than previously thought."
"I think this is going to make the world realize that we've been nihilistic about the treatment of hemorrhagic stoke. I think it's going to help standardize treatment," he told reporters, pointing to the better outcomes across both groups than seen in the prior MISTIE II trial.
One reason why surgery for ICH has failed in the past and isn't recommended in the guidelines may be that it caused too much secondary damage, Awad suggested.
"There is almost definitely a role for minimally invasive surgery," he said. "We think that the least invasive and least mechanically disruptive, the better."
Removing the blood may eliminate toxins that cause edema and inhibit recovery, the researchers suggested.
The Procedure
The procedure was done under general anaesthesia and CT imaging guidance after the hematoma has stopped expanding but within 72 hours. It involved drilling a hole in the skull, placing a rigid cannula into the hematoma, clot aspiration with suction by hand, and then placement of a soft catheter with closed drainage system. Alteplase (Activase) was injected into the clot through that catheter at 6 hours after catheter placement, and then at 1.0 mg in 1 mL followed by 3 mL flush every 8 hours for up to nine doses until no more than 15 mL of hematoma remained or there was clinically symptomatic rebleeding. Treatment was open label.
All 506 patients got care as recommended by the American Heart Association and European Stroke Organisation recommendations, including monitoring airways, ventilation, intracranial pressure, sedation, and pharmacological treatment of intracranial mass effect.
"If you skimp on those and just do the procedures, you're not going to get the outcomes," Awad said. "All of the components of care matter."
As expected, the intervention cut hematoma size much more than standard care, by a mean 69% versus 3% for an average end-of-treatment volume of 16 versus 47 mL.
Inclusion criteria were ICH of at least 30 mL, with vascular defects excluded by CT angiography.
The techniques used in the trial are skills all neurosurgeons have, Hanley noted. "We think it's easily exportable worldwide."
Results didn't vary by size of ICH or by time since symptom onset to treatment. "The window appears to be quite wide," Hanley said, so "most Americans are going to be eligible."
Other approaches to hematoma removal are being developed, but "ours is the gentlest technique" with just hand suction and no negative pressure or use of cutting devices, Hanley noted. There may be more brain injury with the other approaches, but future studies will be required to sort out which approach is best for outcomes, he added.

The study was funded by the National Institute of Neurological Disorders and Stroke and Genentech.
Hanley disclosed relationships with BrainScope, Neurotrope, Op2Lysis, Portola Pharmaceuticals, and Medtronic.
Awad disclosed no relevant relationships with industry.
Mocco disclosed relationships with Rebound Therapeutics.

last updated 02.08.2019

• Primary Source

  The Lancet

  Source Reference: Hanley DF, et al "Efficacy and safety of minimally invasive surgery with thrombolysis in intracerebral hemorrhage evacuation (MISTIE III): a randomised, controlled, open-label, blinded endpoint phase 3 trial" Lancet 2019; DOI: 10.1016/S0140-6736(19)30195-3.

• Secondary Source

  The Lancet

  Source Reference: Salman RA-S, et al "Minimally invasive surgery plus alteplase for intracerebral haemorrhage" Lancet 2019; DOI: 10.1016/S0140-6736(19)30309-5.

Upbeat attitude may help prevent a second stroke, study says

For a lot of people that upbeat attitude is only going to be possible after 100% recovery from the first stroke. THAT IS YOUR DOCTORS' RESPONSIBILITY.

I am upbeat almost all the time, having the time of my life now that I'm retired. 

Upbeat attitude may help prevent a second stroke, study says

Researchers say a positive outlook can help lower blood pressure, which can lower the risk of stroke.

By

Serena Gordon, HealthDay News

New research suggests an upbeat attitude could help prevent a second stroke. Photo by go_see/Pixabay

If you've had a stroke, a positive outlook might just help prevent another one, a new study suggests.
Researchers found that when people felt they could protect themselves from a second stroke, they had lower blood pressure. High blood pressure is a significant risk factor for a recurrent stroke.

"You can protect yourself against stroke by reducing your risk factors. And this study shows that if you think you can do it, you can," said the study's senior author, Bernadette Boden-Albala. She's a professor of epidemiology at NYU College of Global Public Health in New York City.
The connection between the mind and the body is of growing interest in medicine. But can people actually think themselves well?

The study seems to suggest it's possible.
The researchers looked at data on more than 400 people who survived a mild or moderate stroke or had had a transient ischemia attack(But what about severe strokes? Don't you believe in doing real world research?) (also known as a TIA or mini-stroke). The group was half female. Their average age was 64.
Thirty percent of the group was white, about one-third were black and another one-third were Hispanic.

The study volunteers were asked to agree or disagree with statements, such as: "I worry about having a stroke"; "I can protect myself against having a stroke"; and "Some people are more likely to have a stroke than others."
Almost 80 percent agreed with the statement that they could protect themselves. When compared to a group of people who disagreed, those who thought they could protect themselves reduced their systolic blood pressure by about 6 mm Hg more than the negative-thinking group a year post-stroke. Systolic blood pressure is the top number in a reading.
Boden-Albala said the researchers didn't include diastolic (the bottom number) blood pressure readings in the analysis, because systolic pressure is the one that appears related to stroke risk. The higher your systolic pressure, the greater the risk of stroke, she said.

How might a positive outlook affect your blood pressure?
"It may be that self-efficacy [feeling as if you can protect yourself] is a proxy for readiness to change," Boden-Albala said. So it may be that people who had a brighter outlook were able to cut back on salt, eat more fruits and vegetables, or exercise more, she suggested.
While everyone in the study was given some information on preventing another stroke, those with positive thinking may have had the "confidence to take control over their lives," she added.
Boden-Albala said stress may play a role as well. And those who felt they had control would likely feel less stressed.
"The worst thing you can do is tell someone that they can't do anything about a situation. People need skills and resources to do something, or they'll be stressed," Boden-Albala explained.
Dr. Deepan Singh is a psychiatrist at NYU Winthrop Hospital in Mineola, N.Y.
He said, "Patients with a positive attitude had lower systolic blood pressure, irrespective of gender, race, etc., and regardless of intervention status. People with a sense of control seemed destined to have a better outcome."
But that doesn't mean positive thinking should replace standard treatment strategies. It does, however, suggest the importance of treating patients holistically, said Singh, who wasn't involved in the study.
Singh said the take-home message from this study is really for care providers: "Be proactive with educating patients and be aware that maintaining a positive outlook can have a positive outcome."
Both experts said it would be a good idea for doctors to pay attention to their patients' attitudes. Someone expressing a lot of negativity may need to be directed to additional resources to learn how to reduce their risk of another stroke, and perhaps referred for more help.
The study results were scheduled for presentation Wednesday at an American Stroke Association meeting in Honolulu. Findings presented at meetings should be viewed as preliminary until they're published in a peer-reviewed journal.
More information Learn more about how positive thinking can boost your health from Johns Hopkins Medicine. Copyright © 2019 HealthDay. All rights reserved.

Assessing the Concordance Between Stroke Rehabilitation Research Participants & 'Real World'Stoke Patients

This is a major problem, cherry picking patients for clinical trials. So until they start actually using real world data, IT IS YOUR RESPONSIBILITY TO HAVE PERFECT STROKES AND PERFECT HEALTH.

Assessing the Concordance Between Stroke Rehabilitation Research Participants & 'Real World'Stoke Patients

Michelle Nelson

Originally published1 Feb 2019https://doi.org/10.1161/str.50.suppl_1.115Stroke. 2019;50:A115

Abstract

Stroke rehabilitation programs have been transformed to better align with stroke Clinical Practice Guidelines (CPGs), which prioritize randomized control trials as evidence-based best practices. However, a recent review of stroke rehabilitation randomized control trials (RCTs) found that the RCTS tended to include younger participants, excluded participants based on age related criteria, and often excluded individuals with comorbidities. The objective of this study was to determine the proportion of stroke patients that would meet the enrolment criteria of stroke rehabilitation randomized controlled trials. A retrospective chart audit was conducted for all patients discharged from a high intensity stroke rehabilitation unit for a one-year period (n=110). RCT exclusion criteria were extracted from a recent review that analyzed the study inclusion and exclusions of 428 RCTs (age, cognitive impairment, previous stroke, and comorbidities). These study exclusions were applied to the 110 patients to determine how many patients would have been eligible to participate in the RCTs. Patients admitted to the stroke rehab unit had a mean age of 67.4 years and an average of 6.2 co-morbidities. 60.1% of these patients would have been excluded from participating in the RCTs by one or more exclusion criteria. 5.5% of patients would have been excluded based on age, 84.5% of patients would have been ineligible for 54% of RCTs based on cognitive impairment, 28% of patients would have been ineligible for 36% of RCTs based on a previous stroke, and 4.2% of patients would have been excluded based on the presence of a CCI condition or stroke risk factor. Results highlight the difference between trial subjects and ‘real world’ patients. Based on our understanding of how people accumulate chronic conditions with age, it can be inferred that the high quality evidence may not reflect the clinical reality of stroke rehabilitation. Given the high prevalence of increased age and comorbidities among stroke rehabilitation patients, this study emphasizes the importance of including ‘typical stroke patients’ in research studies or supporting the use of alternative methodologies that addresses application of study results to older patients with comorbidities.

Applying Clinical Practice Guidelines to the Complex Patient: Insights for Practice and Policy from Stroke Rehabilitation

Oh you poor babies, having to deal with real world patients. Survivors have it much worse, having to deal with doctors that don't know one damn thing about stroke recovery.
https://www.researchgate.net/profile/Michelle_Nelson9/publication/307951994_IMPROVING_EVIDENCE_AND_MEASURES_OF_PERFORMANCE_Applying_Clinical_Practice_Guidelines_to_the_Complex_Patient_Insights_for_Practice_and_Policy_from_Stroke_Rehabilitation/links/57d2e8f008ae0c0081e26ad0.pdf

Abstract

In Canada, policy makers are working to align services with the Stroke Rehabilitation Best Practice Recommendations (SRBPR). Complicating the application of clinical practice guidelines (CPGs) is the fact that most strokes occur in the context of other diagnoses. We sought to understand clinicians’ use of the CPGs and ascertain how much guidance regarding multimorbidity was available in the SRBPR. Study results  indicated  that  using  the  recommendations was problematic due to a perceived lack of guidance regarding comorbidities and multimorbidity, and concerns regarding

the applicability to “real-life patients.” Comorbidities were mentioned in less than half of the recommendations, but no explicit guidance was provided regarding the management

of comorbidities. Given the prevalence of multimorbidity in stroke rehabilitation, this clinical context is ideal for development and testing of CPGs that account for multimorbidity and  other  complexity  factors.  Results  may  also  suggest limitations to using CPGs in the development of activity-

based funding models.