Characteristics of Acute Stroke Patients Readmitted to Inpatient Rehabilitation Facilities: A Cohort Study.

BACKGROUND: Reducing acute care readmissions from inpatient rehabilitation facilities (IRFs) is a healthcare reform goal. Stroke patients have higher acute readmission rates and persistent impairments, warranting second IRF hospitalization consideration. OBJECTIVE: To provide evidence-based information to justify IRF readmission for patients with post-stroke impairments. MAIN OUTCOME MEASURE: Variables that increase the likelihood of a second IRF hospitalization. DESIGN: Retrospective cohort study. SETTING: Seven-center rehabilitation network. PARTICIPANTS: Stroke patients, readmitted to acute care, who returned or did not return to an in-network IRF between 1 October 2014-31 December 2017(n = 380). INTERVENTIONS: Univariable analyses (Returned/Did Not Return to IRF) described demographics, stroke type and risk factors. Between group differences in readmission causes, motor impairments and functional independence measure (FIM) scores were examined. Return to IRF logistic regression model included variables with P < .1. Odds ratio and 95% CI were calculated; Relative risk was calculated for categorical variables. P < .05 equaled statistical significance. RESULTS: One hundred ninety-two stroke patients returned to IRF, 188 did not. Returned to IRF patients were younger (60.6 vs. 66 years; P < .001), sustained hemorrhagic strokes (22.4 vs. 14.2%; P = .01), had lower cardiac disease prevalence (41.7 vs. 55.3%; P = .008) or non-Medicare insurance (59.9 vs. 39.4%; P < .001). Did Not Return to IRF patients had higher admission and discharge motor and total FIM scores. Per point decrease in discharge FIM, second IRF hospitalization odds increased 4% (OR 1.04; 95% CI 1.01-1.07; P = .02). Hemorrhagic stroke patients had 33% increased odds or a 15% higher relative risk of second IRF hospitalization than patients with ischemic stroke [OR 1.33; 95% CI 1.21-1.47; RR 1.15; 95% CI 1.1-1.2; P < .001]. Non-Medicare insurance was associated with 39% increased odds or a 20% higher relative risk of second IRF hospitalization than Medicare [OR 1.39; 95% CI 1.01-1.92; RR 1.2, 95% CI 1.006-1.404; P = .04). CONCLUSIONS: Hemorrhagic stroke, non-Medicare insurance or lower discharge FIM score during the first IRF hospitalization predict a second IRF stay. Further work is needed to establish the validity of within IRF stay readmission measures.

Randomized Clinical Trial of Near Visual Performance with Digital Devices Using Spherical and Toric Contact Lenses.

SIGNIFICANCE: Visual demands today incorporate a significant amount of time using digital devices. Results of this randomized crossover study of spherical and toric contact lenses demonstrated that participants were able to read smaller print size more comfortably and preferred toric contact lenses when using digital devices. PURPOSE: The purpose of this study was to assess how toric contact lens correction affects subjective and objective outcomes of astigmatic patients using real-world digital devices. METHODS: Adult participants, aged between 20 and 38 years with -0.75 to -1.50 D of astigmatism were enrolled in this double-masked randomized crossover 10-day study of Alcon Dailies Aqua Comfort Plus Sphere and Toric (Alcon, Geneva, Switzerland) contact lenses. Electronic high- and low-contrast near logMAR visual acuity and contrast sensitivity were tested. Reading performance was assessed using custom iPad applications; one used a reading sentences test, whereas the other analyzed zoom, contrast, and distance with website-based articles. Participants completed the Near Activity Visual Questionnaire and stated their preferred contact lens correction. RESULTS: Thirty seven participants were screened, 35 participants were enrolled, and 34 participants completed the study. Toric lens correction improved near high- and low-contrast visual acuity by 0.5 to 1 full line (P < .0001) and allowed participants to read one line smaller text on the iPad (P = .01). Participants increased the zoom 11% (P = .004) and the contrast 4% (P = .006) more with spherical lenses while reading articles. Participants held the iPad at approximately the same distance, about 33 cm (P = .63). Eighty five percent of participants preferred the toric correction (P < .0001). Participants reported improved satisfaction with toric lens correction (P = .0002) and noticed the most benefit with tasks such as reading small print and labels/instructions. CONCLUSIONS: This study used digital devices to demonstrate realistic benefits of toric contact lens designs for astigmatic patients.

Use of a Smartphone-Based Mobile App for Weight Management in Obese Minority Stroke Survivors: Pilot Randomized Controlled Trial With Open Blinded End Point.

BACKGROUND: Minorities have an increased incidence of early-onset, obesity-related cerebrovascular disease. Unfortunately, effective weight management in this vulnerable population has significant barriers. OBJECTIVE: Our objective was to determine the feasibility and preliminary treatment effects of a smartphone-based weight loss intervention versus food journals to monitor dietary patterns in minority stroke patients. METHODS: Swipe out Stroke was a pilot prospective randomized controlled trial with open blinded end point. Minority stroke patients and their caregivers were screened for participation using cluster enrollment. We used adaptive randomization for assignment to a behavior intervention with (1) smartphone-based self-monitoring or (2) food journal self-monitoring. The smartphone group used Lose it! to record meals and communicate with us. Reminder messages (first 30 days), weekly summaries plus reminder messages on missed days (days 31-90), and weekly summaries only (days 91-180) were sent via push notifications. The food journal group used paper diaries. Both groups received 4 in-person visits (baseline and 30, 90, and 180 days), culturally competent counseling, and educational materials. The primary outcome was reduced total body weight. RESULTS: We enrolled 36 stroke patients (n=23, 64% African American; n=13, 36% Hispanic), 17 in the smartphone group, and 19 in the food journal group. Mean age was 54 (SD 9) years; mean body mass index was 35.7 (SD 5.7) kg/m2; education, employment status, and family history of stroke or obesity did not differ between the groups. Baseline rates of depression (Patient Health Questionnaire-9 [PHQ-9] score median 5.5, IQR 3.0-9.5), cognitive impairment (Montreal Cognitive Assessment score median 23.5, IQR 21-26), and inability to ambulate (5/36, 14% with modified Rankin Scale score 3) were similar. In total, 25 (69%) stroke survivors completed Swipe out Stroke (13/17 in the smartphone group, 12/19 in the food journal group); 1 participant in the smartphone group died. Median weight change at 180 days was 5.7 lb (IQR -2.4 to 8.0) in the smartphone group versus 6.4 lb (IQR -2.2 to 12.5; P=.77) in the food journal group. Depression was significantly lower at 30 days in the smartphone group than in the food journal group (PHQ-9 score 2 vs 8; P=.03). Clinically relevant depression rates remained in the zero to minimal range for the smartphone group compared with mild to moderate range in the food journal group at day 90 (PHQ-9 score 3.5 vs 4.5; P=.39) and day 180 (PHQ-9 score 3 vs 6; P=.12). CONCLUSIONS: In a population of obese minority stroke survivors, the use of a smartphone did not lead to a significant difference in weight change compared with keeping a food journal. The presence of baseline depression (19/36, 53%) was a confounding variable, which improved with app engagement. Future studies that include treatment of poststroke depression may positively influence intervention efficacy. TRIAL REGISTRATION: ClinicalTrials.gov NCT02531074; https://www.clinicaltrials.gov/ct2/show/NCT02531074.

Cluster Enrollment: A Screening Tool for Stroke Risk Factors in Minority Women Caregivers.

BACKGROUND AND PURPOSE: Women minorities have an overall increased lifetime incidence of cerebrovascular disease. The provision of risk factor modification in this group can prove difficult. In a population-based study, we used cluster enrollment to identify vascular risk factors in the female caregivers of stroke survivor study participants. METHODS: Obese women caregivers were identified as part of Swipe out Stroke, a Phase I PROBE study assessing the use of SmartPhone based intervention for dietary modification in minority stroke survivors. After written informed consent was obtained, both patients and caregivers were screened for vascular risk factors at study enrollment. Descriptive statistics were used to depict the study population. Continuous baseline variables were compared using 2 sample t-test or Wilcoxon rank-sum test by caregivers and patients. Categorical baseline variables were compared using Fisher's exact test. RESULTS: Thirty-six stroke patients (63.9% African-American, 36.1% Hispanic) and thirteen female caregivers (69.2% African-American, 30.8% Hispanic) were enrolled. Mean age, patients - 54.1 (SD 9.4), caregivers - 51.3 (SD 15.6) years, education, employment status and family history of stroke or obesity did not differ significantly. Compared to stroke patients, female caregivers were significantly less likely to self-report hypertension (69.2 versus 97.2%; P = 0.01) and hyperlipidemia (16.7 versus 60%; P = 0.02). Female caregivers were more likely to have elevated systolic blood pressure (147.6 vs 127.7 mmHg; P = 0.05), total cholesterol (207.5 versus 167 mg/dL; P = 0.01) and low density lipoprotein values (119.5 versus 88 mg/dL; P = 0.03) compared to stroke patients. CONCLUSIONS: Using cluster enrollment, we discovered minority female caregivers were more likely to have unknown or poorly controlled vascular risk factors compared to stroke patients. Innovative health screening tools may benefit the extended family of minority patients participating in clinical trials.

The Reticulospinal Pathway Does Not Increase Its Contribution to the Strength of Contralesional Muscles in Stroke Survivors as Compared to Ipsilesional Side or Healthy Controls.

OBJECTIVE: Startling acoustic stimulation (SAS), via activation of reticulospinal (RS) pathways, has shown to increase muscle strength in healthy subjects. We hypothesized that, given RS hyperexcitability in stroke survivors, SAS could increase muscle strength in stroke survivors. The objective was to quantify the effect of SAS on maximal and sub-maximal voluntary elbow flexion on the contralesional (impaired) side in stroke survivors as compared to ipsilesional (non-impaired) side and healthy controls. DESIGN: Thirteen hemiparetic stroke survivors and 12 healthy subjects volunteered for this investigation. Acoustic stimulation was given at rest, during ballistic maximal and sustained sub-maximal isometric elbow contractions using low (80 dB) and high intensity sound (105 dB). The effect of acoustic stimuli was evaluated from EMG and force recordings. RESULTS: Prevalence of acoustic startle reflex with shorter latency in the impaired biceps was greater as compared to the response in the non-impaired side of stroke subjects and in healthy subjects. Delivery of SAS resulted in earlier initiation of elbow flexion and greater peak torque in healthy subjects and in stroke subjects with spastic hemiplegia during maximal voluntary elbow flexion tasks. During sub-maximal elbow flexion tasks, SAS-induced force responses were slightly greater on the impaired side than the non-impaired side. However, no statistically significant difference was found in SAS-induced responses between impaired and non-impaired sides at maximal and sub-maximal elbow flexion tasks. CONCLUSION: The findings suggest RS hyperexcitability in stroke survivors with spastic hemiplegia. The results of similar SAS-induced responses between healthy and stroke subjects indicate that RS projections via acoustic stimulation are not likely to contribute to muscle strength for stroke survivors to a significant extent.

Re-evaluation of EMG-torque relation in chronic stroke using linear electrode array EMG recordings.

The objective was to re-evaluate the controversial reports of EMG-torque relation between impaired and non-impaired sides using linear electrode array EMG recordings. Ten subjects with chronic stroke performed a series of submaximal isometric elbow flexion tasks. A 20-channel linear array was used to record surface EMG of the biceps brachii muscles from both impaired and non-impaired sides. M-wave recordings for bilateral biceps brachii muscles were also made. Distribution of the slope of the EMG-torque relations for the individual channels showed a quasi-symmetrical "M" shaped pattern. The lowest value corresponded to the innervation zone (IZ) location. The highest value from the slope curve for each side was selected for comparison to minimize the effect of electrode placement and IZ asymmetry. The slope was greater on the impaired side in 4 of 10 subjects. There were a weak correlation between slope ratio and strength ratio and a moderate to high correlation between slope ratio and M-wave ratio between two sides. These findings suggest that the EMG-torque relations are likely mediated and influenced by multiple factors. Our findings emphasize the importance of electrode placement and suggest the primary role of peripheral adaptive changes in the EMG-torque relations in chronic stroke.

Correlation of Resting Elbow Angle with Spasticity in Chronic Stroke Survivors.

OBJECTIVE: To evaluate whether resting joint angle is indicative of severity of spasticity of the elbow flexors in chronic stroke survivors. METHODS: Seventeen hemiparetic stroke subjects (male: n = 13; female: n = 4; age: 37-89 years; 11 right and 6 left hemiplegia; averaged 54.8 months after stroke, ranging 12-107 months) participated in the study. The number of subjects with modified Ashworth scale score (MAS) = 0, 1, 1+, 2, and 3 was 3, 3, 5, 3, and 3, respectively. In a single experimental session, resting elbow joint angle, MAS, and Tardieu scale score (Tardieu R1) were measured. A customized motorized stretching device was used to stretch elbow flexors at 5, 50, and 100°/s, respectively. Biomechanical responses (peak reflex torque and reflex stiffness) of elbow flexors were quantified. Correlation analyses between clinical and biomechanical assessments were performed. RESULTS: Resting elbow joint angle showed a strong positive correlation with Tardieu R1 (r = 0.77, p < 0.01) and a very strong negative correlation with MAS (r = -0.89, p < 0.01). The resting angle also had strong correlations with biomechanical measures (r = -0.63 to -0.76, p < 0.01). CONCLUSION: Our study provides experimental evidence for anecdotal observation that the resting elbow joint angle correlates with severity of spasticity in chronic stroke. Resting angle observation for spasticity assessment can and will be an easy, yet a valid way of spasticity estimation in clinical settings, particularly for small muscles or muscles which are not easily measurable by common clinical methods.

Activation deficit correlates with weakness in chronic stroke: evidence from evoked and voluntary EMG recordings.

OBJECTIVE: To use evoked (M-wave) and voluntary (during maximal voluntary contraction (MVC)) EMG recordings to estimate the voluntary activation level in chronic stroke. METHODS: Nine chronic hemiparetic stroke subjects participated in the experiment. M-wave (EMGM-wave) and MVC (EMGMVC) EMG values of the biceps brachii muscles were recorded. RESULTS: Peak torque was significantly smaller on the impaired than non-impaired side. EMGM-wave was also significantly smaller on the impaired than non-impaired side. However, the normalized EMGM-wave/TorqueMVC ratio was not significantly different between two sides. In contrast, both absolute EMGMVC and normalized EMGMVC/TorqueMVC were smaller on the impaired than non-impaired side. The voluntary activation level, EMGMVC/M-wave, was also smaller on the impaired than non-impaired side. The voluntary activation level on the impaired side was highly correlated with weakness (R=0.72), but very low (R=0.32) on the non-impaired side. CONCLUSION: Collectively, our findings suggest that both peripheral and central factors contribute to post-stroke weakness, but activation deficit correlates most closely with weakness as estimated from maximum voluntary torque generation. SIGNIFICANCE: These findings serve to highlight the potential benefit from high-intensity exercises to enhance central activation for facilitation of motor recovery.