Association of Caregiver Availability and Training With Patient Community Discharge After Stroke.

Objective: To examine the association between committed caregivers and caregiver training with community discharge from inpatient rehabilitation after a stroke. Design: Secondary analysis of data extracted from electronic health records linked with the Uniform Data System for Medical Rehabilitation. Setting: Three hospital-based inpatient rehabilitation facilities (IRF) in a major metropolitan area. Participants: 1397 adult patients (mean ± SD age: 69.4 [13.5]; 724 men) transferred from an acute care setting to inpatient rehabilitation after an ischemic or hemorrhagic stroke (N=1397). Intervention: None. Main Outcome Measure: Community discharge from IRF. Results: 82.4% of patients had caregivers, 63.4% of patient caregivers received training at the IRF, and 79.5% had community discharge. After adjusting for age, stroke severity, functional status, and other social risk factors, having a committed caregiver and caregiver training were significantly associated with community discharge (odds ratio [OR]=7.80, 95% confidence interval [CI]: 5.03-12.10 and OR=4.89, 95% CI: 3.16-7.57, respectively). Conclusion: Caregivers increase a patient's likelihood of discharge from IRF; the added benefit of caregiver training needs to be further assessed, with essential elements prioritized prior to patients' IRF discharge.

Association of Medicare-Medicaid Dual Eligibility and Race and Ethnicity With Ischemic Stroke Severity.

Importance: Black and Hispanic US residents are disproportionately affected by stroke incidence, and patients with dual eligibility for Medicare and Medicaid may be predisposed to more severe strokes. Little is known about differences in stroke severity for individuals with dual eligibility, Black individuals, and Hispanic individuals, but understanding hospital admission stroke severity is the first important step for focusing strategies to reduce disparities in stroke care and outcomes. Objective: To examine whether dual eligibility and race and ethnicity are associated with stroke severity in Medicare beneficiaries admitted to acute hospitals with ischemic stroke. Design, Setting, and Participants: This retrospective cross-sectional study was conducted using Medicare claims data for patients with ischemic stroke admitted to acute hospitals in the United States from October 1, 2016, to November 30, 2017. Data were analyzed from July 2021 and January 2022. Exposures: Dual enrollment for Medicare and Medicaid; race and ethnicity categorized as White, Black, Hispanic, and other. Main Outcomes and Measures: Claim-based National Institutes of Health Stroke Scale (NIHSS) categorized into minor (0-7), moderate (8-13), moderate to severe (14-21), and severe (22-42) stroke. Results: Our sample included 45 459 Medicare fee-for-service patients aged 66 and older (mean [SD] age, 80.2 [8.4]; 25 303 [55.7%] female; 7738 [17.0%] dual eligible; 4107 [9.0%] Black; 1719 [3.8%] Hispanic; 37 715 [83.0%] White). In the fully adjusted models, compared with White patients, Black patients (odds ratio [OR], 1.21; 95% CI, 1.06-1.39) and Hispanic patients (OR, 1.54; 95% CI, 1.29-1.85) were more likely to have a severe stroke. Using White patients without dual eligibility as a reference group, White patients with dual eligibility were more likely to have a severe stroke (OR, 1.75; 95% CI, 1.56-1.95). Similarly, Black patients with dual eligibility (OR, 2.15; 95% CI, 1.78-2.60) and Hispanic patients with dual eligibility (OR, 2.50; 95% CI, 1.98-3.16) were more likely to have a severe stroke. Conclusions and Relevance: In this cross-sectional study, Medicare fee-for-service patients with ischemic stroke admitted to acute hospitals who were Black or Hispanic had a higher likelihood of worse stroke severity. Additionally, dual eligibility status had a compounding association with stroke severity regardless of race and ethnicity. An urgent effort is needed to decrease disparities in access to preventive and poststroke care for dual eligible and minority patients.

Complementary and integrative health interventions in post-stroke rehabilitation: a systematic PRISMA review.

AIM: Researchers have reported measurable improvements in emotional and physical health among adults post-stroke after participating in complementary and integrative health techniques. The aim of this manuscript was to systematically review the effectiveness of active complementary and integrative health interventions as a treatment modality for adults post-stroke. METHOD: For this review, active interventions were defined as those that required participants to be in control of initiating their own body movement. Five active complementary and integrative health techniques were reviewed and included: Feldenkrais Method, qigong, Pilates, Tai Chi, and yoga. A key word search was conducted in Medline, Cochrane Library, EBSCO, Google Scholar, and PubMed. Inclusion criteria for studies were (1) randomized controlled trials on the effects of active complementary and integrative health interventions, (2) all participants had to be post-stroke, and (3) studies appeared in English in a peer-reviewed journal. RESULTS: Articles in this review included one Qigong, five Pilates, nine Tai Chi, and five yoga studies. All 20 manuscripts reported improvements for participants. Participants in Pilates experienced improvements in quality of life. Improvements in functional balance, standing and dynamic balance, reaction time, maximum excursion, and quality of life were reported in the Pilates studies. Participants in the TC studies experienced a range of positive results including center of gravity, increased reaction time, improved aerobic endurance, fewer falls, sway length and velocity, functional reach, dynamic gait, walking speed, and static and dynamic balance. Improvements after participation in the yoga manuscripts consisted of reduced depression, decreased state and trait anxiety, improved balance, reduction in fear of falling, and enhanced quality of life. CONCLUSION: Based on the small number of randomized controlled trials, this systematic review reported the effectiveness of four active mind-body interventions for individuals post-stroke. The strongest evidence was for the use of Tai Chi, followed by Pilates and yoga.Implications for rehabilitationClinicians should consider the benefits of qigong, Pilates, Tai Chi, and yoga to best meet individual patient needs and goals.Clinicians who offer qigong, Pilates, Tai Chi, and/or yoga should be qualified to instruct the specific active complementary and integrative health technique or refer patients to those who are qualified.Locate qigong, Pilates, Tai Chi, and yoga classes that are appropriate for people post-stroke in the community to help integrate patients into a program after treatment.

Medicare Claim-Based National Institutes of Health Stroke Scale to Predict 30-Day Mortality and Hospital Readmission.

BACKGROUND: The Centers for Medicare and Medicaid Services (CMS) penalizes hospitals for higher than expected 30-day mortality rates using methods without accounting for condition severity risk adjustment. For patients with stroke, CMS claims did not quantify stroke severity until recently, when the National Institutes of Health Stroke Scale (NIHSS) reporting began. OBJECTIVE: Examine the predictive ability of claim-based NIHSS to predict 30-day mortality and 30-day hospital readmission in patients with ischemic stroke. DESIGN: Retrospective cohort study of Medicare claims data. PATIENTS: Medicare beneficiaries with ischemic stroke (N=43,241) acute hospitalization between October 2016 and November 2017. MEASUREMENTS: All-cause 30-day mortality and 30-day hospital readmission. NIHSS score was derived from ICD-10 codes and stratified into the following: minor to moderate, moderate, moderate to severe, and severe categories. RESULTS: Among 43,241 patients with ischemic stroke with NIHSS from 2,659 US hospitals, 64.6% had minor to moderate stroke, 14.3% had moderate, 12.7% had moderate to severe, and 8.5% had a severe stroke,10.1% died within 30 days, 12.1% were readmitted within 30 days. The NIHSS exhibited stronger discriminant property (C-statistic 0.83, 95% CI: 0.82-0.84) for 30-day mortality compared to Elixhauser (0.74, 95% CI: 0.73-0.75). A monotonic increase in the adjusted 30-day mortality risk occurred relative to minor to moderate stroke category: hazard ratio [HR]=2.92 (95% CI=2.59-3.29) for moderate stroke, HR=5.49 (95% CI=4.90-6.15) for moderate to severe stroke, and HR=7.82 (95% CI=6.95-8.80) for severe stroke. After accounting for competing risk of mortality, there was a significantly higher readmission risk in the moderate stroke (HR=1.11, 95% CI=1.03-1.20), but significantly lower readmission risk in the severe stroke (HR=0.84, 95% CI=0.74-0.95) categories. LIMITATION: Timing of NIHSS reporting during hospitalization is unknown. CONCLUSIONS: Medicare claim-based NIHSS is significantly associated with 30-day mortality in Medicare patients with ischemic stroke and significantly improves discriminant property relative to the Elixhauser comorbidity index.

Generalizing the predictive relationship between 1-month motor skill retention and Rey-Osterrieth Delayed Recall scores from nondemented older adults to individuals with chronic stroke: a short report.

Motor learning is fundamental to motor rehabilitation outcomes. There is growing evidence from non-neurological populations supporting the role of visuospatial memory function in motor learning, but current predictive models of motor recovery of individuals with stroke generally exclude cognitive measures, thereby overlooking the potential link between motor learning and visuospatial memory. Recent work has demonstrated that a clinical test of visuospatial memory (Rey-Osterrieth Complex Figure Delayed Recall) may predict 1-month skill learning in older adults; however, whether this relationship persists in individuals with chronic stroke remains unknown. The purpose of this short report was to validate previous findings using Rey-Osterrieth Complex Figure Delayed Recall test scores to predict motor learning and determine if this relationship generalized to a set of individuals post-stroke. Two regression models (one including Delayed Recall scores and one without) were trained using data from non-stroke older adults. To determine the extent to which Delayed Recall test scores impacted prediction accuracy of 1-month skill learning in older adults, we used leave-one-out cross-validation to evaluate the prediction error between models. To test if this predictive relationship generalized to individuals with chronic ischemic stroke, we then tested each trained model on an independent stroke dataset. Results indicated that in both stroke and older adult datasets, inclusion of Delayed Recall scores explained significantly more variance of 1-month skill performance than models that included age, education, and baseline motor performance alone. This proof-of-concept suggests that the relationship between delayed visuospatial memory and 1-month motor skill performance generalizes to individuals with chronic stroke, and supports the idea that visuospatial testing may provide prognostic insight into clinical motor rehabilitation outcomes.

Acute Effects of Assisted Cycling Therapy on Post-Stroke Motor Function: A Pilot Study.

BACKGROUND: Stroke is the most common cause of long-term disability in the United States (US). Assisted Cycling Therapy (ACT) at cadences of about 80 rpm has been associated with improvements in motor and clinical function in other clinical populations. The acute effects of ACT on motor function of persons with stroke have not been investigated. OBJECTIVES: The primary purpose of this cross-over trial was to compare the effects of ACT, voluntary cycling (VC), and no cycling (NC) on upper (Box and Blocks Test) and lower extremity motor function (Lower Extremity Motor Coordination Test) in adults with chronic stroke (age: 60 ± 16 years; months since stroke: 96 ± 85). The secondary purpose was to examine average cycling cadence and ratings of perceived exertion as predictors of change in motor function following the exercise session. METHODS: Twenty-two participants (female = 6, male = 16) completed one 20-min session each of ACT (mean cadence = 79.5 rpm, VC (mean cadence = 51.5 rpm), and NC on separate days in quasi-counterbalanced fashion). RESULTS: Main effects of intervention did not differ between ACT and VC. Within-intervention analyses revealed significant (p < 0.05) pre- to posttest changes in all outcome measures for ACT but only in the Lower Extremity Motor Coordination Test on the non-paretic side for VC. Trend analyses revealed a positive relationship between average ACT cadences and improvements in upper and lower extremity motor function (p < 0.05). A positive relationship between average VC cadences and lower extremity function was also revealed (p < 0.05). CONCLUSION: ACT and VC produced similar acute improvements in paretic and non-paretic lower extremity motor function whereas changes in upper extremity motor function were more limited. Faster cycling cadences seem to be associated with greater acute effects.

Step count accuracy and reliability of two activity tracking devices in people after stroke.

BACKGROUND/PURPOSE: The increasing popularity of activity tracking devices presents an opportunity to monitor physical activity in patients after stroke. We sought to determine the reliability and accuracy of the Garmin Vivofit and Fitbit Zip for adults after stroke. METHODS: Twenty-four participants with stroke-induced hemiparesis wore a Fitbit Zip on the nonparetic hip and Garmin Vivofits on both wrists during a 6-minute walk test to determine the accuracy of the devices against video-determined step counts. Participants also wore the devices during two trials of exactly 50 steps to determine the reliability of the devices. RESULTS: Fitbit Zip showed excellent reliability (ICC2,1 = 0.974) and accuracy (4.2% error) for participants who walked faster than 0.35 m/s. Garmin Vivofit (nonparetic side) had excellent reliability (ICC2,1 = 0.964) but poor accuracy (≤-16.0%) for all participants. Garmin Vivofit (paretic side) had excellent reliability (ICC2,1 = 0.858) and accuracy (-4.0% error) for faster walkers (>0.48 m/s) but poor accuracy (-68.2%) for slower walkers. CONCLUSION: Fitbit Zip was more accurate and reliable for persons with stroke than Garmin Vivofit, but slower walking speeds were associated with greater undercounting of steps for both devices. The Fitbit Zip is appropriate for counting steps in adults poststroke who range from household to community ambulators.

Oxygen Consumption Deficits in Patients With Residual Fatigue After Primary Coccidioidomycosis.

Patients with coccidioidomycosis often report prolonged and debilitating fatigue after other evidence of infection has resolved. In this study, we quantify fatigue, muscle weakness, and impaired aerobic capacity in 5 such individuals. A closer examination of the cardiorespiratory system may contribute to a better understanding of underlying mechanisms and potential interventions.

Feasibility of Measuring Ventilatory Threshold in Adults With Stroke-Induced Hemiparesis: Implications for Exercise Prescription.

OBJECTIVES: To assess the feasibility of measuring ventilatory threshold (VT) in adults with walking impairments due to stroke. Secondary objectives are to assess reliability of VT over trials; assess whether participants could sustain treadmill walking at VT; and compare mean heart rate during sustained treadmill walking to estimated heart rate reserve (HRR). DESIGN: Cross-sectional, single-group design. SETTING: University research laboratory. PARTICIPANTS: Volunteer sample of adults (N=8) with impaired walking resulting from chronic stroke. INTERVENTIONS: Three submaximal treadmill walking tests on 3 separate days; a 30-minute treadmill walking session on a fourth day. MAIN OUTCOME MEASURES: Gas exchange variables were measured, and 2 independent observers identified VT. Mean heart rate response to treadmill walking at VT was measured and compared with estimated 40% of HRR. RESULTS: VT was measured successfully in 88% of all trials. There was no difference in VT among trials (P=.17). After multiple imputations to account for 3 missing data points, the intraclass correlation coefficient was .87 (95% confidence interval, .80-.95). All participants were able to walk for 20 minutes at VT. Mean ± SD heart rate during the session was 66.0%±8.0% of estimated maximal heart rate. There was no significant difference between mean heart rate and estimated HRR values (P=.70). CONCLUSIONS: In adults with impaired walking resulting from stroke, VT can be safely measured during submaximal treadmill walking. Participants were able to sustain walking at VT, and this value may provide an appropriate stimulus for aerobic exercise prescription in this population.

Review of therapeutic electrical stimulation for dorsiflexion assist and orthotic substitution from the American Congress of Rehabilitation Medicine stroke movement interventions subcommittee.

Ankle dorsiflexion weakness that impedes walking affects some 30% of people after a stroke, which increases the risk of falls and mortality. Recent advances in functional electrical stimulation or electrical stimulation orthotic substitute walking devices facilitate the use of surface electrode stimulation during therapeutic gait training and as an orthotic substitute. However, many therapists who could promote the use of these electrical stimulation orthotic substitute devices are not doing so, possibly because of a lack of knowledge about the devices and uncertainty about which patients could benefit from the devices but also because of a lack of reimbursement by some insurance providers. In addition, there is limited evidence about the efficacy of electrical stimulation orthotic substitute devices for therapeutic use or as a substitute for a traditional ankle-foot orthosis (AFO). This article provides clinicians with information to guide them in the use of electrical stimulation orthotic substitute devices, discusses current research about the use of electrical stimulation orthotic substitute devices for therapeutic and orthotic purposes, and compares the use of electrical stimulation orthotic substitute devices and AFOs. There is insufficient evidence thus far to conclude that walking with an electrical stimulation orthotic substitute device is superior to walking with an AFO, but electrical stimulation orthotic substitute devices may be the optimal choice for some patients.

The heart rate response to nintendo wii boxing in young adults.

PURPOSE: To determine if 30 minutes of Nintendo Wii Sports boxing provides cardiorespiratory benefits and contributes to the daily exercise recommendations for healthy young adults. METHODS: Twenty healthy 23- to 27-year-olds participated in two sessions to measure maximum heart rate (HR(max)) via a treadmill test and heart rate (HR) response to 30 minutes of Wii Sports boxing. Heart rate in beats per minute (bpm) was measured continuously, and exercise intensity during each minute of play was stratified as a percentage of HR(max). Mixed designs analysis of variance (ANOVA) and Pearson product moment correlations were used to analyze the data. RESULTS: Mean (SD) HR response to boxing was 143 (15) bpm or 77.5% (10.0%) of HR(max). The mean HR response for experienced participants was significantly lower than inexperienced participants, P = .007. The ANOVA revealed a significant interaction between experience and time spent at various intensities, P = .009. Experienced participants spent more time in light to vigorous intensities, inexperienced participants in moderate to very hard intensities. Fitness was not correlated with mean HR response to boxing, P = .49. CONCLUSION: Thirty minutes of Nintendo Wii Sports boxing provides a moderate to vigorous aerobic response in healthy young adults and can contribute to daily recommendations for physical activity.

Functional and physiological effects of yoga in women with rheumatoid arthritis: a pilot study.

CONTEXT: Stress, both psychological and physiological, has been implicated as having a role in the onset and exacerbations of rheumatoid arthritis (RA). OBJECTIVE: This study investigated whether neuroendocrine and physical function in women with RA can be altered through a yoga intervention. DESIGN: Exercise intervention. SETTING: University research conducted at a medical clinic. PARTICIPANTS: Sixteen independently living, postmenopausal women with an RA classification of I, II, or III according to the American College of Rheumatology functional classification system served as either participants or controls. INTERVENTION: The study group participated in three 75-minute yoga classes a week over a 10-week period. MAIN OUTCOME MEASURES: At baseline and on completion of the 10-week intervention, diurnal cortisol patterns and resting heart rate were measured. Balance was measured using the Berg Balance Test. Participants completed the Health Assessment Questionnaire (HIQ), a visual analog pain scale, and the Beck Depression Inventory. RESULTS: Yoga resulted in a significantly decreased HAQ disability index, decreased perception of pain and depression, and improved balance. Yoga did not result in a significant change in awakening or diurnal cortisol patterns (P = .12).

Whole-body intensive rehabilitation is feasible and effective in chronic stroke survivors: a retrospective data analysis.

PURPOSE: Upper extremity (UE) intensive repetitive training, locomotor training, and functional strength training, delivered in isolation, promote neural plasticity and functional recovery after stroke. However, the effectiveness of a comprehensive whole-body approach combining these interventions has not been thoroughly investigated. The purpose of this retrospective data analysis was to evaluate the efficacy and feasibility of intensive, comprehensive rehabilitation for a heterogeneous population of chronic stroke survivors in a community clinic setting. METHOD: Whole-body intensive rehabilitation (3-6 hours/day, 4-5 days/week, >or= 2 weeks) consisted of locomotor, balance, and transfer training; progressive resistive strengthening exercise; and repetitive task-specific UE practice. Outcome measures were collected from all patients participating in the program between March 2003 and January 2008 who were diagnosed with a stroke >or= 12 months prior to treatment initiation (N = 35). RESULTS: Significant improvements in function were observed as measured by the Fugl-Meyer Assessment, Wolf Motor Function Test (WMFT), Box and Block test, Berg Balance Scale, Timed Up & Go Test (TUG), and 6-minute walk test. CONCLUSION: Whole-body intensive rehabilitation is an effective and feasible approach to promote recovery in chronic stroke survivors with moderate to severe deficits. Further research is necessary to confirm these results in a more controlled environment.

Changes in functional walking distance and health-related quality of life after gastric bypass surgery.

BACKGROUND AND PURPOSE: Early physical functional changes after gastric bypass surgery (GBS) are unclear, and the relationship between these changes and health-related quality of life (HR-QOL) has not been reported. We measured distances from a 6-minute walk test (6MWT) and scores on the 36-Item Short-Form Health Survey (SF-36) before and after GBS. SUBJECTS AND METHODS: Twenty-five people undergoing GBS completed the SF-36 and 6MWT presurgically and at the 3-month and 6-month follow-up visits. Ratings of perceived exertion (RPE) were measured during 6MWTs. RESULTS: Presurgical walking distance (X+/-SD; 414.1+/-103.7 m) was 55%+/-14% of normative values. Distances increased significantly at 3 months (505.2+/-98.0 m) and at 6 months (551.5+/-101.2 m). Final RPEs decreased significantly, and HR-QOL improved significantly. Both physical and mental health components of the SF-36 improved significantly. Distance was inversely correlated with body mass throughout the study and positively correlated with the SF-36 Physical Component Summary change from 3 to 6 months. DISCUSSION AND CONCLUSION: Improved functional capacity was associated with enhanced HR-QOL. At 6 months, walking distances remained 75% of those for age-matched peers who had normal weight.

The HPA axis response to stress in women: effects of aging and fitness.

This study tested the hypotheses that aging is associated with greater hypothalamic-pituitary-adrenal (HPA) axis reactivity to psychological stress, and whether aerobic fitness is associated with a lower HPA axis response to psychological stress. Three groups, consisting of young-unfit women (27.9+/-2.5 yr, n=10), older-unfit women (66.3+/-1.4 yr, n=14), and older-fit women (66.6+/-2.0 yr, n=12), underwent the Matt Stress Reactivity Protocol (MSRP). The MSRP is a stress test battery that combines mental challenges, a physical challenge, and a psychosocial stressor. Definition of fitness was based on maximal oxygen consumption (VO(2max)) where unfit was defined as having VO(2max)average for the respective age group. The MSRP elicited increases in heart rate, blood pressure, ACTH, and cortisol (P<0.001). The older-unfit women had significantly greater cortisol responses to the challenge than both the young-unfit and the older-fit women (P<0.05), who did not differ from each other. ACTH levels were significantly higher in the older-unfit women at baseline and throughout the trial, compared to both young-unfit and the older-fit (P<0.01). The ACTH response was not different between any of the groups. The young-unfit women had greater heart rate responses than the older-unfit (P<0.01), while the latter had greater systolic blood pressure responses (P<0.01). There were no significant differences between the older-unfit and older-fit in terms of heart rate or blood pressure responses. Our result shows that among unfit women, aging is associated with greater HPA axis reactivity to psychological stress, and that higher aerobic fitness among older women can attenuate these age-related changes as indicated by a blunted cortisol response to psychological stress. These findings suggest that exercise training may be an effective way of modifying some of the neuroendocrine changes associated with aging.

Hypothalamic-pituitary-adrenal axis response and recovery from high-intensity exercise in women: effects of aging and fitness.

This study tested the hypotheses that aging is associated with prolonged recovery after a challenge to the hypothalamic-pituitary-adrenal axis (acute exercise) and that aerobic fitness is associated with a blunting of the age-related loss of negative feedback sensitivity. Young (27 +/- 2.8 yr, n = 9), older (64.6 +/- 1.4 yr, n = 11), and older-fit women (66.3 +/- 2.2 yr, n = 11) underwent a short bout of treadmill exercise at high (but submaximal) intensity. The exercise trial elicited significant increases in heart rate, blood pressure, ACTH, and cortisol (P < 0.001). Although the young and the older women exhibited similar cortisol response to the trial and throughout the recovery period, the older women had a slower decrease of ACTH levels (P < 0.05), suggesting reduced negative feedback sensitivity with aging. Between the two groups of older women, the older-fit group had significantly greater rate of recovery of ACTH levels (P < 0.05) compared with the older unfit women. However, older fit women had greater cortisol production during the recovery period (P < 0.05), suggesting greater adrenal sensitivity to ACTH. These results suggest that aging is associated with changes in the dynamic function of the hypothalamic-pituitary-adrenal axis and that these changes are attenuated by aerobic fitness.