Anticoagulation Type and Early Recurrence in Cardioembolic Stroke

So we still know nothing and have NO PROTOCOL. Hope you are OK with your doctor making a wild-assed guess on what to do. This is precisely why we need survivors in charge, we would actually demand results instead of this wishy-washy crapola. 

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

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

Anticoagulation Type and Early Recurrence in Cardioembolic Stroke

The IAC Study

Shadi Yaghi

,

Eva Mistry

,

Ava L. Liberman

,

James Giles

,

Syed Daniyal Asad

,

Angela Liu

,

Muhammad Nagy

,

Ashutosh Kaushal

,

Idrees Azher

,

Brian Mac Grory

,

Hiba Fakhri

, … See all authors

Originally published6 Aug 2020https://doi.org/10.1161/STROKEAHA.120.028867Stroke. 2020;51:2724–2732

• This article is commented on by the following:

Abstract

Background and Purpose:

In patients with acute ischemic stroke and atrial fibrillation, treatment with low molecular weight heparin increases early hemorrhagic risk without reducing early recurrence, and there is limited data comparing warfarin to direct oral anticoagulant (DOAC) therapy. We aim to compare the effects of the treatments above on the risk of 90-day recurrent ischemic events and delayed symptomatic intracranial hemorrhage.

Methods:

We included consecutive patients with acute ischemic stroke and atrial fibrillation from the IAC (Initiation of Anticoagulation after Cardioembolic) stroke study pooling data from stroke registries of 8 comprehensive stroke centers across the United States. We compared recurrent ischemic events and delayed symptomatic intracranial hemorrhage between each of the following groups in separate Cox-regression analyses: (1) DOAC versus warfarin and (2) bridging with heparin/low molecular weight heparin versus no bridging, adjusting for pertinent confounders to test these associations.

Results:

We identified 1289 patients who met the bridging versus no bridging analysis inclusion criteria and 1251 patients who met the DOAC versus warfarin analysis inclusion criteria. In adjusted Cox-regression models, bridging (versus no bridging) treatment was associated with a high risk of delayed symptomatic intracranial hemorrhage (hazard ratio, 2.74 [95% CI, 1.01–7.42]) but a similar rate of recurrent ischemic events (hazard ratio, 1.23 [95% CI, 0.63–2.40]). Furthermore, DOAC (versus warfarin) treatment was associated with a lower risk of recurrent ischemic events (hazard ratio, 0.51 [95% CI, 0.29–0.87]) but not delayed symptomatic intracranial hemorrhage (hazard ratio, 0.57 [95% CI, 0.22–1.48]).

Conclusions:

Our study suggests that patients with ischemic stroke and atrial fibrillation would benefit from the initiation of a DOAC without bridging therapy. Due to our study limitations, these findings should be interpreted with caution pending confirmation from large prospective studies.

 

The impact of physical therapy on functional outcomes after stroke: what's the evidence?

You may have found strong evidence but this is totally useless since it is not put into a publicly available database for survivors to find. Bad research, the mentors and senior researchers need to be keel hauled.  There was this from 1990;

A review of stroke rehabilitation and physiotherapy. This was written in 1990 

And this from 2014:

What Is the Evidence for Physical Therapy Poststroke? A Systematic Review and Meta-Analysis

This is what is so fucking bad about stroke. They don't mention updating any stroke protocols.  30 years and still no protocols.  Which means every therapist in the world needs to analyze this and create their own. Aren't you lucky your therapist is making wild assed guesses on what might work in your rehab?. 

The latest here from 2004:

The impact of physical therapy on functional outcomes after stroke: what's the evidence?

    RPS Van Peppen
 Department of Physical Therapy, VU University Medical Center, Amsterdam,
 G Kwakkel
 Department ofPhysical Therapy, VU University Medical Center, Amsterdam and Center of Excellence for Rehabilitation Medicine ‘deHoogstraat’, Utrecht, The Netherlands,
 S Wood-Dauphinee
 School of Physical and Occupational Therapy, Department ofEpidemiology and Biostatistics, McGill University, Montreal, Canada,
HJM Hendriks
Dutch Institute of Allied Health Care (Npi),Amersfoort and Maastricht University, Department of Epidemiology, Maastricht,
 PhJ Van der Wees
 Royal Dutch Society forPhysical Therapy (KNGF), Amersfoort and
 J Dekker
 Institute for Research in Extramural Medicine (EMGO Institute),Department of Rehabilitation Medicine, VU University Medical Center, Amsterdam, The NetherlandsReceived 23rd March 2004; returned for revisions 10th June 2004; revised manuscript accepted 25th July 2004.
Objective: 

To determine the evidence for physical therapy interventions aimed at improving functional outcome after stroke.
Methods: 

MEDLINE, CINAHL, Cochrane Central Register of Controlled Trials,Cochrane Database of Systematic Reviews, DARE, PEDro, EMBASE and DocOnline were searched for controlled studies. Physical therapy was divided into 10intervention categories, which were analysed separately. If statistical pooling(weighted summary effect sizes) was not possible due to lack of comparability between interventions, patient characteristics and measures of outcome, a best-research synthesis was performed. This best-research synthesis was based on methodological quality (PEDro score).
Results: 

In total, 151 studies were included in this systematic review; 123 were randomized controlled trials (RCTs) and 28 controlled clinical trials (CCTs).  Methodological quality of all RCTs had a median of 5 points on the 10-point PEDroscale (range 2-8 points). Based on high-quality RCTs strong evidence was found in favour of task-oriented exercise training to restore balance and gait, and for strengthening the lower paretic limb. Summary effect sizes (SES) for functional outcomes ranged from 0.13 (95% CI 0.03-0.23) for effects of high intensity of exercise training to 0.92 (95% CI 0.54-1.29) for improving symmetry when moving from sitting to standing. Strong evidence was also found for therapies that were focused on functional training of the upper limb such as constraint-induced movement therapy (SES 0.46; 95% CI 0.07-0.91), treadmill training with or without body weight support, respectively 0.70 (95% CI 0.29-1.10) and 1.09 (95% CI 0.56-1.61), aerobics (SES 0.39; 95% CI 0.05-0.74), external auditory rhythms during gait(SES 0.91; 95% CI 0.40-1.42) and neuromuscular stimulation for glenohumeral subluxation (SES 1.41; 95% CI 0.76-2.06). No or insufficient evidence in terms of functional outcome was found for: traditional neurological treatment approaches;exercises for the upper limb; biofeedback; functional and neuromuscular electrical stimulation aimed at improving dexterity or gait performance; orthotics and assistive
Address for correspondence: Gert Kwakkel, Department of Physical Therapy, VU University Medical Center, PO Box 7057,1007 MB Amsterdam, The Netherlands.e-mail: g.kwakkel@vumc.nl

What Is the Evidence for Physical Therapy Poststroke? A Systematic Review and Meta-Analysis

My conclusion from this is that there are NO PROTOCOLS. And thus you are stuck with wild-assed guesses and guidelines. Hope you like ambiguity.  With no plan to get you 100% recovered you will be disabled for the rest of your life.  I use a lot of compensation and risk-taking to live my pretty normal life. But then I am just physically disabled a bit.

What Is the Evidence for Physical Therapy Poststroke? A Systematic Review and Meta-Analysis

Abstract

Background:
Physical therapy (PT) is one of the key disciplines in interdisciplinary stroke rehabilitation. The aim of this systematic review was to provide an update of the evidence for stroke rehabilitation interventions in the domain of PT.
Methods and Findings:
Randomized controlled trials (RCTs) regarding PT in stroke rehabilitation were retrieved through a systematic search. Outcomes were classified according to the ICF. RCTs with a low risk of bias were quantitatively analyzed. Differences between phases poststroke were explored in subgroup analyses. A best evidence synthesis was performed for neurological treatment approaches. The search yielded 467 RCTs (N=25373; median PEDro score 6 [IQR 5–7]), identifying 53 interventions. No adverse events were reported. Strong evidence was found for significant positive effects of 13 interventions related to gait, 11 interventions related to arm-hand activities, 1 intervention for ADL, and 3 interventions for physical fitness. Summary Effect Sizes (SESs) ranged from 0.17 (95%CI 0.03–0.70; I2 =0%) for therapeutic positioning of the paretic arm to 2.47 (95%CI 0.84–4.11; I2 =77%) for training of sitting balance. There is strong evidence that a higher dose of practice is better, with SESs ranging from 0.21 (95%CI 0.02–0.39; I2 =6%) for motor function of the paretic arm to 0.61 (95%CI 0.41–0.82; I2 =41%) for muscle strength of the paretic leg. Subgroup analyses yielded significant differences with respect to timing poststroke for 10 interventions. Neurological treatment approaches to training of body functions and activities showed equal or unfavorable effects when compared to other training interventions. Main limitations of the present review are not using individual patient data for meta-analyses and absence of correction for multiple testing.
Conclusions:
There is strong evidence for PT interventions favoring intensive high repetitive task-oriented and task-specific training in all phases poststroke. Effects are mostly restricted to the actually trained functions and activities. Suggestions for prioritizing PT stroke research are given.
 

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