Truncal impairment after stroke: clinical correlates, outcome and impact on ambulatory and functional outcomes after rehabilitation

INTRODUCTION@#Good trunk performance is important for activities such as sitting and standing. In a cohort of patients with stroke, we sought to evaluate changes in trunk performance after stroke, establish factors correlated to trunk performance and assess the impact of trunk performance on discharge ambulatory and functional status.@*METHODS@#This was a retrospective review of the data of patients with stroke admitted to Tan Tock Seng Hospital rehabilitation centre, Singapore, over a two-year period. Data analysed included the National Institutes of Health Stroke Scale (NIHSS), Montreal Cognitive Assessment (MOCA), Fugl-Meyer Assessment (FMA) of limb motor impairment and Functional Independence Measure-motor (FIM-motor) scores, which measures self-care ability. Trunk performance was assessed on the Trunk Impairment Scale (TIS).@*RESULTS@#577 patients with stroke (mean age 63.2 ± 11.8 years) were analysed. Truncal impairment was present in 96.4% of patients. Mean admission TIS score was 14.3 ± 6.1 and this improved to 17.2 ± 5.2 on discharge (p < 0.001). Admission TIS score was positively correlated with admission MOCA, FMA-upper limb and FMA-lower limb scores, and negatively correlated to NIHSS score and neglect. Admission TIS scores significantly predicted discharge FIM-motor scores (p < 0.001) and ambulatory status (p < 0.001).@*CONCLUSION@#Truncal impairment was common and improvements in trunk performance were seen after rehabilitation. Trunk performance was significantly correlated to stroke severity, upper and lower limb motor power, cognition and neglect. As admission trunk performance predicted discharge functional and ambulatory status, it is recommended that trunk performance be evaluated for all patients with stroke.

Interview Functional Independence Measure score: self-reporting as a simpler alternative to multidisciplinary functional assessment

INTRODUCTION@#The Functional Independence Measure (FIM) is a validated, objective assessment of functional status. It is widely used in rehabilitation centres but may not be practical for all patients due to time and/or personnel constraints. Studies show positive and negative agreement on self-reported FIM scores for patients with spinal cord injuries and amputees. We tested the validity of the self-reported FIM motor score among stroke patients.@*METHODS@#We conducted a prospective double-blind comparative study of patient self-reporting against multidisciplinary assessment, using the standard FIM algorithm. All eligible stroke patients (n = 47) admitted to our rehabilitation centre were included. 33 patients were included in the final analysis.@*RESULTS@#There was substantial agreement on overall FIM motor score between patient self-reporting and multidisciplinary assessment (intraclass correlation coefficient [ICC] 0.651, 95% confidence interval 0.404-0.811). The scores of individual motor items also showed fair-to-good agreement (ICC range 0.431-0.618), except for eating, grooming, bathing and dressing of the lower body (ICC < 0.400).@*CONCLUSION@#There was no FIM assessment for 14 (29.8%) patients, highlighting the need for alternative assessment tools. Discrepancies in some scores could be due to patients' ignorance of their own limitations or feelings of embarrassment about reporting. Our results may not be valid for patient populations with cognitive or communication deficits. However, a modest agreement between patient self-reporting and multidisciplinary assessment of FIM motor score was demonstrated. Although patients tend to overrate their performance, self-reported FIM motor scores could be an alternative in situations where multidisciplinary FIM assessment is difficult.

Advances in rehabilitation medicine

Rehabilitation medicine is the medical specialty that integrates rehabilitation as its core therapeutic modality in disability management. More than a billion people worldwide are disabled, and the World Health Organization has developed the International Classification of Functioning, Disability and Health as a framework through which disability is addressed. Herein, we explore paradigm shifts in neurorehabilitation, with a focus on restoration, and provide overviews on developments in neuropharmacology, rehabilitation robotics, virtual reality, constraint-induced therapy and brain stimulation. We also discuss important issues in rehabilitation systems of care, including integrated care pathways, very early rehabilitation, early supported discharge and telerehabilitation. Finally, we highlight major new fields of rehabilitation such as spasticity management, frailty and geriatric rehabilitation, intensive care and cancer rehabilitation.

Level and predictors of participation in patients with stroke undergoing inpatient rehabilitation

<p><b>INTRODUCTION</b>The level of participation is an important factor influencing rehabilitation outcome. However, few studies have evaluated rehabilitation participation and its clinical predictors in patients with stroke. This study aimed to establish the level of participation in patients with stroke undergoing inpatient rehabilitation, and define the clinical predictors for participation.</p><p><b>METHODS</b>This was a prospective observational study of first-time patients with stroke admitted to a rehabilitation centre over a 12-month period. The primary outcome measure was the level of rehabilitation participation as measured on the Pittsburgh Rehabilitation Participation Scale (PRPS). PRPS measurements were made one week after admission and one week before planned discharge from inpatient rehabilitation. Other outcome measures evaluated were the National Institute of Health Stroke Scale, Functional Independence Measure (FIM), Elderly Cognitive Assessment Questionnaire (ECAQ), Centre for Epidemiologic Studies-Depression Scale, Fatigue Severity Scale (FSS), Lubben Social Network Scale-Revised, and Multidimensional Health Questionnaire.</p><p><b>RESULTS</b>A total of 122 patients with stroke were studied. The mean PRPS score on admission was relatively high at 4.30 ± 0.90, and this improved to 4.65 ± 0.79 before planned discharge (p < 0.001). On multivariate analysis, the mean PRPS score on admission was predicted by FIM, EACQ and FSS scores on admission, but not by variables such as age, gender, depression, social support, or health attitudes and beliefs.</p><p><b>CONCLUSION</b>Patients with lower levels of participation were more likely to be functionally dependent, cognitively impaired and have more fatigue. We suggest that in addition to cognition, fatigue should be routinely screened in patients with stroke undergoing rehabilitation.</p>

Factors affecting falls in community-dwelling individuals with stroke in Singapore after hospital discharge

<p><b>INTRODUCTION</b>This study aimed to investigate the factors affecting the incidence of falls among individuals with stroke living in the community one year after discharge from a rehabilitation hospital in Singapore.</p><p><b>METHODS</b>A cross-sectional telephone survey of individuals with stroke living in the community was carried out one year after discharge. The interview covered aspects such as incidence and circumstances of fall, use of walking aids, and presence of environmental obstacles. Each participant's case record was retrospectively reviewed using discharge Fugl-Meyer (FM) assessment of the upper and lower limbs, functional independence measure (FIM) and Berg Balance Scale (BBS).</p><p><b>RESULTS</b>A total of 126 individuals with stroke were interviewed. Overall, 24% fell in the year following their discharge. Factors associated with falls were longer length of hospital stay, lower BBS and lower-limb FM scores, and lower discharge FIM scores for the Bladder and Bowel Management, Transfer, Mobility, Communication, and Social Cognition domains (p < 0.05). The fallers were more likely to use walking aids, and required help with basic activities of daily living after discharge (p < 0.05). Multivariate logistic regression analysis revealed that only the Transfer domain was an independent factor for falls.</p><p><b>CONCLUSION</b>Discharge FIM outcomes, especially for the Transfer domain, can be used to identify communitydwelling individuals with stroke who have a high fall risk after discharge. Identification of such individuals will enable early fall prevention management, which will in turn minimise fall events in the community.</p>

Bridging the gap between primary and specialist care--an integrative model for stroke

Stroke is a major cause of death and disability in Singapore and many parts of the world. Chronic disease management programmes allow seamless care provision across a spectrum of healthcare facilities and allow appropriate services to be brought to the stroke patient and the family. Randomised controlled trials have provided evidence for efficacious interventions. After the management of acute stroke in a stroke unit, most stable stroke patients can be sent to their family physician for continued treatment and rehabilitation supervision. Disabled stroke survivors may need added home-based services. Suitable community resources will need to be harnessed. Clinic-based stroke nurses may enhance service provision and coordination. Close collaboration between the specialist and family physician would be needed to right-site patients and also allow referrals in either direction where necessary. Barriers to integration can be surmounted by trust and improved communication. Audits would allow monitoring of care provision and quality care enhancement. The Wagner model of chronic care delivery involves self-management support, shared clinical information systems, delivery system redesign, decision support, healthcare organisation and community resources. The key and critical feature is the need for an informed, activated (or motivated) patient, working in collaboration with the specialist and family physician, and a team of nursing and allied healthcare professionals across the continuum of care. The 3-year Integrating Services and Interventions for Stroke (ISIS) project funded by the Ministry of Health will test such an integrative system.

Emerging therapies in stroke rehabilitation

Traditionally, practitioners of stroke rehabilitation are taught that benefits of rehabilitation are achieved primarily through training patients in new techniques to compensate for impairments, and that neurological recovery is predominantly spontaneous in nature. Recent animal and human experiments have, however, indicated that the adult brain is capable of reorganisation and the term plasticity has been coined to describe this ability. Furthermore, it has been shown that cerebral reorganisation is use-dependent and can be manipulated via appropriate stimuli. This has resulted in a paradigm shift in the way stroke survivors should be rehabilitated and also given rise to several novel rehabilitation techniques.